J Thompson Coon

Does Participating in Physical Activity in Outdoor Natural Environments Have a Greater Effect on Physical and Mental Wellbeing than Physical Activity Indoors? A Systematic Review

Our objective was to compare the effects on mental and physical wellbeing, health related quality of life and long-term adherence to physical activity, of participation in physical activity in natural environments compared with physical activity indoors. We conducted a systematic review using the following data sources: Medline, Embase, Psychinfo, GreenFILE, SportDISCUS, The Cochrane Library, Science Citation Index Expanded, Social Sciences Citation Index, Arts and Humanities Citation Index, Conference Proceedings Citation Index--Science and BIOSIS from inception to June 2010. Internet searches of relevant Web sites, hand searches of relevant journals, and the reference lists of included papers and other review papers identified in the search were also searched for relevant information. Controlled trials (randomized and nonrandomized) were included. To be eligible trials had to compare the effects of outdoor exercise initiatives with those conducted indoors and report on at least one physical or mental wellbeing outcome in adults or children. Screening of articles for inclusion, data extraction, and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Due to the heterogeneity of identified studies a narrative synthesis was performed. Eleven trials (833 adults) were included. Most participants (6 trials; 523 adults) were young students. Study entry criteria and methods were sparsely reported. All interventions consisted of a single episode of walking or running indoors with the same activity at a similar level conducted outdoors on a separate occasion. A total of 13 different outcome measures were used to evaluate the effects of exercise on mental wellbeing, and 4 outcome measures were used to assess attitude to exercise. Most trials (n = 9) showed some improvement in mental wellbeing on one or other of the outcome measures. Compared with exercising indoors, exercising in natural environments was associated with greater feelings of revitalization and positive engagement, decreases in tension, confusion, anger, and depression, and increased energy. However, the results suggested that feelings of calmness may be decreased following outdoor exercise. Participants reported greater enjoyment and satisfaction with outdoor activity and declared a greater intent to repeat the activity at a later date. None of the identified studies measured the effects of physical activity on physical wellbeing or the effect of natural environments on exercise adherence. The hypothesis that there are added beneficial effects to be gained from performing physical activity outdoors in natural environments is very appealing and has generated considerable interest. This review has shown some promising effects on self-reported mental wellbeing immediately following exercise in nature which are not seen following the same exercise indoors. However, the interpretation and extrapolation of these findings is hampered by the poor methodological quality of the available evidence and the heterogeneity of outcome measures employed. The review demonstrates the paucity of high quality evidence on which to base recommendations and reveals an undoubted need for further research in this area. Large, well designed, longer term trials in populations who might benefit most from the potential advantages of outdoor exercise are needed to fully elucidate the effects on mental and physical wellbeing. The influence of these effects on the sustainability of physical activity initiatives also awaits investigation.

Heavy metals in traditional chinese medicines: A systematic review

Clinical Pharmacology & Therapeutics (2001) 70, 497–504; doi: 10.1016/S0009‐9236(01)79918‐3

Systematic review: herbal medicinal products for non-ulcer dyspepsia.

Background : Non‐ulcer dyspepsia is predominantly a self‐managed condition, although it accounts for a significant number of general practitioner consultations and hospital referrals. Herbal medicinal products are often used for the relief of dyspeptic symptoms.

Dasatinib and Nilotinib for Imatinib-Resistant or -Intolerant Chronic Myeloid Leukaemia: A Systematic Review and Economic Evaluation

BACKGROUND Chronic myeloid leukaemia (CML) is a form of cancer affecting the blood, characterised by excessive proliferation of white blood cells in the bone marrow and circulating blood. In the UK, an estimated 560 new cases of CML are diagnosed each year. OBJECTIVES The purpose of this study was to assess the clinical effectiveness and cost-effectiveness of dasatinib and nilotinib in the treatment of people with imatinib-resistant (ImR) and imatinib-intolerant (ImI) CML. A systematic review of the clinical effectiveness literature, a review of manufacturer submissions and a critique and exploration of manufacturer submissions for accelerated phase and blast crisis CML were carried out and a decision-analytic model was developed to estimate the cost-effectiveness of dasatinib and nilotinib in chronic phase CML. SYSTEMATIC REVIEW METHODS: Key databases were searched for relevant studies from their inception to June 2009 [MEDLINE (including MEDLINE In-Process & Other Non-Indexed Citations), EMBASE, (ISI Web of Science) Conference Proceedings Citation Index and four others]. One reviewer assessed titles and abstracts of studies identified by the search strategy, with a sample checked by a second reviewer. The full text of relevant papers was obtained and screened against the full inclusion criteria independently by two reviewers. Data from included studies were extracted by one reviewer and checked by a second. Clinical effectiveness studies were synthesised through narrative review. ECONOMIC EVALUATION METHODS: Cost-effectiveness analyses reported in manufacturer submissions to the National Institute of Health and Clinical Excellence were critically appraised and summarised narratively. In addition, the models for accelerated phase and blast crisis underwent a more detailed critique and exploration. Two separate decision-analytic models were developed for chronic phase CML, one simulating a cohort of individuals who have shown or developed resistance to normal dose imatinib and one representing individuals who have been unable to continue imatinib treatment owing to adverse events. One-way, multiway and probabilistic sensitivity analyses were performed to explore structural and parameter uncertainty. RESULTS Fifteen studies were included in the systematic review. Chronic phase: effectiveness data were limited but dasatinib and nilotinib appeared efficacious in terms of obtaining cytogenetic response and haematological response in both ImR and ImI populations. In terms of cost-effectiveness, it was extremely difficult to reach any conclusions regarding either agent in the ImR population. All three models (Novartis, PenTAG and Bristol-Myers Squibb) were seriously flawed in one way or another, as a consequence of the paucity of data appropriate to construct robust decision-analytic models. Accelerated and blast crisis: all available data originated from observational single-arm studies and there were considerable and potentially important differences in baseline characteristics which seriously undermined any process for making meaningful comparisons between treatments. Owing to a lack of available clinical data, de novo models of accelerated phase and blast crisis have not been developed. The economic evaluations carried out by the manufacturers of nilotinib and dasatinib were seriously undermined by the absence of evidence on high-dose imatinib in these populations. LIMITATIONS The study has been necessarily constrained by the paucity of available clinical data, the differences in definitions used in the studies and the subsequent impossibility of undertaking a meaningful cost-effectiveness analyses to inform all policy questions. CONCLUSIONS Dasatinib and nilotinib appeared efficacious in terms of obtaining cytogenetic and haematological responses in both ImR and ImI populations. It was difficult to reach any cost-effectiveness conclusions as a consequence of the paucity of the data. Future research should include a three-way, double-blind, randomised clinical trial of dasatinib, nilotinib and high-dose imatinib.

Surveillance of cirrhosis for hepatocellular carcinoma: a cost–utility analysis

Using a decision-analytic model, we evaluated the effectiveness and cost-effectiveness of surveillance for hepatocellular carcinoma (HCC) in individuals with cirrhosis. Separate cohorts with cirrhosis due to alcoholic liver disease, hepatitis B and hepatitis C were simulated. Results were also combined to approximate a mixed aetiology population. Comparisons were made between a variety of surveillance algorithms using α-foetoprotein (AFP) assay and/or ultrasound at 6- and 12-monthly intervals. Parameter estimates were obtained from comprehensive literature reviews. Uncertainty was explored using one-way and probabilistic sensitivity analyses. In the mixed aetiology cohort, 6-monthly AFP+ultrasound was predicted to be the most effective strategy. The model estimates that, compared with no surveillance, this strategy may triple the number of people with operable tumours at diagnosis and almost halve the number of people who die from HCC. The cheapest strategy employed triage with annual AFP (incremental cost-effectiveness ratio (ICER): £20 700 per quality-adjusted life-year (QALY) gained). At a willingness-to-pay threshold of £30 000 per QALY the most cost-effective strategy used triage with 6-monthly AFP (ICER: £27 600 per QALY gained). The addition of ultrasound to this strategy increased the ICER to £60 100 per QALY gained. Surveillance appears most cost-effective in individuals with hepatitis B-related cirrhosis, potentially due to younger age at diagnosis of cirrhosis. Our results suggest that, in a UK NHS context, surveillance of individuals with cirrhosis for HCC should be considered effective and cost-effective. The economic efficiency of different surveillance strategies is predicted to vary markedly according to cirrhosis aetiology.

Sunitinib and bevacizumab for first-line treatment of metastatic renal cell carcinoma: a systematic review and indirect comparison of clinical effectiveness

Background:Two new agents have recently been licensed for use in the treatment of metastatic renal cell carcinoma (RCC) in Europe. This paper aims to systematically review the evidence from all available randomised clinical trials of sunitinib and bevacizumab (in combination with interferon-α (IFN-α)) in the treatment of advanced metastatic RCC.Methods:Systematic literature searches were performed in six electronic databases. Bibliographies of included studies were searched for further relevant studies. Individual conference proceedings were searched using their online interfaces. Studies were selected according to the predefined criteria. All randomised clinical trials of sunitinib or bevacizumab in combination with IFN for treating advanced metastatic RCC in accordance with the European licensed indication were included. Study selection, data extraction, validation and quality assessment were performed by two reviewers with disagreements being settled by discussion. The effects of sunitinib and bevacizumab (in combination with IFN-α) on progression-free survival were compared indirectly using Bayesian Markov Chain Monte-Carlo (MCMC) sampling in Win BUGS, with IFN as a common comparator.Results:Three studies were included. Median progression-free survival was significantly prolonged with both interventions (from approximately 5 months to between 8 and 11 months) compared with IFN. Overall survival was also prolonged, compared with IFN, although the published data are not fully mature. Indirect comparison suggests that sunitinib is superior to bevacizumab plus IFN in terms of progression-free survival (hazard ratios 0.796; 95% CI 0.63–1.0; P=0.0272).Conclusion:There is evidence to suggest that treatment with sunitinib and treatment with bevacizumab plus IFN has clinically relevant and statistically significant advantages over treatment with IFN alone in patients with metastatic RCC.

Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review

Objective To compare the effects on mental and physical wellbeing, health related quality of life and long term adherence to physical activity, of participation in physical activity in natural environments compared with physical activity indoors. Design Systematic review. Data sources Medline, Embase, Psychinfo, GreenFILE, SportDISCUS, The Cochrane Library, Science Citation Index Expanded, Social Sciences Citation Index, Arts and Humanities Citation Index, Conference Proceedings Citation Index – Science and BIOSIS from inception to June 2010. Internet searches of relevant websites, hand searches of relevant journals and the reference lists of included papers and other review papers identified in the search. Methods Controlled trials (randomised and non-randomised) were included. Eligible trials compared the effects of outdoor exercise initiatives with those conducted indoors and reported on at least one physical or mental wellbeing outcome in adults or children. Screening of articles for inclusion, data extraction and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Heterogeneity of outcome measures precluded formal meta-analysis. Results Eleven trials (833 adults) were included. Most participants (6 trials; 523 adults) were young students. Study entry criteria and methods were sparsely reported. All interventions consisted of a single episode of walking or running indoors with the same activity at a similar level conducted outdoors on a separate occasion. A total of 13 different outcome measures were used to evaluate the effects of exercise on mental wellbeing and four outcome measures were used to assess attitude to exercise. Most trials (n=9) showed some improvement in mental wellbeing on one or other of the outcome measures. Compared with exercising indoors, exercising in natural environments was associated with greater feelings of revitalisation and positive engagement, decreases in tension, confusion, anger and depression and increased energy. Participants reported greater enjoyment and satisfaction with outdoor activity and declared a greater intent to repeat the activity at a later date. None of the identified studies measured the effects of physical activity on physical wellbeing, or the effect of natural environments on exercise adherence. Conclusions The results show some promising effects on self-reported mental wellbeing immediately following exercise in nature which are not seen following the same exercise indoors. However, the interpretation and extrapolation of these finding is hampered by the poor methodological quality of the available evidence and the heterogeneity of outcome measures employed. The influence of these effects on the sustainability of physical activity initiatives also awaits investigation.

OP68 Implementing and disseminating best practice in the care home setting: A systematic scoping review

Background Research continues to increase our knowledge of what can be done to improve the care of those resident in care homes but there is a persistent gap between this knowledge and the care that people actually receive. The aims of this scoping review are, first, to examine the extent, range, and nature of research on different ways of disseminating and implementing research findings in terms of (a) the effectiveness of approaches and (b) the identification of factors that may help or hinder successful adoption and, second, to identify and map gaps in the existing literature. Methods Fifteen electronic databases were searched from inception to July 2015. Backward and forward citation searching was conducted and websites of relevant organisations were searched to identify unpublished material. Quantitative and qualitative studies addressing dissemination or implementation within the residential care setting were included with no restriction on study design, date, or language of publication. Titles, abstracts, and full texts were screened independently by two reviewers. Data extraction (topic, study design, size and type of setting, type of dissemination or implementation strategy used, types of outcome reported) was performed by one reviewer using a piloted, bespoke data extraction form and checked by a second. Discrepancies at all stages were resolved by discussion with arbitration by a third reviewer where necessary. Data were tabulated and synthesised descriptively using the EPOC taxonomy to classify the type (professional, organisational, financial or regulatory) of strategies used, and the approach taken. Protocol registration: CRD42015025094 Results Of the 5374 citations screened, 4811 and 303 were excluded on the basis of title and abstract and full-text respectively; 260 met the inclusion criteria. Less than 10% of papers focussed on the dissemination of knowledge; the remainder describe implementation in areas of care including falls prevention, pressure ulcers, pain, dementia, incontinence, nutrition, and vaccination uptake. Eighty percent of papers were published in the last ten years and approximately 50% report factors that may help or hinder the dissemination and implementation of best practice in this setting derived predominantly from qualitative interviews and focus groups. Further analysis of the types of implementation strategy used and the mapping of gaps in the evidence is underway. Conclusion The review describes the range of dissemination and implementation strategies that have been utilised in care homes and highlights important gaps in the evidence. The findings will inform the focus of future dissemination and implementation research.

PP24 Interventions to Reduce Inappropriate Prescribing of Antipsychotic Medications to People with Dementia Living in Residential Care: A Systematic Review

Background The use of antipsychotic medications in dementia is associated with increased mortality. A significant proportion of long-term antipsychotic use is believed to be inappropriate. The Department of Health National Dementia Strategy recently targeted a two-thirds reduction in antipsychotic usage. The aim of this review is to explore qualitative and quantitative literature to identify interventions that have been used to reduce inappropriate prescribing of antipsychotics and the barriers and enablers to the implementation of these interventions. Methods Potentially relevant papers were identified in the following ways i) electronic searches inMedline, PsycINFO, Embase, AMED, Social Policy and Practice including AgeInfo (OvidSp); CDSR, CENTRAL (Cochrane Library); CINAHL (EBSCOhost); British Nursing Index, AMED (NHS Evidence) and Science Citation Index and Social Science Citation Index (Web of Science) from inception to November 2012, ii) forward and backward citation chases, iii) hand searches of review papers identified in the search, iii) searching of relevant organisations’ websites. All comparative studies were included. Screening of articles for inclusion, data extraction and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Results Eleven studies (involving staff and patients in 55 care homes) met the inclusion criteria. All reported quantitative data. Studies were conducted in the UK (n = 4), Canada (n = 2), USA (n = 2) Australia (n = 1) and Norway (n = 1). Studies were of varied design with associated quality issues. No papers in which barriers to the implementation of interventions had been studied were identified. All interventions were unique and involved the delivery of an education or training package (n = 5), the use of in-reach teams in which regular visits by psychiatrists, mental health nurses and psychologists enabled regular patient review in the care home (n = 4), audit followed by feedback and re-audit (n = 1) or regular review, education and the development of a behavioural management approach (n = 1). In all studies, the proportion of residents receiving antipsychotic medication was reduced following the intervention. Conclusion There is some evidence to suggest that simple changes to the way patients are reviewed and monitored and/or enhanced education and training can reduce the prescription rates of antipsychotics for people with dementia living in residential care. In order to guide best practice in this area, further qualitative study is required to explore the barriers and enablers to successful implementation of these interventions. Large rigorous studies with extended post-intervention data collection are also necessary to ascertain the long term impact on prescribing practices.