Quality of systematic reviews: an example of studies comparing artificial disc replacement with fusion in the cervical spine.

Cervical artificial disc replacement (C-ADR) is now an alternative to anterior cervical discectomy and fusion (ACDF). Many studies have evaluated the efficacy of C-ADR compared with ACDF. This led to a series of systematic reviews and meta-analyses to evaluate the evidence of the superiority of one intervention against the other. The aim of the study presented here was to evaluate the quality of these reviews and meta-analyses. Medline via Ovid, Embase, and Cochrane Library were searched using the keywords: (total disk replacement, prosthesis, implantation, discectomy, and arthroplasty) AND (cervical vertebrae, cervical spine, and spine) AND (systematic reviews, reviews, and meta-analysis). Screening and data extraction were conducted by two reviewers independently. Two reviewers then assessed the quality of the selected reviews and meta-analysis using 11-item AMSTAR score which is a validated measurement tool to assess the methodological quality of systematic reviews. Screening of full reports of 46 relevant abstracts resulted in the selection of 15 systematic reviews and/or meta-analyses as eligible for this study. The two reviewers' inter-rater agreement level was high as indicated by kappa of >0.72. The AMSTAR score of the reviews ranged from 3 to 11. Only one study (a Cochrane review) scored 100% (AMSTAR 11). Five studies scored below (AMSTAR 5) indicating low-quality reviews. The most significant drawbacks of reviews of a score below 5 were not using an extensive search strategy, failure to use the scientific quality of the included studies appropriately in formulating a conclusion, not assessing publication bias, and not reporting the excluded studies. With a significant exception of a Cochrane review, the methodological quality of systematic reviews evaluating the evidence of C-ADR versus ACDF has to be improved

Variation and ethnic inequalities in treatment of common mental disorders before, during and after pregnancy : combined analysis of routine and research data in the Born in Bradford cohort

BACKGROUND: Common mental disorders (CMD) such as anxiety and depression during the maternal period can cause significant morbidity to the mother in addition to disrupting biological, attachment and parenting processes that affect child development. Pharmacological treatment is a first-line option for moderate to severe episodes. Many women prescribed pharmacological treatments cease them during pregnancy but it is unclear to what extent non-pharmacological options are offered as replacement. There are also concerns that treatments offered may not be proportionate to need in minority ethnic groups, but few data exist on treatment disparities in the maternal period. We examined these questions in a multi-ethnic cohort of women with CMD living in Bradford, England before, during and up to one year after pregnancy. METHODS: We searched the primary care records of women enrolled in the Born in Bradford cohort for diagnoses, symptoms, signs ('identification'), referrals for treatment, non-pharmacological and pharmacological treatment and monitoring ('treatment') related to CMD. Records were linked with maternity data to classify women identified with a CMD as treated prior to, and one year after, delivery. We examined rates and types of treatment during pregnancy, and analysed potential ethnic group differences using adjusted Poisson and multinomial logistic regression models. RESULTS: We analysed data on 2,234 women with indicators of CMD. Most women were discontinued from pharmacological treatment early in pregnancy, but this was accompanied by recorded access to non-drug treatments in only 15 % at the time of delivery. Fewer minority ethnic women accessed treatments compared to White British women despite minority ethnic women being 55-70 % more likely than White British women to have been identified with anxiety in their medical record. CONCLUSIONS: Very few women who discontinued pharmacological treatment early in their pregnancy were offered other non-pharmacological treatments as replacement, and most appeared to complete their pregnancy untreated. Further investigation is warranted to replicate the finding that minority ethnic women are more likely to be identified as being anxious or having anxiety and understand what causes the variation in access to treatments

Recognition of Depression in Older Medical Inpatients

BACKGROUND: Studies of recognition of depression in older (aged 65 or more) medical inpatients show low rates of recognition of depression by attending physicians. However, few studies have compared different measures of recognition of depression. OBJECTIVES: (1) To compare the validity of four indicators of recognition of depression and a global measure of recognition against a diagnosis of depression and (2) to explore the effect of patient characteristics on recognition of depression. METHODS: In a cohort of 264 medical inpatients 65 years and older (115 with major or minor depression, 78 with no depression), sensitivities, specificities, and diagnostic odds ratios (DOR) of 4 indicators of recognition (symptoms, diagnosis, treatment, and referral) and a global measure of recognition (any of the 4 indicators) were calculated. The associations between patient characteristics (age, sex, history of depression, antidepressant use before admission, severity of depression, comorbidity, duration of hospitalization, disability, and hospital of admission) and recognition were explored using multiple logistic regression. RESULTS: Less than half of the depressed patients were recognized. The indicator with the highest sensitivity was treatment (27.8%, 95% confidence interval [CI] 20.0–37.0), whereas the indicator with the best specificity was diagnosis (96.6%, 95% CI 91.9–98.7). The unadjusted DOR of global recognition was 2.6 (95% CI 1.5, 4.4). Less comorbidity, more severe depression symptoms, a history of depression, longer hospital stay, and antidepressant use before admission were significantly associated with better global recognition. CONCLUSION: Recognition of depression in elderly medical inpatients depends upon the indicator of recognition used

Exploring the impact of carer stressors and psychological inflexibility on depression and anxiety in family carers of people with dementia

This study aimed to explore the impact of carer stressors (neuropsychiatric symptoms of dementia, level of independence in activities of daily living, hours of caring per week), demographic factors (carer age, relationship with the person with dementia, dementia type, dementia severity, number of years since diagnosis and cohabitation status) and psychological inflexibility on depression and anxiety in family carers of people with dementia. Eighty-nine family carers with a mean age of 69.13 years old completed self-reported and interview-based questionnaires. Participants were primarily female family members aged 65 years or older looking after a person with severe Alzheimer's disease. Two final regression models (Depression model R2 = 0.43; Anxiety model R2 = 0.43) demonstrated that psychological inflexibility (β = 0.52) and the number of hours devoted to caregiving (β = 0.23) had a significant impact on carer depression, while psychological inflexibility was the only significant independent predictor of carer anxiety (β = 0.55). The findings demonstrated psychological inflexibility to be a common factor explaining mental health problems in this population even after controlling for other variables known to have an impact. Acceptance and Commitment Therapy (ACT) may be beneficial for concomitantly treating depression and anxiety in this population. Considering that fifty-two per cent of participants responded that they devote more than 41 h to caregiving per week, a non-traditional face to face approach such as online ACT may have potential in future research. Future studies should also explore the suggested models in understudied subgroups of carers (e.g., carers of early-onset dementia, carers of people with early-stage dementia)

Transitions of People with Dementia in the Continuing Care System

Aging of the population raises a number of challenges to health care and continuing care systems around the world. One of them is ensuring that seniors with disabilities receive the best care at home and in the continuing care system, in order to avoid unnecessary transitions. Dementia is one of the major sources of disability in seniors and the literature exploring the transitions of people with dementia in the continuing care system is growing. Nevertheless, there are still important gaps in the literature pertaining to specific factors that govern these transitions, especially those related to informal caregivers. Moreover, the complexity of the continuing care system makes it difficult to meaningfully incorporate research data on transitions into policies meant to improve the outcomes of people with dementia. The work reported in this dissertation focuses on addressing these gaps and applying system thinking to policy making in continuing care. The systematic review and meta-analysis provided pooled estimates of known and less well-known risk factors for long-term care (LTC) placement in people with dementia. Also, our review highlighted the scarcity of data on resident and caregiver related factors that may delay the LTC placement in people with dementia living in supporting living (SL) settings. This gap in the literature was addressed in the second study, which found that low strength of social relationships, among other factors, significantly increases the risk of LTC placement (HR=1.57, 95% CI: 1.02 – 2.43). Also, the number of activities performed by the informal caregivers modified the effect of residents’ level of ADL impairment on the risk of LTC placement. Specifically, among residents with severe ADL impairment, those with caregivers that performed 5 to 7 activities had a significantly lower risk of LTC placement, compared to those with caregivers that performed 4 or fewer activities (p=0.017). These research findings, along with data extracted from various reports and information obtained from continuing care stakeholders, were used to build a system dynamics (SD) model that describes the Alberta Continuing Care System (ACCS). This computer simulation model was used to explore policy options in the ACCS, illustrating the applicability of system thinking to developing and testing policies in continuing care. In the particular case of modifying benchmarks for staff/resident ratios in the continuing care system, increasing the availability of trained staff in SL might help decrease costs in the system by reducing the rapid transitions of people with dementia from SL to LTC, and consequently, reducing the pressure for adding LTC beds in the system. A better understanding of the transitions of people with dementia in the continuing care system, provided by this research, may help researchers to develop and test interventions aimed at improving the outcomes of people with dementia in the continuing care system and allowing them to age in place. Moreover, it lays the foundation for future work in planning, developing and evaluating various components of continuing care using system thinking

Transitions in care of people with dementia

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