Mona Kanaan

Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies

Background The influence of social relationships on morbidity is widely accepted, but the size of the risk to cardiovascular health is unclear. Objective We undertook a systematic review and meta-analysis to investigate the association between loneliness or social isolation and incident coronary heart disease (CHD) and stroke. Methods Sixteen electronic databases were systematically searched for longitudinal studies set in high-income countries and published up until May 2015. Two independent reviewers screened studies for inclusion and extracted data. We assessed quality using a component approach and pooled data for analysis using random effects models. Results Of the 35 925 records retrieved, 23 papers met inclusion criteria for the narrative review. They reported data from 16 longitudinal datasets, for a total of 4628 CHD and 3002 stroke events recorded over follow-up periods ranging from 3 to 21 years. Reports of 11 CHD studies and 8 stroke studies provided data suitable for meta-analysis. Poor social relationships were associated with a 29% increase in risk of incident CHD (pooled relative risk: 1.29, 95% CI 1.04 to 1.59) and a 32% increase in risk of stroke (pooled relative risk: 1.32, 95% CI 1.04 to 1.68). Subgroup analyses did not identify any differences by gender. Conclusions Our findings suggest that deficiencies in social relationships are associated with an increased risk of developing CHD and stroke. Future studies are needed to investigate whether interventions targeting loneliness and social isolation can help to prevent two of the leading causes of death and disability in high-income countries. Study registration number CRD42014010225.

Acupuncture in practice: mapping the providers, the patients and the settings in a national cross-sectional survey

Background There is relatively limited knowledge about the practitioners who provide acupuncture treatment within the UK, what conditions patients consult for and the treatment provided. Objectives To characterise the conditions treated and by whom, to examine characteristics of the treatment and to explore trends over time. Method A cross-sectional survey of the UK acupuncture practitioners was conducted; 800 practitioners were selected by computer-generated randomisation sequences from the four major UK-based professional associations. Data collected on the practitioners included demographic details, association membership, statutorily regulated status, practice setting, style of acupuncture, diagnostic methods and needle response sought. Practitioners recorded details of their 10 most recent patients, including demographic details, primary reason for consulting and lifestyle advice provided. Results 330 practitioners responded comprising doctors (29%) physiotherapists (29%), nurses (15%) and independent acupuncturists (27%): 62% were women with median age of 48 years. The majority (68%) practiced in independent settings and 42% practiced within the National Health Service. Patients most commonly consulted for low back, neck, shoulder and knee pain, as well as headaches and migraine. Treatment for infertility by independent acupuncturists was found to have increased fivefold in 10 years. Conclusion Acupuncture provides a substantial contribution to the healthcare of the UK, with an estimated 4 million sessions provided annually. The primary complaints for which patients consult reflect the growing evidence base on acupuncture for these conditions. These data provide a basis for decision-making regarding policy and practice.

Action to stop smoking in suspected tuberculosis (ASSIST) in Pakistan: a cluster randomized, controlled trial.

BACKGROUND Tobacco use is responsible for a large proportion of the total disease burden from tuberculosis. Pakistan is one of the 10 high-burden countries for both tuberculosis and tobacco use. OBJECTIVE To assess the effectiveness of a behavioral support intervention and bupropion in achieving 6-month continuous abstinence in adult smokers with suspected pulmonary tuberculosis. DESIGN Cluster randomized, controlled trial. (Current Controlled Trials: ISRCTN08829879) SETTING Health centers in the Jhang and Sargodha districts in Pakistan. PATIENTS 1955 adult smokers with suspected tuberculosis. INTERVENTION Health centers were randomly assigned to provide 2 brief behavioral support sessions (BSS), BSS plus 7 weeks of bupropion therapy (BSS+), or usual care. MEASUREMENTS The primary end point was continuous abstinence at 6 months after the quit date and was determined by carbon monoxide levels in patients. Secondary end points were point abstinence at 1 and 6 months. RESULTS Both treatments led to statistically significant relative risks (RRs) for abstinence compared with usual care (RR for BSS+, 8.2 [95% CI, 3.7 to 18.2]; RR for BSS, 7.4 [CI, 3.4 to 16.4]). Equivalence between the treatments could not be established. In the BSS+ group, 275 of 606 patients (45.4% [CI, 41.4% to 49.4%]) achieved continuous abstinence compared with 254 of 620 (41.0% [CI, 37.1% to 45.0%]) in the BSS group and 52 of 615 (8.5% [CI, 6.4% to 10.9%]) in the usual care group. There was substantial heterogeneity of program effects across clusters. LIMITATIONS Imbalances in the urban and rural proportions and smoking habits among treatment groups, and inability to confirm adherence to bupropion treatment and validate longer-term abstinence or the effect of smoking cessation on tuberculosis outcomes. CONCLUSION Behavioral support alone or in combination with bupropion is effective in promoting cessation in smokers with suspected tuberculosis. PRIMARY FUNDING SOURCE International Development Research Centre.

Loneliness, social isolation and social relationships: what are we measuring? A novel framework for classifying and comparing tools

Objectives We present a novel way of classifying and comparing measures of social relationships to help readers interpret the growing literature on loneliness and social isolation and to provide researchers with a starting point to guide their choice of measuring tool. Methods Measures of social relationships used in epidemiological studies were identified from two systematic reviews—one review on the association between social relationships and health and social care service use, and a second review on the association between social relationships and health. Questions from each measure were retrieved and tabulated to derive a classification of social relationship measures. Results We present a classification of measures according to two dimensions: (1) whether instruments cover structural or functional aspects of social relationships and (2) the degree of subjectivity asked of respondents. We explain how this classification can be used to clarify the remit of the many questionnaires used in the literature and to compare them. Conclusions Different dimensions of social relationships are likely to have different implications for health. Our classification of social relationship measures transcends disciplinary and conceptual boundaries, allowing researchers to compare tools that developed from different theoretical perspectives. Careful choice of measures is essential to further our understanding of the links between social relationships and health, to identify people in need of help and to design appropriate prevention and intervention strategies.

The effect of training doctors in communication skills on women’s satisfaction with doctor–woman relationship during labour and delivery: a stepped wedge cluster randomised trial in Damascus

Objectives To determine the effect of training residents in interpersonal and communication skills on women’s satisfaction with doctor–woman relationship in labour and delivery rooms. Design A stepped wedge cluster randomised trial. Setting 4 tertiary care teaching maternity hospitals in Damascus, Syria. Participants 2000 women who gave birth to a living baby in the four study hospitals and consented to participate in the intervention took part in the study. Women with difficult labour and high-risk pregnancies were excluded. All were interviewed at home after discharge. Interventions A specially designed training package in communication skills was delivered to all resident doctors at the four hospitals. Primary outcome measures The main outcome measure was women’s satisfaction with interpersonal relationships in labour and delivery rooms measured via a series of questions on a Likert scale modified from the Medical Interview Satisfaction Scale. Results At the individual level, the mean for the average satisfaction score was 3.23 (SD 0.72) of a possible score of 5 in the control group and 3.42 (SD 0.73) in the intervention group. Using generalised linear mixed models, we were unable to detect a difference between the mean for the average satisfaction score of women in the intervention arm and that of women in the control arm; the 95% CI associated with the effect of the intervention ranged from –0.08 to 0.15. Conclusions Despite slight changes in the observed residents’ communication skills, the training package in communication skills does not seem to be associated with higher satisfaction scores of women. This raises the question of whether training individuals without further structural changes in the delivery of care and without further reinforcement of the training can have an impact on improving the quality of doctor–patient communication. Trial Registration Number ISRCTN80243969

A randomised controlled trial of three or one breathing technique training sessions for breathlessness in people with malignant lung disease

BackgroundAbout 90 % of patients with intra-thoracic malignancy experience breathlessness. Breathing training is helpful, but it is unknown whether repeated sessions are needed. The present study aims to test whether three sessions are better than one for breathlessness in this population.MethodsThis is a multi-centre randomised controlled non-blinded parallel arm trial. Participants were allocated to three sessions or single (1:2 ratio) using central computer-generated block randomisation by an independent Trials Unit and stratified for centre. The setting was respiratory, oncology or palliative care clinics at eight UK centres. Inclusion criteria were people with intrathoracic cancer and refractory breathlessness, expected prognosis ≥3 months, and no prior experience of breathing training. The trial intervention was a complex breathlessness intervention (breathing training, anxiety management, relaxation, pacing, and prioritisation) delivered over three hour-long sessions at weekly intervals, or during a single hour-long session. The main primary outcome was worst breathlessness over the previous 24 hours (‘worst’), by numerical rating scale (0 = none; 10 = worst imaginable). Our primary analysis was area under the curve (AUC) ‘worst’ from baseline to 4 weeks. All analyses were by intention to treat.ResultsBetween April 2011 and October 2013, 156 consenting participants were randomised (52 three; 104 single). Overall, the ‘worst’ score reduced from 6.81 (SD, 1.89) to 5.84 (2.39). Primary analysis [n = 124 (79 %)], showed no between-arm difference in the AUC: three sessions 22.86 (7.12) vs single session 22.58 (7.10); P value = 0.83); mean difference 0.2, 95 % CIs (–2.31 to 2.97). Complete case analysis showed a non-significant reduction in QALYs with three sessions (mean difference –0.006, 95 % CIs –0.018 to 0.006). Sensitivity analyses found similar results. The probability of the single session being cost-effective (threshold value of £20,000 per QALY) was over 80 %.ConclusionsThere was no evidence that three sessions conferred additional benefits, including cost-effectiveness, over one. A single session of breathing training seems appropriate and minimises patient burden.Trial registrationRegistry: ISRCTN; Trial registration number: ISRCTN49387307; http://www.isrctn.com/ISRCTN49387307; registration date: 25/01/2011

Effect of Cessation Interventions on Hookah Smoking: Post-Hoc Analysis of a Cluster-Randomized Controlled Trial

INTRODUCTION We explored the differential effect of cessation interventions (behavioral support sessions with [BSS+] and without [BSS] bupropion) between hookah and cigarette smokers. METHODS We reanalyzed the data from a major cluster-randomized controlled trial, ASSIST (Action to Stop Smoking In Suspected Tuberculosis), which consisted of 3 conditions: (a) behavioral support sessions (BSS), (b) behavioral support sessions plus 7 weeks of bupropion therapy (BSS+), and (c) controls receiving usual care. The trial originally recruited 1,955 adult smokers with suspected tuberculosis from 33 health centers in the Jhang and Sargodha districts of Pakistan between 2010 and 2011. The primary endpoint was continuous 6-month smoking abstinence, which was determined by carbon monoxide levels. Subgroup-specific relative risks (RRs) of smoking abstinence were computed and tested for differential intervention effect using log binomial regression (generalized linear model) between 3 subgroups (cigarette-only: 1,255; mixed: 485; and hookah-only: 215). RESULTS The test result for homogeneity of intervention effects between the smoking forms was statistically significant (p-value for BSS+: .04 and for BSS: .02). Compared to the control, both interventions appeared to be effective among hookah smokers (RR = 2.5; 95% CI = 1.3-4.7 and RR = 2.2; 95% CI = 1.3-3.8, respectively) but less effective among cigarette smokers (RR = 6.6; 95% CI = 4.6-9.6 and RR = 5.8; 95% CI = 4.0-8.5), respectively. CONCLUSIONS The differential intervention effects on hookah and cigarette smokers were seen (a) because the behavioral support intervention was designed primarily for cigarette smokers; (b) because of differences in demographic characteristics, behavioral, and sociocultural determinants; or (c) because of differences in nicotine dependency levels between the 2 groups.

Use of smokeless tobacco and risk of cardiovascular disease: A systematic review and meta-analysis

Objective The purpose of this study was to assess the risk of ischaemic heart disease (IHD) and stroke (non-fatal and fatal) among adult ever-users of smokeless tobacco (ST). Design The study design involved a systematic review and meta-analysis of observational studies. Methods Data sources for the review included key electronic databases and reference lists. Studies were included based on design (cohort or case-control), exposure (exclusive use of ST or adjusted for smoking), and outcome (non-fatal and fatal IHD and stroke). Data extraction included reported measures of association (risk ratios (RRs) or odds ratios (ORs)) between ever-use of ST (current or past) and cardiovascular disease (CVD) outcomes among non-smokers, and other study characteristics. The Newcastle-Ottawa scale was used to assess study quality. Summary measures were estimated using random effects models. Results Twenty studies were included in the meta-analyses. Overall, significantly increased risk of IHD deaths (1.15, 95% confidence interval (CI: 1.01–1.30) and stroke deaths (1.39, 95% CI: 1.29–1.49) was found among ever-users of ST. We did not find an overall significant increased risk for IHD (1.14, 95% CI: 0.92–1.42) or stroke (1.01, 95% CI: 0.90–1.13). But geographical variations were marked for IHD, with significant positive association in Asian studies (1.40, 95% CI: 1.01–1.95), and the INTERHEART study, where ST data was mainly reported from Asia (2.23, 95% CI: 1.41–3.53). European studies did not show an increased risk for non-fatal CVD. Conclusion An association was found between ever use of ST and risk of fatal IHD and stroke, consistent with previous reviews. ST consumption also appears to significantly increase risk of non-fatal IHD among users in Asia, but not in Europe.

Patients as teachers: a randomised controlled trial on the use of personal stories of harm to raise awareness of patient safety for doctors in training

Background Patient safety training often provides learners with a health professionals perspective rather than the patients. Personal narratives of health-related harm allow patients to share their stories with health professionals to influence clinical behaviour by rousing emotions and improving attitudes to safety. Aim This study measured the impact of patient narratives used to train junior doctors in patient safety. Methods An open, multi-centre, two-arm, parallel design randomised controlled trial was conducted in the North Yorkshire East Coast Foundation School (NYECFS). The intervention consisted of 1-h-long patient narratives followed by discussion. The control arm received conventional faculty-delivered teaching. The Attitude to Patient Safety Questionnaire (APSQ) and the Positive and Negative Affect Schedule (PANAS) were used to measure the impact of the intervention. Results 142 trainees received the intervention; 141 the control teaching. There was no evidence of a difference in post-intervention APSQ scores between the groups. There was a statistically significant difference in the underlying distribution of both post PA (positive affect) and post NA (negative affect) scores between the groups on the PANAS (p<0.001) with indications of both higher PA and NA scores in the intervention group. Conclusions Involving patients with experiences of safety incidents in training has an ideological appeal and seems an obvious choice in designing safety interventions. On the basis of our primary outcome measure, we were unable to demonstrate effectiveness of the intervention in changing general attitudes to safety compared to control. While the intervention may impact on emotional engagement and learning about communication, we remain uncertain whether this will translate into improved behaviours in the clinical context or indeed if there are any negative effects. Trial registration number Grant reference no. RP-PG-0108-10049.

Gender differences in determinants of weight-control behaviours among adolescents in Beirut

OBJECTIVE To investigate the association between self-esteem, physical activity, engaging in risky behaviours, social and cultural capital, attitudes towards thinness, parental and personal characteristics with weight-control behaviours among adolescents in Beirut, Lebanon. DESIGN A community-based cross-sectional study. A stratified cluster sampling design was used and information gathered by means of a questionnaire. Associations were investigated using multinomial logistic regression, accounting for the survey design. Odds ratios were calculated for trying to lose weight, or trying to gain weight, compared with no weight-control behaviour. SETTING The study was conducted in three underprivileged urban areas of Beirut in 2003. SUBJECTS The sample size was 1294 adolescents aged 13-19 years. RESULTS Determinants of weight-control behaviour among girls included their attitudes towards thinness (OR(loss) = 4.29, OR(gain) = 0.38), dissatisfaction with weight (OR(loss) = 10.9, OR(gain) = 9.63), engaging in physical activity (OR(loss) = 2.22), smoking (OR(loss) approximately 3) and the mother working (OR(loss) = 2.77). Determinants of weight-control behaviour in boys included their attitudes towards thinness (OR(loss) = 14.7, OR(gain) = 0.35), dissatisfaction with weight (OR(loss) = 15.6, OR(gain) = 17.7), being involved in a cultural activity (OR(gain) = 2.51), engaging in a fight (OR(loss) = 5.25, OR(gain) = 1.64) and engaging in physical activity (OR(loss) = 2.56, OR(gain) = 2.17). CONCLUSIONS Attitudes towards thinness, weight dissatisfaction and physical activity are common determinants for weight-control among boys and girls, although to varying degrees of influence. Self-esteem, social capital, cultural capital and parental characteristics were not significant predictors when accounting for the other variables.