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حَدَّثَنَا هَنَّادٌ، حَدَّثَنَا أَبُو مُعَاوِيَةَ، عَنِ الأَعْمَشِ، عَنْ ذَرٍّ، عَنْ يُسَيْعٍ الْكِنْدِيِّ، عَنِ النُّعْمَانِ بْنِ بَشِيرٍ، عَنِ النَّبِيِّ صلى الله عليه وسلم فِي قَوْلِهِ ‏:‏ ‏(‏وَقَالَ رَبُّكُمُ ادْعُونِي أَسْتَجِبْ لَكُمْ ‏)‏ قَالَ ‏"‏ الدُّعَاءُ هُوَ الْعِبَادَةُ ‏"‏ ‏.‏ وَقَرَأَ ‏:‏‏(‏ وَقَالَ رَبُّكُمُ ادْعُونِي أَسْتَجِبْ لَكُمْ ‏)‏ إِلَى قَوْلِهِ ‏(‏ دَاخِرِينَ ‏)‏ ‏.‏ قَالَ أَبُو عِيسَى هَذَا حَدِيثٌ حَسَنٌ صَحِيحٌ ‏.‏

Narrated An-Nu'man bin Bashir:from the Prophet (ﷺ) regarding Allah's saying: Your Lord said: Invoke Me, I shall respond to you (40:60, it appears that the author intended to apply it to Al-Baqarah 2:186). - he said: "The supplication is the worship." And he recited: 'Your Lord said: Invoke Me, I shall respond to you.' up to His saying: 'in humiliation

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Protocol for a randomized controlled trial comparing the Circle of Security-parenting (COS-P) with treatment as usual in child mental health services

BACKGROUND: The quality of a child's attachment to its primary caregiver plays an important role for its long-term socioemotional development. While 'secure' attachment is associated with better outcomes, 'insecure' attachment is associated with a higher risk of externalizing and internalizing symptoms. Children referred to mental health services show much higher rates of insecure attachment than the general population, yet the parent-child relationship is rarely in treatment focus. Attachment quality is closely associated with parental sensitive responsiveness that is target of attachment-based interventions like Circle of Security (COS). COS has shown to improve attachment quality and the well-being of both children and parents. No randomized controlled trials have investigated the effect of COS on parental sensitivity and child psychiatric symptoms in child mental health services. OBJECTIVES: To investigate whether COS-Parenting (COS-P) can increase observed maternal sensitivity and decrease children's psychiatric symptoms as an add on to treatment as usual (TAU). METHODS: In a randomized controlled parallel superiority trial COS-P is compared with TAU for parents of children referred to child mental health services (n = 186). Families are randomized 2:1 to intervention or control group, if their child is between 3 and 8 years old and scores ≥ 93d percentile on both the CBCL total score and the oppositional defiant disorder or conduct disorder subscale. Primary outcome is maternal sensitivity, secondary and exploratory outcomes include, among others, child psychiatric symptoms, parental stress and coping with children's negative emotions. Outcomes and adverse events are assessed before (T0) and after 10 weeks of treatment (T1) and 6 months later (T2). Regression analysis and /or ANOVA will be used for all outcomes. PERSPECTIVES: Targeting the parent-child relation has the potential to reduce psychiatric symptoms in children. This trial will provide valuable information if attachment-based interventions like COS-P can enhance treatment as usual in child mental health services. TRAIL REGISTRATION: ClinicalTrials.gov Identifier: NCT03578016.

PLoS ONE · clinical trial · 8 citationsread the source →

Promoting positive parenting practices in primary pare: outcomes and mechanisms of change in a randomized controlled risk reduction trial.

The aim of the present study was to evaluate whether a short parent-training program (PT) reduces risk factors related to development of childhood socio-emotional and behavior problems in a non-clinical community sample. Data were obtained from parents in a randomized controlled trial (RCT) on PT for children aged 2 to 8 years (N=186) at pre-intervention, post-intervention and one-year-follow up. There were significant differences in the changes in the two groups, with reductions in harsh parenting and child behavior problems, an enhancement of positive parenting and of the parents' sense of competence in the intervention group. The effects on parenting and parents' satisfaction all lasted through one-year follow up. Our findings suggests that a shortened version of a well-structured parenting intervention, The Incredible Years program, implemented in primary care at community level, reduces harsh parenting and strengthens positive parenting and parents' sense of competence, as reported by the parents. Issues related to a public health approach to promote positive parenting are discussed.

Scandinavian journal of psychology · randomised controlled trial · 36 citationsread the source →

Continuous low-level vagus nerve stimulation reduces stellate ganglion nerve activity and paroxysmal atrial tachyarrhythmias in ambulatory canines.

Background: We hypothesize that left-sided low-level vagus nerve stimulation (LL-VNS) can suppress sympathetic outflow and reduce atrial tachyarrhythmias in ambulatory dogs. Methods and results: We implanted a neurostimulator in 12 dogs to stimulate the left cervical vagus nerve and a radiotransmitter for continuous recording of left stellate ganglion nerve activity, vagal nerve activities, and ECGs. Group 1 dogs (N=6) underwent 1 week of continuous LL-VNS. Group 2 dogs (N=6) underwent intermittent rapid atrial pacing followed by active or sham LL-VNS on alternate weeks. Integrated stellate ganglion nerve activity was significantly reduced during LL-VNS (7.8 mV/s; 95% confidence interval [CI] 6.94 to 8.66 versus 9.4 mV/s [95% CI, 8.5 to 10.3] at baseline; P=0.033) in group 1. The reduction was most apparent at 8 am, along with a significantly reduced heart rate (P=0.008). Left-sided low-level vagus nerve stimulation did not change vagal nerve activity. The density of tyrosine hydroxylase-positive nerves in the left stellate ganglion 1 week after cessation of LL-VNS were 99 684 μm(2)/mm(2) (95% CI, 28 850 to 170 517) in LL-VNS dogs and 186 561 μm(2)/mm(2) (95% CI, 154 956 to 218 166; P=0.008) in normal dogs. In group 2, the frequencies of paroxysmal atrial fibrillation and tachycardia during active LL-VNS were 1.4/d (95% CI, 0.5 to 5.1) and 8.0/d (95% CI, 5.3 to 12.0), respectively, significantly lower than during sham stimulation (9.2/d [95% CI, 5.3 to 13.1]; P=0.001 and 22.0/d [95% CI, 19.1 to 25.5], P<0.001, respectively). Conclusions: Left-sided low-level vagus nerve stimulation suppresses stellate ganglion nerve activities and reduces the incidences of paroxysmal atrial tachyarrhythmias in ambulatory dogs. Significant neural remodeling of the left stellate ganglion is evident 1 week after cessation of continuous LL-VNS.

Circulation · 180 citationsread the source →

Effectiveness of a bite-sized web-based intervention to improve healthcare worker wellbeing: A randomized clinical trial of WISER.

Importance: Problems with the wellbeing of healthcare workers (HCWs) are widespread and associated with detrimental consequences for the workforce, organizations, and patients. Objective: This study tested the effectiveness of the Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention, a positive psychology program, to improve six dimensions of the wellbeing of HCWs. Design: We conducted a randomized controlled trial of HCWs between 1 April 2018 and 22 July 2019. Cohort 1 received WISER daily for 10 days. Cohort 2 acted as a waitlist control before receiving WISER. Setting: Web-based intervention for actively employed HCWs across the United States. Participants: Eligibility criteria included being ≥18 years old and working as a HCW. Each participant was randomized to start the intervention or serve as a waitlist control for 14 days before starting the intervention. Interventions: Cohorts received links via 10 texts exposing them to introductory videos and positive psychology exercises (3 good things, cultivating awe, random acts of kindness, cultivating relationships, and gratitude letters). Main outcomes and measures: The primary outcome was emotional exhaustion; secondary outcomes included depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. All outcomes were assessed at baseline, 1-week post-intervention (primary endpoint), and 1, 6, and 12-month post-intervention. Outcomes were measured using six validated wellbeing instruments, rescaled to 100-point scales for comparison. Six items assessed participants' WISER experience. The analysis employed mixed-effects models. Results: In cohorts 1 and 2, 241 and 241 initiated WISER, and 178 (74%) and 186 (77%) completed the 6-month follow-up, respectively. Cohort populations were similar at baseline, mostly female (81; 76%) and nurses (34; 32%) or physicians (22; 23%), with 1-10 years of experience in their current position (54; 52%). Relative to control, WISER significantly improved depressive symptoms [-7.5 (95%CI: -11.0, -4.0), p < 0.001], work-life integration [6.5 (95%CI: 4.1, 8.9), p < 0.001], happiness [5.7 (95%CI: 3.0, 8.4), p < 0.001], emotional thriving [6.4 (95%CI: 2.5, 10.3), p = 0.001], and emotional recovery [5.3 (95%CI: 1.7, 8.9), p = 0.004], but not emotional exhaustion [-3.7 (95%CI: -8.2, 0.8), p = 0.11] at 1 week. Combined cohort results at 1, 6, and 12 months showed that all six wellbeing outcomes were significantly improved relative to baseline (p < 0.05 for all). Favorable impressions of WISER were reported by 87% of participants at the 6-month post-assessment. Conclusion and relevance: WISER improved HCW depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. Improvements in all HCW wellbeing outcomes endured at the 1-, 6-, and 12-month follow-ups. HCW's impressions of WISER were positive. Clinical trials number: https://clinicaltrials.gov/ct2/show/, identifier: NCT02603133. Web-based Implementation for the Science of Enhancing Resilience Study (WISER).

Frontiers in public health · randomised controlled trial · 17 citationsread the source →

Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: A meta-analysis of head-to-head comparisons.

The purpose of this meta-analysis was to examine rates of treatment refusal and premature termination for pharmacotherapy alone, psychotherapy alone, pharmacotherapy plus psychotherapy, and psychotherapy plus pill placebo treatments. A systematic review of the literature resulted in 186 comparative trials that included a report of treatment refusal and/or premature termination for at least 2 of the 4 treatment conditions. The data from these studies were pooled using a random-effects analysis. Odds Ratio effect sizes were then calculated to compare the rates between treatment conditions, once across all studies and then again for specific client disorder categories. An average treatment refusal rate of 8.2% was found across studies. Clients who were assigned to pharmacotherapy were 1.76 times more likely to refuse treatment compared with clients who were assigned psychotherapy. Differences in refusal rates for pharmacotherapy and psychotherapy were particularly evident for depressive disorders, panic disorder, and social anxiety disorder. On average, 21.9% of clients prematurely terminated their treatment. Across studies, clients who were assigned to pharmacotherapy were 1.20 times more likely to drop out compared with clients who were assigned to psychotherapy. Pharmacotherapy clients with anorexia/bulimia and depressive disorders dropped out at higher rates compared with psychotherapy clients with these disorders. Treatment refusal and dropout are significant problems in both psychotherapy and pharmacotherapy and providers of these treatments should seek to employ strategies to reduce their occurrence. (PsycINFO Database Record

Psychotherapy (Chicago, Ill.) · meta-analysis · 88 citationsread the source →

Parental education and inequalities in child mortality: a global systematic review and meta-analysis.

Background: The educational attainment of parents, particularly mothers, has been associated with lower levels of child mortality, yet there is no consensus on the magnitude of this relationship globally. We aimed to estimate the total reductions in under-5 mortality that are associated with increased maternal and paternal education, during distinct age intervals. Methods: This study is a comprehensive global systematic review and meta-analysis of all existing studies of the effects of parental education on neonatal, infant, and under-5 child mortality, combined with primary analyses of Demographic and Health Survey (DHS) data. The literature search of seven databases (CINAHL, Embase, MEDLINE, PsycINFO, PubMed, Scopus, and Web of Science) was done between Jan 23 and Feb 8, 2019, and updated on Jan 7, 2021, with no language or publication date restrictions. Teams of independent reviewers assessed each record for its inclusion of individual-level data on parental education and child mortality and excluded articles on the basis of study design and availability of relevant statistics. Full-text screening was done in 15 languages. Data extracted from these studies were combined with primary microdata from the DHS for meta-analyses relating maternal or paternal education with mortality at six age intervals: 0-27 days, 1-11 months, 1-4 years, 0-4 years, 0-11 months, and 1 month to 4 years. Novel mixed-effects meta-regression models were implemented to address heterogeneity in referent and exposure measures among the studies and to adjust for study-level covariates (wealth or income, partner's years of schooling, and sex of the child). This study was registered with PROSPERO (CRD42020141731). Findings: The systematic review returned 5339 unique records, yielding 186 included studies after exclusions. DHS data were compiled from 114 unique surveys, capturing 3 112 474 livebirths. Data extracted from the systematic review were synthesized together with primary DHS data, for meta-analysis on a total of 300 studies from 92 countries. Both increased maternal and paternal education showed a dose-response relationship linked to reduced under-5 mortality, with maternal education emerging as a stronger predictor. We observed a reduction in under-5 mortality of 31·0% (95% CI 29·0-32·6) for children born to mothers with 12 years of education (ie, completed secondary education) and 17·3% (15·0-18·8) for children born to fathers with 12 years of education, compared with those born to a parent with no education. We also showed that a single additional year of schooling was, on average, associated with a reduction in under-5 mortality of 3·04% (2·82-3·23) for maternal education and 1·57% (1·35-1·72) for paternal education. The association between higher parental education and lower child mortality was significant for both parents at all ages studied and was largest after the first month of life. The meta-analysis framework incorporated uncertainty associated with each individual effect size into the model fitting process, in an effort to decrease the risk of bias introduced by study design and quality. Interpretation: To our knowledge, this study is the first effort to systematically quantify the transgenerational importance of education for child survival at the global level. The results showed that lower maternal and paternal education are both risk factors for child mortality, even after controlling for other markers of family socioeconomic status. This study provides robust evidence for universal quality education as a mechanism to achieve the Sustainable Development Goal target 3.2 of reducing neonatal and child mortality. Funding: Research Council of Norway, Bill & Melinda Gates Foundation, and Rockefeller Foundation-Boston University Commission on Social Determinants, Data, and Decision Making (3-D Commission).

Lancet (London, England) · meta-analysis · 132 citationsread the source →

Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial.

Background: Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the effectiveness of cognitive behavioural therapy (CBT) plus standardised medical care with standardised medical care alone for the reduction of dissociative seizure frequency. Methods: In this pragmatic, parallel-arm, multicentre randomised controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardised medical care or CBT plus standardised medical care, using a web-based system. Randomisation was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomisation. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were: seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. p values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544. Findings: Between Jan 16, 2015, and May 31, 2017, we randomly assigned 368 patients to receive CBT plus standardised medical care (n=186) or standardised medical care alone (n=182); of whom 313 had primary outcome data at 12 months (156 [84%] of 186 patients in the CBT plus standardised medical care group and 157 [86%] of 182 patients in the standardised medical care group). At 12 months, no significant difference in monthly dissociative seizure frequency was identified between the groups (median 4 seizures [IQR 0-20] in the CBT plus standardised medical care group vs 7 seizures [1-35] in the standardised medical care group; estimated incidence rate ratio [IRR] 0·78 [95% CI 0·56-1·09]; p=0·144). Dissociative seizures were rated as less bothersome in the CBT plus standardised medical care group than the standardised medical care group (estimated mean difference -0·53 [95% CI -0·97 to -0·08]; p=0·020). The CBT plus standardised medical care group had a longer period of dissociative seizure freedom in the previous 6 months (estimated IRR 1·64 [95% CI 1·22 to 2·20]; p=0·001), reported better health-related quality of life on the EuroQoL-5 Dimensions-5 Level Health Today visual analogue scale (estimated mean difference 6·16 [95% CI 1·48 to 10·84]; p=0·010), less impairment in psychosocial functioning on the Work and Social Adjustment Scale (estimated mean difference -4·12 [95% CI -6·35 to -1·89]; p<0·001), less overall psychological distress than the standardised medical care group on the Clinical Outcomes in Routine Evaluation-10 scale (estimated mean difference -1·65 [95% CI -2·96 to -0·35]; p=0·013), and fewer somatic symptoms on the modified Patient Health Questionnaire-15 scale (estimated mean difference -1·67 [95% CI -2·90 to -0·44]; p=0·008). Clinical improvement at 12 months was greater in the CBT plus standardised medical care group than the standardised medical care alone group as reported by patients (estimated mean difference 0·66 [95% CI 0·26 to 1·04]; p=0·001) and by clinicians (estimated mean difference 0·47 [95% CI 0·21 to 0·73]; p<0·001), and the CBT plus standardised medical care group had greater satisfaction with treatment than did the standardised medical care group (estimated mean difference 0·90 [95% CI 0·48 to 1·31]; p<0·001). No significant differences in patient-reported seizure severity (estimated mean difference -0·11 [95% CI -0·50 to 0·29]; p=0·593) or seizure freedom in the last 3 months of the study (estimated odds ratio [OR] 1·77 [95% CI 0·93 to 3·37]; p=0·083) were identified between the groups. Furthermore, no significant differences were identified in the proportion of patients who had a more than 50% reduction in dissociative seizure frequency compared with baseline (OR 1·27 [95% CI 0·80 to 2·02]; p=0·313). Additionally, the 12-item Short Form survey-version 2 scores (estimated mean difference for the Physical Component Summary score 1·78 [95% CI -0·37 to 3·92]; p=0·105; estimated mean difference for the Mental Component Summary score 2·22 [95% CI -0·30 to 4·75]; p=0·084), the Generalised Anxiety Disorder-7 scale score (estimated mean difference -1·09 [95% CI -2·27 to 0·09]; p=0·069), and the Patient Health Questionnaire-9 scale depression score (estimated mean difference -1·10 [95% CI -2·41 to 0·21]; p=0·099) did not differ significantly between groups. Changes in dissociative seizures (rated by others) could not be assessed due to insufficient data. During the 12-month period, the number of adverse events was similar between the groups: 57 (31%) of 186 participants in the CBT plus standardised medical care group reported 97 adverse events and 53 (29%) of 182 participants in the standardised medical care group reported 79 adverse events. Interpretation: CBT plus standardised medical care had no statistically significant advantage compared with standardised medical care alone for the reduction of monthly seizures. However, improvements were observed in a number of clinically relevant secondary outcomes following CBT plus standardised medical care when compared with standardised medical care alone. Thus, adults with dissociative seizures might benefit from the addition of dissociative seizure-specific CBT to specialist care from neurologists and psychiatrists. Future work is needed to identify patients who would benefit most from a dissociative seizure-specific CBT approach. Funding: National Institute for Health Research, Health Technology Assessment programme.

The lancet. Psychiatry · randomised controlled trial · 192 citationsread the source →

Workplace based mindfulness practice and inflammation: a randomized trial.

We have developed a low dose Mindfulness-Based Intervention (MBI-ld) that reduces the time committed to meetings and formal mindfulness practice, while conducting the sessions during the workday. This reduced the barriers commonly mentioned for non-participation in mindfulness programs. In a controlled randomized trial we studied university faculty and staff (n=186) who were found to have an elevated CRP level,>3.0 mg/ml, and who either had, or were at risk for cardiovascular disease. This study was designed to evaluate if MBI-ld could produce a greater decrease in CRP, IL-6 and cortisol than an active control group receiving a lifestyle education program when measured at the end of the 2 month interventions. We found that MBI-ld significantly enhanced mindfulness by 2-months and it was maintained for up to a year when compared to the education control. No significant changes were noted between interventions in cortisol, IL-6 levels or self-reported measures of perceived stress, depression and sleep quality at 2-months. Although not statistically significant (p=.08), the CRP level at 2-months was one mg/ml lower in the MBI-ld group than in the education control group, a change which may have clinical significance (Ridker et al., 2000; Wassel et al., 2010). A larger MBI-ld effect on CRP (as compared to control) occurred among participants who had a baseline BMI <30 (-2.67 mg/ml) than for those with BMI >30 (-0.18 mg/ml). We conclude that MBI-ld should be more fully investigated as a low-cost self-directed complementary strategy for decreasing inflammation, and it seems most promising for non-obese subjects.

Brain, behavior, and immunity · randomised controlled trial · 112 citationsread the source →

Effect of naltrexone plus bupropion on weight loss in overweight and obese adults (COR-I): a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial.

Background: Despite increasing public health concerns regarding obesity, few safe and effective drug treatments are available. Combination treatment with sustained-release naltrexone and bupropion was developed to produce complementary actions in CNS pathways regulating bodyweight. The Contrave Obesity Research I (COR-I) study assessed the effect of such treatment on bodyweight in overweight and obese participants. Methods: Men and women aged 18-65 years who had a body-mass index (BMI) of 30-45 kg/m(2) and uncomplicated obesity or BMI 27-45 kg/m(2) with dyslipidaemia or hypertension were eligible for enrolment in this randomised, double-blind, placebo-controlled, phase 3 trial undertaken at 34 sites in the USA. Participants were prescribed mild hypocaloric diet and exercise and were randomly assigned in a 1:1:1 ratio to receive sustained-release naltrexone 32 mg per day plus sustained-release bupropion 360 mg per day combined in fixed-dose tablets (also known as NB32), sustained-release naltrexone 16 mg per day plus sustained-release bupropion 360 mg per day combined in fixed-dose tablets (also known as NB16), or matching placebo twice a day, given orally for 56 weeks. The trial included a 3-week dose escalation. Randomisation was done by use of a centralised, computer-generated, web-based system and was stratified by study centre. Co-primary efficacy endpoints at 56 weeks were percentage change in bodyweight and proportion of participants who achieved a decrease in bodyweight of 5% or more. The primary analysis included all randomised participants with a baseline weight measurement and a post-baseline weight measurement while on study drug (last observation carried forward). This study is registered with ClinicalTrials.gov, number NCT00532779. Findings: 1742 participants were enrolled and randomised to double-blind treatment (naltrexone 32 mg plus bupropion, n=583; naltrexone 16 mg plus bupropion, n=578; placebo, n=581). 870 (50%) participants completed 56 weeks of treatment (n=296; n=284; n=290, respectively) and 1453 (83%) were included in the primary analysis (n=471; n=471; n=511). Mean change in bodyweight was -1.3% (SE 0.3) in the placebo group, -6.1% (0.3) in the naltrexone 32 mg plus bupropion group (p<0.0001 vs placebo) and -5.0% (0.3) in the naltrexone 16 mg plus bupropion group (p<0.0001 vs placebo). 84 (16%) participants assigned to placebo had a decrease in bodyweight of 5% or more compared with 226 (48%) assigned to naltrexone 32 mg plus bupropion (p<0.0001 vs placebo) and 186 (39%) assigned to naltrexone 16 mg plus bupropion (p<0.0001 vs placebo). The most frequent adverse event in participants assigned to combination treatment was nausea (naltrexone 32 mg plus bupropion, 171 participants [29.8%]; naltrexone 16 mg plus bupropion, 155 [27.2%]; placebo, 30 [5.3%]). Headache, constipation, dizziness, vomiting, and dry mouth were also more frequent in the naltrexone plus bupropion groups than in the placebo group. A transient increase of around 1.5 mm Hg in mean systolic and diastolic blood pressure was followed by a reduction of around 1 mm Hg below baseline in the naltrexone plus bupropion groups. Combination treatment was not associated with increased depression or suicidality events compared with placebo. Interpretation: A sustained-release combination of naltrexone plus bupropion could be a useful therapeutic option for treatment of obesity. Funding: Orexigen Therapeutics.

Lancet (London, England) · randomised controlled trial · 622 citationsread the source →

Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans

Importance: Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. Objective: To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans. Design, Setting, and Participants: This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021. Interventions: Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions. Main Outcomes and Measures: The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life. Results: Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events. Conclusions and Relevance: This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01928732.

JAMA Network Open · cohort or longitudinal · 176 citationsread the source →

A study of early complementary feeding determinants in the Republic of Ireland based on a cross-sectional analysis of the Growing Up in Ireland infant cohort.

Objective: Early complementary feeding has been shown to increase the risk of overweight, obesity and chronic diseases later in life. Poor compliance with current guidelines on complementary feeding has been reported by Irish studies. The aim of the present paper is to identify predictors of early complementary feeding in order to help health professionals target population groups in greater need of dietary intervention as well as to provide effective advice. Design: Cross-sectional analysis of the national, longitudinal Growing Up in Ireland study. Setting: Data were derived from the first wave (2007-2008) of the Growing Up in Ireland infant cohort. Subjects: A cohort of mothers (n 11 134) from the Republic of Ireland, interviewed when their infants were 9 months of age. Results: Of the infants, 1469 (13·5 %) had been regularly taking solids in the period between 12 and 16 weeks; this percentage increased to 47·0 % of the sample in the period between 16 and 20 weeks. Timing of formula feeding commencement, high maternal BMI and choosing a relative as the infant's minder were strongly associated with early introduction of solids both in bivariate and multivariate analysis. Those infants who started formula feeding at >4 months were 88·4% less likely to be introduced to solids early compared with those who started at <2 months (OR = 0·116; 95% CI 0·072, 0·186; P < 0·001). Conclusions: The results demonstrate that biological, social and behavioural aspects exert an important role in infant feeding practices. These findings are relevant to the design of policies and intervention programmes aimed at educating parents.

Public health nutrition · 19 citationsread the source →

How Do Corticosteroids Work in Asthma?

Reviews2 September 2003How Do Corticosteroids Work in Asthma?Peter J. Barnes, DM, DSc and Ian M. Adcock, PhDPeter J. Barnes, DM, DScFrom National Heart and Lung Institute, Imperial College, London, United Kingdom. Search for more papers by this author and Ian M. Adcock, PhDFrom National Heart and Lung Institute, Imperial College, London, United Kingdom. Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-139-5_Part_1-200309020-00012 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical PrinciplesAsthma is the most common chronic disease in westernized countries. Patients with asthma have an underlying chronic inflammation of the airways characterized by activated mast cells, eosinophils, and T-helper 2 lymphocytes. This results in increased responsiveness of the airways to such triggers as exercise, allergens, and air pollutants. This chronic inflammation underlies the typical symptoms of asthma, which include intermittent wheezing, coughing, shortness of breath, and chest tightness. Corticosteroids are the most effective treatment for asthma, and inhaled corticosteroids have become first-line treatment for children and adults with persistent symptoms. Corticosteroids suppress the chronic airway inflammation in patients with asthma, and the molecular ...References1. Busse WW, Lemanske RF. Asthma. N Engl J Med. 2001;344:350-62. [PMID: 11172168] CrossrefMedlineGoogle Scholar2. Barnes PJ, Chung KF, Page CP. Inflammatory mediators of asthma: an update. Pharmacol Rev. 1998;50:515-96. [PMID: 9860804] MedlineGoogle Scholar3. Barnes PJ, Adcock IM. Transcription factors and asthma. Eur Respir J. 1998;12:221-34. [PMID: 9701442] CrossrefMedlineGoogle Scholar4. Hart LA, Krishnan VL, Adcock IM, Barnes PJ, Chung KF. Activation and localization of transcription factor, nuclear factor-B, in asthma. 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Therapeutic benefit of a dissociated glucocorticoid and the relevance of in vitro separation of transrepression from transactivation activity. J Immunol. 2001;166:1975-82. [PMID: 11160246] CrossrefMedlineGoogle Scholar75. Bledsoe RK, Montana VG, Stanley TB, Delves CJ, Apolito CJ, McKee DD, . Crystal structure of the glucocorticoid receptor ligand binding domain reveals a novel mode of receptor dimerization and coactivator recognition. Cell. 2002;110:93-105. [PMID: 12151000] CrossrefMedlineGoogle Scholar76. Barnes PJ. New treatments for COPD. Nat Rev Drug Discov. 2002;1:437-46. [PMID: 12119745] CrossrefMedlineGoogle Scholar77. Ito K, Lim S, Chung KF, Barnes PJ, Adcock IM. Theophylline enhances histone deacetylase activity and restores glucocorticoid function during oxidative stress [Abstract]. Am J Respir Crit Care Med. 2002;165:A625. Google Scholar Author, Article, and Disclosure InformationAffiliations: From National Heart and Lung Institute, Imperial College, London, United Kingdom. Disclosures:Grants received: P.J. Barnes, I.M. Adcock (GlaxoSmithKline and AstraZeneca); Grants pending: P.J. Barnes, I.M. Adcock (GlaxoSmithKline and AstraZeneca).Corresponding Author: P.J. Barnes, DM, DSc, Department of Thoracic Medicine, National Heart and Lung Institute, Dovehouse Street, London SW3 6LY, United Kingdom; e-mail, p.j.[email protected]ac.uk. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited ByNanotechnology based advanced therapeutic strategies for targeting interleukins in chronic respiratory diseasesLipopolysaccharide Regulates Pro- and Anti-Inflammatory Cytokines, Corticosterone, and Melatonin in ToadsThe central role of IL-33/IL-1RL1 pathway in asthma: From pathogenesis to interventionAsthma and COVID-19: Emphasis on Adequate of as of and as a Effect of the resistance in asthma: and molecular effects of on a of allergic between and and gene expression of glucocorticoid and receptors from the for of human respiratory with glucocorticoids in the treatment of asthma: of the oral corticosteroids and persistent in from the asthma to bronchial asthma as for A of of Melatonin and Glucocorticoid with in the a between Melatonin and of in Steroid Drug by of proteins during the Efficacy of to in a of corticosteroids in asthma: the between and the novel mode of action of the Association and 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Annals of Internal Medicine · review · 370 citationsread the source →

Testing the Efficacy of a Multicomponent, Self-Guided, Smartphone-Based Meditation App: Three-Armed Randomized Controlled Trial.

Background: A growing number of randomized controlled trials (RCTs) suggest psychological benefits associated with meditation training delivered via mobile health. However, research in this area has primarily focused on mindfulness, only one of many meditative techniques. Objective: This study aims to evaluate the efficacy of 2 versions of a self-guided, smartphone-based meditation app-the Healthy Minds Program (HMP)-which includes training in mindfulness (Awareness), along with practices designed to cultivate positive relationships (Connection) or insight into the nature of the self (Insight). Methods: A three-arm, fully remote RCT compared 8 weeks of one of 2 HMP conditions (Awareness+Connection and Awareness+Insight) with a waitlist control. Adults (≥18 years) without extensive previous meditation experience were eligible. The primary outcome was psychological distress (depression, anxiety, and stress). Secondary outcomes were social connection, empathy, compassion, self-reflection, insight, rumination, defusion, and mindfulness. Measures were completed at pretest, midtreatment, and posttest between October 2019 and April 2020. Longitudinal data were analyzed using intention-to-treat principles with maximum likelihood. Results: A total of 343 participants were randomized and 186 (54.2%) completed at least one posttest assessment. The majority (166/228, 72.8%) of those assigned to HMP conditions downloaded the app. The 2 HMP conditions did not differ from one another in terms of changes in any outcome. Relative to the waitlist control, the HMP conditions showed larger improvements in distress, social connectedness, mindfulness, and measures theoretically linked to insight training (d=-0.28 to 0.41; Ps≤.02), despite modest exposure to connection- and insight-related practice. The results were robust to some assumptions about nonrandom patterns of missing data. Improvements in distress were associated with days of use. Candidate mediators (social connection, insight, rumination, defusion, and mindfulness) and moderators (baseline rumination, defusion, and empathy) of changes in distress were identified. Conclusions: This study provides initial evidence of efficacy for the HMP app in reducing distress and improving outcomes related to well-being, including social connectedness. Future studies should attempt to increase study retention and user engagement. Trial registration: ClinicalTrials.gov NCT04139005; https://clinicaltrials.gov/ct2/show/NCT04139005.

JMIR mental health · 62 citationsread the source →

What General and Pain-associated Psychological Distress Phenotypes Exist Among Patients with Hip and Knee Osteoarthritis?

Background: Psychological distress can negatively influence disability, quality of life, and treatment outcomes for individuals with hip and knee osteoarthritis (OA). Clinical practice guidelines recommend a comprehensive disease management approach to OA that includes the identification, evaluation, and management of psychological distress. However, uncertainty around the best psychological screening and assessment methods, a poor understanding of the heterogeneity of psychological distress in those with OA, and lack of guidance on how to scale treatment have limited the growth of OA care models that effectively address individual psychological needs. Questions/purposes: (1) Across which general and pain-related psychological distress constructs do individuals seeking conservative care for hip or knee OA report higher scores than the general population of individuals seeking conservative care for musculoskeletal pain conditions? (2) What common psychological phenotypes exist among nonsurgical care-seeking individuals with hip or knee OA? Methods: The sample included participants from the Duke Joint Health Program (n = 1239), a comprehensive hip and knee OA care program, and the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort studies (n = 871) comprising individuals seeking conservative care for knee, shoulder, low back, or neck pain. At the initial evaluation, patients completed the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool, which assesses 11 general and pain-related psychological distress constructs (depression, anxiety, fear of movement, self-efficacy for managing one's own pain). We used OSPRO-YF scores to compare levels of psychological distress between the cohorts. Cohen's d effect sizes were calculated to determine the magnitude of differences between the groups, with d = 0.20, d = 0.50, and d = 0.80 indicating small, medium, and large effect sizes, respectively. We used a latent class analysis to derive psychological distress phenotypes in people with OA based on the 11 OSPRO-YF psychological distress indicators. Psychological distress phenotypes are characterized by specific mood, belief, and behavioral factors that differentiate subgroups within a population. Phenotyping can help providers develop scalable treatment pathways that are better tailored to the common needs of patients. Results: Patients with OA demonstrated higher levels of general and pain-related psychological distress across all psychological constructs except for trait anxiety (that is, anxiety level as a personal characteristic rather than as a response to a stressful situation, like surgery) with small-to-moderate effect sizes. Characteristics with the largest effect sizes in the OA and overall OSPRO cohort were (Cohen's d) general anxiety (-0.66, lower in the OA cohort), pain catastrophizing (the tendency to ruminate over, maginfiy, or feel helpless about a pain experience, 0.47), kinesiophobia (pain-related fear of movement, 0.46), pain self-efficacy (confidence in one's own ability to manage his or her pain, -0.46, lower in the OA cohort), and self-efficacy for rehabilitation (confidence in one's own ability to perform their rehabilitation treatments, -0.44, lower in the OA cohort). The latent class analysis yielded four phenotypes (% sample): high distress (52%, 647 of 1239), low distress (26%, 322 of 1239), low self-efficacy and acceptance (low confidence in managing and willingness to accept pain) (15%, 186 of 1239), and negative pain coping (exhibiting poor pain coping skills) (7%, 84 of 1239). The classification error rate was near zero (2%), and the median of posterior probabilities used to assign subgroup membership was 0.99 (interquartile range 0.98 to 1.00), both indicating excellent model performance. The high-distress group had the lowest mean age (61 ± 11 years) and highest levels of pain intensity (6 ± 2) and disability (HOOS JR: 50 ± 15; KOOS JR: 47 ± 15), whereas the low-distress group had the highest mean age (63 ± 10 years) and lowest levels of pain (4 ± 2) and disability (HOOS JR: 63 ± 15; KOOS JR: 60 ± 12). However, none of these differences met or exceeded anchor-based minimal clinically important difference thresholds. Conclusions: General and pain-related psychological distress are common among individuals seeking comprehensive care for hip or knee OA. Predominant existing OA care models that focus on biomedical interventions, such as corticosteroid injection or joint replacement that are designed to directly address underlying joint pathology and inflammation, may be inadequate to fully meet the care-related needs of many patients with OA due to their underlying psychological distress. We believe this because biomedical interventions do not often address psychological characteristics, which are known to influence OA-related pain and disability independent of joint pathology. Healthcare providers can develop new comprehensive hip and knee OA treatment pathways tailored to these phenotypes where services such as pain coping skills training, relaxation training, and psychological therapies are delivered to patients who exhibit phenotypes characterized by high distress or negative pain coping. Future studies should evaluate whether tailoring treatment to specific psychological phenotypes yields better clinical outcomes than nontailored treatments, or treatments that have a more biomedical focus. Level of evidence: Level III, diagnostic study.

Clinical orthopaedics and related research · 79 citationsread the source →

Effects of Poly-Victimization on Adolescent Social Support, Self-Concept, and Psychological Distress.

Past research has demonstrated the particularly damaging effects of exposure to multiple forms of victimization, or "poly-victimization," on youth mental health. The primary objective of the present study is to begin to identify the mechanisms that help explain its powerful impact. Analyses are based on two waves of longitudinal data from the National Survey of Children's Exposure to Violence (NatSCEV), conducted in 2008 and 2010, that comprised a telephone sample of 1,186 youth ages 10 to 17. Using structural equation modeling, we examine direct and indirect effects on distress symptoms of increased, decreased, and stable high poly-victimization between Waves 1 and 2 compared to no or low victimization in both waves. Specifically, we consider the extent to which reductions in core psychosocial resources, including family support, peer support, self-esteem, and mastery, mediate the relationship between these poly-victimization conditions and distress. Relative to stable low victimization, both increased poly-victimization and stable high poly-victimization were associated with declines in all four resources. However, only self-esteem and mastery significantly mediated the association between poly-victimization and distress, with mastery showing the strongest effect. Although significant indirect effects were evident, poly-victimization still had a strong direct effect on distress with resource factors controlled. Findings support the hypothesis that the potent effect of poly-victimization on youth mental health is, in part, due to its damaging influence on core psychosocial resources.

Journal of interpersonal violence · 119 citationsread the source →

Socioeconomic inequalities in the risk of SARS-CoV-2 infection - First results from an analysis of surveillance data from Germany.

Experiences with acute respiratory diseases which caused virus epidemics in the past and initial findings in the research literature on the current COVID-19 pandemic suggest a higher SARS-CoV-2 infection risk for socioeconomically disadvantaged populations. Nevertheless, further research on such a potential association between socioeconomic status and SARS-CoV-2 incidence in Germany is required. This article reports on the results of a first Germany-wide analysis of COVID-19 surveillance data to which an area-level index of socioeconomic deprivation was linked. The analysis included 186,839 laboratory-confirmed COVID-19 cases, the data of which was transferred to the Robert Koch Institute by 16 June 2020, 00:00. During the early stage of the epidemic up to mid-April, the data show a socioeconomic gradient with higher incidence in less deprived regions of Germany. Over the course of the epidemic, however, this gradient becomes less measurable and finally reverses in south Germany, the region hardest hit by the epidemic, to the greater detriment of the more deprived regions. These results highlight the need to continue monitoring social epidemiological patterns in COVID-19 and analysing the underlying causes to detect dynamics and trends early on and countering a potential exacerbation of health inequalities.

Journal of health monitoring · 35 citationsread the source →

Assessing child development scores among minority and Indigenous language versus dominant language speakers: a cross-sectional analysis of national Multiple Indicator Cluster Surveys.

Background: Multiple studies have highlighted the inequities minority and Indigenous children face when accessing health care. Health and wellbeing are positively impacted when Indigenous children are educated and receive care in their maternal language. However, less is known about the association between minority or Indigenous language use and child development risks and outcomes. In this study, we provide global estimates of development risks and assess the associations between minority or Indigenous language status and early child development using the ten-item Early Child Development Index (ECDI), a tool widely used for global population assessments in children aged 3-4 years. Methods: We did a secondary analysis of cross-sectional data from 65 UNICEF Multiple Indicator Cluster Surveys (MICS) containing the ECDI from 2009-19 (waves 4-6). We included individual-level data for children aged 2-4 years (23-60 months) from datasets with ECDI modules, for surveys that captured the language of the respondent, interview, or head of household. The Expanded Graded Intergenerational Disruption Scale was used to classify household languages as dominant versus minority or Indigenous at the country level. Our primary outcome was on-track overall development, defined per UNICEF's guidelines as development being on track for at least three of the four ECDI domains (literacy-numeracy, learning, physical, and socioemotional). We performed logistic regression of pooled, weighted ECDI scores, aggregated by language status and adjusting for the covariables of child sex, child nutritional status (stunting), household wealth, maternal education, developmental support by an adult caregiver, and country-level early child education proportion. Regression analyses were done for all children aged 3-4 years with ECDI results, and separately for children with functional disabilities and ECDI results. Findings: 65 MICS datasets were included. 186 393 children aged 3-4 years had ECDI and language data, corresponding to an estimated represented population of 34 714 992 individuals. Estimated prevalence of on-track overall development as measured by ECDI scores was 65·7% (95% CI 64·2-67·2) for children from a minority or Indigenous language-speaking household, and 76·6% (75·7-77·4) for those from a dominant language-speaking household. After adjustment, dominant language status was associated with increased odds of on-track overall development (adjusted OR 1·54, 95% CI 1·40-1·71), which appeared to be largely driven by significantly increased odds of on-track development in the literacy-numeracy and socioemotional domains. For the represented population aged 2-4 years (n=11 465 601), the estimated prevalence of family-reported functional disability was 3·6% (95% CI 3·0-4·4). For the represented population aged 3-4 years with a functional disability (n=292 691), language status was not associated with on-track overall development (adjusted OR 1·02, 95% CI 0·43-2·45). Interpretation: In a global dataset, children speaking a minority or Indigenous language were less likely to have on-track ECDI scores than those speaking a dominant language. Given the strong positive benefits of speaking an Indigenous language on the health and development of Indigenous children, this disparity is likely to reflect the sociolinguistic marginalisation faced by speakers of minority or Indigenous languages as well as differences in the performance of ECDI in these languages. Global efforts should consider performance of measures and monitor developmental data disaggregated by language status to stimulate efforts to address this disparity. Funding: None. Translations: For the Spanish, Kaqchikel and K'iche' translations of the abstract see Supplementary Materials section.

The Lancet. Global health · 2 citationsread the source →

Long-primed germinal centres with enduring affinity maturation and clonal migration.

Germinal centres are the engines of antibody evolution. Here, using human immunodeficiency virus (HIV) Env protein immunogen priming in rhesus monkeys followed by a long period without further immunization, we demonstrate germinal centre B (BGC) cells that last for at least 6 months. A 186-fold increase in BGC cells was present by week 10 compared with conventional immunization. Single-cell transcriptional profiling showed that both light- and dark-zone germinal centre states were sustained. Antibody somatic hypermutation of BGC cells continued to accumulate throughout the 29-week priming period, with evidence of selective pressure. Env-binding BGC cells were still 49-fold above baseline at 29 weeks, which suggests that they could remain active for even longer periods of time. High titres of HIV-neutralizing antibodies were generated after a single booster immunization. Fully glycosylated HIV trimer protein is a complex antigen, posing considerable immunodominance challenges for B cells1,2. Memory B cells generated under these long priming conditions had higher levels of antibody somatic hypermutation, and both memory B cells and antibodies were more likely to recognize non-immunodominant epitopes. Numerous BGC cell lineage phylogenies spanning more than the 6-month germinal centre period were identified, demonstrating continuous germinal centre activity and selection for at least 191 days with no further antigen exposure. A long-prime, slow-delivery (12 days) immunization approach holds promise for difficult vaccine targets and suggests that patience can have great value for tuning of germinal centres to maximize antibody responses.

Nature · 180 citationsread the source →

Effectiveness of app-based interventions for glucose management, cardiometabolic and mental health, and related risk factors: an umbrella review with meta-analysis.

Background: Non-communicable diseases are the leading cause of death globally. Smartphone apps can offer benefits for individuals, health-care professionals, and governments in the prevention and management of such conditions. We aimed to systematically evaluate the effectiveness of app-based interventions in improving the outcomes of non-communicable diseases and in modifying their metabolic and behavioural risk factors. Methods: For this umbrella review and meta-analysis, we searched eight databases (Embase, Epistemonikos, IEEE Xplore Digital Library, APA PsycInfo via Ovid, PubMed, Scopus, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials) for systematic reviews with meta-analysis published between Jan 1, 2013, and Jan 10, 2024, with no restrictions by geographical location or language. Additional studies were located through citation chaining and searching of reference lists. Eligible studies reviewed randomised controlled trials or controlled studies focused on adults (aged ≥18 years) with or at risk of non-communicable diseases and the use of app-based interventions for managing or improving the outcomes of these diseases and related health and risk factors, both metabolic and behavioural. Two investigators (EK and MFV) used COVIDENCE software to screen abstracts and full texts and to subsequently extract data from eligible studies. In case of missing data, authors of the relevant articles were contacted for unreported data or additional details. Effect sizes were measured as the standardised mean difference (SMD) and were aggregated through meta-analyses. 95% CIs for each review were synthesised using a random-effects model and prediction intervals were based on a t distribution. When more than ten reviews were available, publication bias was assessed visually through the inspection of funnel plots and by Egger's test; if bias was suspected, a trim-and-fill analysis was applied to estimate a revised effect size. The quality of the included reviews was evaluated with the AMSTAR 2 checklist, the certainty of evidence for each outcome was assessed using the GRADE framework and the Ioannidis criteria, and heterogeneity was measured by calculating I2 values. This study was registered with PROSPERO, CRD42023426735. Findings: Of 6951 unique records identified by our searches, 383 underwent full-text review and 78 systematic reviews with meta-analysis, covering 31 outcomes, were included in the study. These reviews covered 496 primary studies and involved a total of 177 373 participants. App-based interventions were found to be effective in lowering diastolic blood pressure (SMD -0·414 [95% CI -0·606 to -0·221], I2=93%), systolic blood pressure (-0·444 [-0·689 to -0·199], I2=96%), glycated haemoglobin (-0·587 [-0·715 to -0·460], I2=91%), fasting blood glucose concentration (-1·189 [-1·605 to -0·774], I2=93%), 2 h postprandial glucose concentration (-1·229 [-1·609 to -0·848], I2=95%), anxiety (-0·215 [-0·407 to -0·023], I2=92%), depression (-0·097 [-0·176 to -0·019], I2=77%), stress (-0·336 [-0·528 to -0·143], I2=87%), bodyweight (-0·427 [-0·594 to -0·260], I2=91%), BMI (-0·265 [-0·522 to -0·007], I2=92%), waist circumference (-0·310 [-0·464 to -0·156], I2=75%), and sedentary time (-0·600 [-1·121 to -0·079], I2=22%). Additionally, apps significantly improve diet quality (0·551 [0·261-0·842], I2=91%), exercise capacity (0·259 [0·119-0·398], I2=17%), moderate-to-vigorous physical activity (0·240 [0·025-0·456], I2=75%), number of steps taken daily (0·489 [0·209-0·770], I2=83%), multiple physical activity outcomes (0·466 [0·243-0·689], I2=90%), mindfulness (0·293 [0·177-0·409], I2=77%), wellbeing (0·186 [0·065-0·307], I2=74%), quality of life (0·227 [0·083-0·371], I2=80%), and medication adherence (0·688 [0·410-0·965], I2=88%) when compared with control groups. However, no significant effect was found on cardiovascular mortality; HDL, LDL, total cholesterol, or triglyceride concentrations; body fat; distress; fruit and vegetable intake; hospitalisation; or smoking abstinence. Of the 78 systematic reviews, only one (1%) was rated as being of high quality, with three (4%) of moderate quality, 17 (22%) of low quality, and 57 (73%) of critically low quality. According to Ioannidis criteria, five outcomes were categorised as having highly suggestive (class II) evidence, with eight outcomes having suggestive evidence (class III), eleven outcomes having weak evidence, and seven outcomes categorised as non-significant. Interpretation: Our analyses provide evidence that app-based interventions support significant improvements in multiple outcomes of and risk factors for non-communicable diseases, including cardiovascular diseases, glucose control, mental health outcomes, physical activity, and quality of life. The integration of app-based interventions into health-care systems should be prioritised to enhance patient care and health outcomes. Funding: None.

The Lancet. Digital healthread the source →

Association of tiered restrictions and a second lockdown with COVID-19 deaths and hospital admissions in England: a modelling study.

Background: A second wave of COVID-19 cases in autumn, 2020, in England led to localised, tiered restrictions (so-called alert levels) and, subsequently, a second national lockdown. We examined the impact of these tiered restrictions, and alternatives for lockdown stringency, timing, and duration, on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission and hospital admissions and deaths from COVID-19. Methods: We fit an age-structured mathematical model of SARS-CoV-2 transmission to data on hospital admissions and hospital bed occupancy (ISARIC4C/COVID-19 Clinical Information Network, National Health Service [NHS] England), seroprevalence (Office for National Statistics, UK Biobank, REACT-2 study), virology (REACT-1 study), and deaths (Public Health England) across the seven NHS England regions from March 1, to Oct 13, 2020. We analysed mobility (Google Community Mobility) and social contact (CoMix study) data to estimate the effect of tiered restrictions implemented in England, and of lockdowns implemented in Northern Ireland and Wales, in October, 2020, and projected epidemiological scenarios for England up to March 31, 2021. Findings: We estimated a reduction in the effective reproduction number (Rt) of 2% (95% credible interval [CrI] 0-4) for tier 2, 10% (6-14) for tier 3, 35% (30-41) for a Northern Ireland-stringency lockdown with schools closed, and 44% (37-49) for a Wales-stringency lockdown with schools closed. From Oct 1, 2020, to March 31, 2021, a projected COVID-19 epidemic without tiered restrictions or lockdown results in 280 000 (95% projection interval 274 000-287 000) hospital admissions and 58 500 (55 800-61 100) deaths. Tiered restrictions would reduce hospital admissions to 238 000 (231 000-245 000) and deaths to 48 600 (46 400-50 700). From Nov 5, 2020, a 4-week Wales-type lockdown with schools remaining open-similar to the lockdown measures announced in England in November, 2020-was projected to further reduce hospital admissions to 186 000 (179 000-193 000) and deaths to 36 800 (34 900-38 800). Closing schools was projected to further reduce hospital admissions to 157 000 (152 000-163 000) and deaths to 30 300 (29 000-31 900). A projected lockdown of greater than 4 weeks would reduce deaths but would bring diminishing returns in reducing peak pressure on hospital services. An earlier lockdown would have reduced deaths and hospitalisations in the short term, but would lead to a faster resurgence in cases after January, 2021. In a post-hoc analysis, we estimated that the second lockdown in England (Nov 5-Dec 2) reduced Rt by 22% (95% CrI 15-29), rather than the 32% (25-39) reduction estimated for a Wales-stringency lockdown with schools open. Interpretation: Lockdown measures outperform less stringent restrictions in reducing cumulative deaths. We projected that the lockdown policy announced to commence in England on Nov 5, with a similar stringency to the lockdown adopted in Wales, would reduce pressure on the health service and would be well timed to suppress deaths over the winter period, while allowing schools to remain open. Following completion of the analysis, we analysed new data from November, 2020, and found that despite similarities in policy, the second lockdown in England had a smaller impact on behaviour than did the second lockdown in Wales, resulting in more deaths and hospitalisations than we originally projected when focusing on a Wales-stringency scenario for the lockdown. Funding: Horizon 2020, UK Medical Research Council, and the National Institute for Health Research.

The Lancet. Infectious diseases · 109 citationsread the source →

Racial, Ethnic, and Sex Diversity in Academic Medical Leadership.

Importance: For the past 50 years, significant gaps have existed in gender and racial diversity across various medical specialties, despite the many benefits of a diverse physician workforce. One proposed approach to increasing diversity is top-down diversification, in which diverse leadership results in increased minority and female workforce representation. Objective: To investigate the changes in academic medical leadership diversity from 2007 to 2019 and to assess the recent leadership diversity of various specialties compared with the averages across all specialties. Design, setting, and participants: This was a cross-sectional analysis of physicians in varying academic roles in 2007, 2019, and 2020. Demographic data were collected via specialized reports from the Association of American Medical Colleges. Included were 4 primary care specialties (internal medicine, family medicine, pediatrics, obstetrics/gynecology [OB/GYN] and 4 surgical specialties (orthopedic surgery, neurologic surgery, otolaryngology [ENT], general surgery). Study participants were faculty, program directors, and chairpersons. Data were analyzed for the years 2007, 2019, and 2020. Intervention: Self-reporting of demographic information to residency programs collected via the Graduate Medical Education Track Survey. Main outcomes and measures: Proportions of each race/ethnicity and sex among cohorts of participants and comparisons between them. Results: The total number of individuals investigated included 186 210 faculty from 2019 (79 441 female [42.7%]), 6417 program directors from 2020 (2392 female [37.3%]), 1016 chairpersons from 2007 (89 female [8.8%]), and 2424 chairpersons from 2019 (435 female [17.9%]). When comparing chairperson diversity from 2007 to 2019, only internal medicine and general surgery experienced significant increases in minority (aggregate category used throughout the investigation to refer to anyone who self-identified as anything other than non-Hispanic White) representation (90% increase [11.7 percentage points, from 13.0% in 2007 to 24.7% in 2019]; P = .01 and 96% increase [13.0 percentage points, from 13.5% in 2007 to 26.5% in 2019]; P < .001), respectively; meanwhile, several specialties saw significant increases in female representation during this period (family medicine by 107.4%, P =.002; pediatrics by 83.1%, P =.006; OB/GYN by 53.2%, P =.045; orthopedic surgery by +4.1 percentage points, P =.04; general surgery by 226.9%, P =.005). In general, surgical specialties had lower leadership diversity than the average diversity of all residency programs, whereas primary care specialties had similar or increased diversity. Conclusions and relevance: Study results suggest that some specialties have made significant contributions toward bridging diversity gaps whereas others continue to lag behind. Our recommendations to improve academic medical leadership diversity include programs and institutions (1) publishing efforts and outcomes of diversity representation, (2) incorporating a representative demographic for leadership selection committees, and (3) actively promoting the importance of diversity throughout the selection process.

JAMA network open · 27 citationsread the source →

Predictors of diaphragm use as a potential sexually transmitted disease/HIV prevention method in Zimbabwe.

Background: Women who are the most vulnerable to sexually transmitted diseases/HIV are often unable to consistently use condoms. One potential alternative method currently under investigation is the diaphragm. Goals: The goals of this study were to assess diaphragm uptake and use over time in Zimbabwe and to identify factors associated with self-reported consistent diaphragm use. Study: Women attending family planning clinics who were inconsistent condom users received a diaphragm intervention and were followed for 6 months. Results: Of the 186 participants, 99% ever reported using the diaphragm, and, at study exit, 96% had used it in the previous 2 months. Consistent diaphragm use since the previous visit was reported by 13% to 16% of the women, and in multivariate regression analysis, it was significantly associated with never using condoms (adjusted odds ratio, 24.08; 95% confidence interval, 6.71-86.34). Other factors included discreet use, preferring diaphragms to condoms, timing of insertion, domestic violence, and contraception. Conclusion: Diaphragms were well accepted among women at risk for sexually transmitted diseases/HIV.

Sexually transmitted diseases · 34 citationsread the source →

Death Anxiety in the Elderly: The Role of Spiritual Health and Perceived Social Support

Aging as one of the most important periods of life is associated with many challenges including death anxiety. Therefore, the aim of the current study was to investigate the role of spiritual health and perceived social support in predicting death anxiety in the elderly. The present study was a descriptive-correlational one. The study population consisted of the elderly living in Shahrekord in 2020, among whom 385 were selected using convenience sampling method and were assessed by the scales of Templer Death Anxiety, Zemen Perceived Social Support and Paloutzian & Ellison spiritual health. Data were analyzed using correlation coefficient and linear regression analysis in SPSS software version 22. The results indicated that there is a significant relationship between spiritual health (r=-0.51), perceived social support by family (r=-0.37), friends (r=-0.30) and significant other (r=-0.16) with death anxiety in the elderly. 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