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Reducing Harm in Cultural Transition: Repurposing the 5 Stages of Grief Model for Global Health Experiences.
Get PDFGlobal health programs are increasing in high-income countries (HICs) and accompanied by a wave of trainees traveling to low- and middle-income countries (LMICs) for a clinical elective.1-5 While studies have highlighted the benefits for graduate medical education (GME) trainees participating in global health electives, a growing body of literature is exposing the negative and even harmful consequences that can impact GME trainees and their host institutions, including cultural denigration, unprofessional conduct, patient harm, and strain on local health care professionals
Performance of the Self-Controlled Case Series With Active Comparators for Drug Safety Signal Detection Using the Clinical Practice Research Datalink (CPRD).
Get PDFBACKGROUND: There is little evidence about signal detection using UK primary care electronic health records (EHRs). The self controlled case series (SCCS) is one of the most promising methods for drug safety signal detection using real world data, and incorporating active comparators could potentially improve its performance by addressing confounding by indication. OBJECTIVES: This study aims to evaluate the performance of the SCCS with and without active comparators for signal detection using the UK Clinical Practice Research Datalink (CPRD) Aurum. METHODS: We applied the SCCS to macrolide and fluoroquinolone antibiotics, using amoxicillin and cefalexin as active comparators. In total seven drugs, and 30 outcomes from all organ classes were selected. We developed a reference set of 104 positive controls and 58 negative controls, using a taxonomy framework to ensure the selected drug outcome pairs are theoretically well suited to the SCCS design. Two-year observation periods with a 30-day risk window after each dispensing were used. Diagnostic performance was measured using sensitivity and specificity with respect to the product labels. RESULTS: The sensitivity and specificity of the SCCS without active comparator in the 2017/2018 observation period were 0.57 and 0.77 when limited to pairs with satisfactory power. Specificity increased up to 0.89 with active comparators, however sensitivity decreased to 0.18. Five drug-outcome pairs were signals of disproportionality before they were present on labels. CONCLUSIONS: Using a carefully designed reference set of drug-outcome pairs well suited to the study design, the SCCS performed moderately well for signal detection in CPRD. Whilst active comparators effectively reduced confounding by indication, they also reduced the number of correctly identified positive controls, due to a reduction in power. We showed some evidence that SCCS is able to highlight SDRs before they were present on labels
Outpatient hospital attendances in people with rheumatoid arthritis during the COVID-19 pandemic and beyond: a cohort study in three nations of the UK.
No full textOBJECTIVES: We aimed to estimate how rheumatology outpatient hospital attendances have changed since the COVID-19 pandemic and determine demographic characteristics associated with observed changes. METHODS: Using three primary and secondary care electronic health record datasets in England (with the approval of NHS England), Scotland and Wales, we identified people with a diagnosis of RA before 1 April 2019. We determined the proportion of people with rheumatology hospital outpatient appointments each month [April 2019 to December 2022 (Wales and Scotland), November 2023 (England)] and quantified changes using interrupted time-series analysis. We used logistic regression to determine characteristics associated with having fewer appointments compared with 2019. RESULTS: We identified 145 065, 3813 and 13 637 people coded with RA in England, Scotland and Wales, respectively. At the start of the COVID-19 pandemic the number of rheumatology outpatient appointments dropped sharply across all nations. In England and Scotland, the percentage of monthly appointments has continued to decline. In Wales, while there was a gradual recovery, rheumatology services have not returned to pre-pandemic levels. In contrast, the number of appointments for other specialties has recovered in all nations. People with no rheumatology outpatient appointments were more often aged over 80, male and living in rural areas. Ethnic minorities, those living in more deprived and urban areas had fewer appointments after the start of the pandemic compared with 2019. CONCLUSION: For the first time, we compared healthcare use across three UK nations and found rheumatology outpatient appointments had not recovered to pre-COVID-19 pandemic levels, particularly in Scotland and England
Adverse health outcomes among migrant workers and transnational families in the Asia-Pacific: a systematic review and meta-analysis.
Get PDFBACKGROUND: Labour migration is a growing global phenomenon, with migrant workers known to be more likely to experience exploitative and precarious work, impacting their health. Despite hosting over 27 million international migrant workers, the Asia-Pacific region remains underrepresented in global health evidence, limiting the development of targeted, region-specific health interventions. This study aims to investigate the health status of migrant workers and their transnational families in the Asia-Pacific region. METHODS: We conducted a systematic review and meta-analysis (PROSPERO: CRD42024528561) of primary studies published between Jan 1, 2013, and April 1, 2024. We searched MEDLINE, Embase, PsycINFO, and Ovid Global Health for studies reporting work-related morbidity and mortality among international migrant workers and their transnational families in the Asia-Pacific region. A narrative synthesis identified occupational risks; a meta-analysis estimated pooled prevalence of morbidity among migrant workers and relative risks compared to local workers. FINDINGS: Of 2877 studies identified, 54 met inclusion criteria, including 38 eligible for meta-analysis, encompassing 86,620 individuals across 17 Asia-Pacific countries. Among migrant workers (n = 64,172), 88.4% experienced occupational injuries and illnesses including work-related injuries, pesticide poisoning symptoms and respiratory diseases (n = 45,661), with 75% of migrant workers in this large dataset working in high-risk sectors such as manufacturing, construction, and services (including drivers and restaurant workers). 3.8% reported symptoms of mental health disorders such as anxiety and depression (n = 1975), and 3.8% had musculoskeletal disorders (n = 1973). The pooled prevalence of at least one work-related morbidity was 37% (95% CI: 27-47; I 2 = 99.0%), with a pooled relative risk of 1.29 (95% CI: 1.10-1.52; I 2 = 47.4%) compared with local workers. Among transnational families left behind in the migrant worker's country of origin (n = 22,448), 50.1% reported mental health issues (n = 1520), and 31.4% experienced undernutrition (n = 954). Key contributing factors to poor health outcomes of migrant workers included long working hours, workplace hazards, precarious working conditions, and healthcare access barriers. INTERPRETATION: Migrant workers in the Asia-Pacific face substantial risks of a wide range of occupational injuries and illnesses. Although some studies support the "healthy migrant effect," this advantage clearly diminishes over time due to cumulative exposure to occupational and structural stressors. Strengthening occupational safety, regulating working hours, and improving healthcare access, are urgent priorities for countries hosting large migrant worker populations and employers of migrant workers. FUNDING: Ministry of Education, Taiwan; Wellcome Trust (318501/Z/24/Z and 335954/Z/25/Z); UK Medical Research Council (MR/W006677/1); UK National Health Institute for Health and Care Research (NIHR209895); the 'la Caixa' Foundation (LCF/PR/SP21/52930003)
Health systems as human systems: reflexivity, relationships, and resilience in the pursuit of the SDGs.
Get PDFHealth Policy and Systems Research (HPSR) plays a critical role in efforts to strengthen health systems in pursuit of the Sustainable Development Goals (SDGs). This manuscript, adapted from the 2024 Virchow Lecture, explores the nature of HPSR, presents a systems-thinking perspective on health systems, and outlines key principles and strategies toward health system strengthening. It emphasizes the human dimensions of health systems-relationships, trust, leadership, values and meaning-making-as foundational to their resilience and outcomes. This narrative is informed by decades of experience and research at the intersection of policy, practice, and academia, particularly in low- and middle-income countries. The paper concludes with a call to reimagine health systems as open, dynamic, and human-centered institutions that generate public value and promote equity
Investigating fair data acquisition for risk prediction in resource-constrained settings
Get PDFClinical prediction models (CPMs) play a crucial role in precision medicine, enabling the identification of high-risk patients for targeted interventions. In many settings, additional covariates may be collected to improve risk prediction, but doing so for the entire population may not be feasible due to resource constraints. A key challenge is to determine who should receive these additional resource-intensive assessments in an efficient and equitable manner. Here, we explore policies to select which patients should be selected for additional testing based on a baseline risk estimate. We investigate these policies in the context of an integrated risk tool for cardiovascular disease. This explores how the application of a more complex, and expensive, CPM on a subset of the population can improve fairness. The proposed methodological approaches have the potential to guide future application of CPMs to prioritise patient populations who would most benefit from access to additional investigations and access to more complex CPMs
Two stage least squares with time-varying instruments: An application to an evaluation of treatment intensification for type-2 diabetes.
Get PDFAs routinely collected longitudinal data becomes more available in many settings, policy makers are increasingly interested in the effect of time-varying treatments (sustained treatment strategies). In settings such as this, many commonly used statistical approaches for estimating treatment effects, such as g-methods, often adopt the 'no unmeasured confounding' assumption. Instrumental variable (IV) methods aim to reduce biases due to unmeasured confounding, but have received limited attention in settings with time-varying treatments. This paper extends and critically evaluates a commonly used IV estimating approach, Two Stage Least Squares (2SLS), for evaluating time-varying treatments. Using a simulation study, we found that, unlike standard 2SLS, the extended 2SLS performs relatively well across a wide range of circumstances, including certain model misspecifications. We illustrate the methods in an evaluation of treatment intensification for Type-2 Diabetes Mellitus, exploring the exogeneity in prescribing preferences to operationalise a time-varying instrument
Differences in Parkinson's Disease Populations: Teaching Hospitals Versus Other Settings and Implications for Clinical Trials.
Get PDFBACKGROUND: Parkinson disease (PD) disease-modifying therapy (DMT) trials generally recruit individuals from teaching hospitals. Whether these participants represent the broader PD population is unclear. OBJECTIVE: The objective was to compare individuals with PD seen by neurologists in teaching hospitals early in their disease-a proxy for DMT trial-eligible cohorts-with individuals seen in other settings. METHODS: This retrospective cohort study using population-based data from Ontario (Canada) included individuals with PD from 1995 to 2017. Individuals with ≥1 PD visit with a teaching hospital neurologist within 3 years served as a proxy for DMT trial-eligible participants. Comparators were individuals with PD seen in other settings. We compared age, sex, income, rurality, marginalization, and comorbidities. We measured time to milestones, including drug escalation, surgical/infusion therapies, home care, dementia, long-term care admission, and death. RESULTS: We identified 19,948 individuals with PD, of whom 4386 (22.0%) were seen by a teaching hospital neurologist and 15,562 (78.0%) in other settings. Compared to other settings, individuals with teaching hospital neurology visits were younger, belonged to socioeconomically advantaged neighborhoods, and had fewer comorbidities. They had more drug escalation (unadjusted hazard ratio = 1.30; 95% confidence interval [CI] = (1.21, 1.38), surgical or infusion therapies (2.35 [2.09, 2.64]), and home care (1.06 [1.02, 1.10]). They had less dementia (0.813 [0.77, 0.86]), long-term care admission (0.62 [0.58, 0.67]), and death (0.68 [0.64, 0.72]). CONCLUSIONS: Individuals with PD seen early by teaching hospital neurologists exhibited differences from the PD population. DMT trials in PD may exclude individuals with faster PD progression and from marginalized groups, impacting generalizability. Our study highlights health equity issues. © 2025 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society
Accuracy of VIDASⓇ TB-IGRA in TB patients and individuals with different thresholds of exposure.
No full textOBJECTIVES: To achieve global TB control, more sensitive and user-friendly diagnostic tools for tuberculosis infection (TBI) are necessary, as it is a potential transmission reservoir. VIDASⓇ TB-IGRA (bioMérieux) is a fully automated assay recently developed. We report here the results of a global, multicenter, cross-sectional, prospective study to evaluate the diagnostic accuracy of the assay. METHODS: Patients with TB disease (n=200) or participants at varying levels of TB exposure risk (n=1460; mixed TB-exposure risk population) were tested with both the VIDASⓇ TB-IGRA and the QuantiFERONⓇ-TB Gold Plus (QFTⓇ-Plus, QIAGEN). RESULTS: In culture-confirmed TB cases, VIDASⓇ TB-IGRA had a sensitivity significantly higher than QFTⓇ-Plus (97.5% vs 80.7%, P<0.0001). Specificity evaluated in blood donors from a low-prevalence country (n=125) was high for both VIDASⓇ TB-IGRA and QFTⓇ-Plus (97.6% [93.1-99.5] vs 95.2% [89.8-98.2]; P=0.083), respectively. In the whole mixed TB-exposure risk population, negative (NPA) and positive percent agreement (PPA) were 90.1% (1097/1217) and 92.1% (223/242), respectively. However, regression analyses revealed that VIDASⓇ TB-IGRA correlated better with the TB-exposure risk gradient than QFTⓇ‑Plus. CONCLUSIONS: Compared with QFTⓇ-Plus, VIDASⓇ TB-IGRA was significantly more sensitive without a reduction in specificity, and it correlated better with an exposure gradient, suggesting that it is a valuable tool for TBI diagnosis
Surgery versus conservative management for severe pectus excavatum (RESTORE): protocol for a multicentre, randomised, controlled superiority trial.
Get PDFINTRODUCTION: Severe pectus excavatum (PE) may impair cardiopulmonary and physical function. The effectiveness of surgical treatment to correct PE and restore physical function is widely debated due to a lack of high-quality comparative evidence. The RESTORE trial aims to determine the clinical and cost-effectiveness of corrective surgery for severe PE compared with conservative management for the first time in a randomised controlled trial (RCT).
METHODS AND ANALYSIS: RESTORE is a pragmatic, multicentre, RCT with an embedded observational cohort. 200 participants aged ≥12 years with severe PE will be recruited at around 12 National Health Service cardiothoracic surgical centres in England. Participants will be randomised 1:1 to receive either surgery within 3 months of randomisation (intervention arm) or no surgery until after the primary outcome measurement at 1 year (comparator arm). The primary outcome is change in physical functioning from baseline to 1 year as measured by the Short Form Health Survey (SF-36v2) physical function score. The primary economic outcome is cost-effectiveness. The key secondary outcome is change in % predicted VO2peak at 1 year measured by cardiopulmonary exercise test (CPET). Outcomes will be assessed at 1 year post-randomisation in the comparator arm and 1 year post-surgery in the intervention arm. The primary analyses will be undertaken on an intention-to-treat population using a linear mixed-effects model, adjusted for stratification variables via a binary covariate. Other secondary outcomes will include change from baseline of cardiopulmonary function (CPET and spirometry), health-related quality of life using the EuroQol 5 Dimension 5 Level (EQ-5D-5L) and SF-36v2 questionnaires, Hospital Anxiety and Depression Scale and disease specific symptoms (Phoenix Comprehensive Assessment for Pectus Excavatum Symptoms and Pectus Excavatum Evaluation Questionnaire). Adverse events, complications from surgery and operative technical success (Haller and Compression Indices from preoperative and postoperative CT scans) will also be assessed. Health economic analysis will estimate the incremental cost per quality adjusted life year at 1 year.
ETHICS AND DISSEMINATION: The trial was approved by East of Scotland Research and Ethics Service (24/ES/0034). Participants who are ≥16 years of age will be required to provide written informed consent. For participants <16 years of age who are not judged to be Gillick competent, written assent and written informed consent from a parent/guardian will be required. Results will be submitted for publication in peer-reviewed journals and shared with participants, clinicians and commissioners.
TRIAL REGISTRATION NUMBER: ISRCTN11359779