BMJ Open

McCarthy, Andrew; Samarakoon, Dilupa; Gray, Joanne; Mcmeekin, Peter; McCarthy, Stephen; Newton, Claire; Nobbenhuis, Marielle; Lippiatt, Jonathan; Twigg, Jeremy

doi: 10.1136/bmjopen-2023-073990pmid: 37770262

ObjectiveTo compare the health-related quality of life and cost-effectiveness of robot-assisted laparoscopic surgery (RALS) versus conventional ‘straight stick’ laparoscopic surgery (CLS) in women undergoing hysterectomy as part of their treatment for either suspected or proven gynaecological malignancy.DesignMulticentre prospective observational cohort study.SettingPatients aged 16+ undergoing hysterectomy as part of their treatment for gynaecological malignancy at 12 National Health Service (NHS) cancer units and centres in England between August 2017 and February 2020.Participants275 patients recruited with 159 RALS, 73 CLS eligible for analysis.Outcome measuresPrimary outcome was the European Organisation for Research and Treatment of Cancer Quality of Life measure (EORTC). Secondary outcomes included EuroQol-5 Dimension (EQ-5D-5L) utility, 6-minute walk test (6MWT), NHS costs using pounds sterling (£) 2018–2019 prices and cost-effectiveness. The cost-effectiveness evaluation compared EQ-5D-5L quality adjusted life years and costs between RALS and CLS.ResultsNo difference identified between RALS and CLS for EORTC, EQ-5D-5L utility and 6MWT. RALS had unadjusted mean cost difference of £556 (95% CI −£314 to £1315) versus CLS and mean quality adjusted life year (QALY) difference of 0.0024 (95% CI −0.00051 to 0.0057), non-parametric incremental cost-effectiveness ratio of £231 667per QALY. For the adjusted cost-effectiveness analysis, RALS dominated CLS with a mean cost difference of −£188 (95% CI −£1321 to £827) and QALY difference of 0.0024 (95% CI −0.0008 to 0.0057).ConclusionsFindings suggest that RALS versus CLS in women undergoing hysterectomy (after adjusting for differences in morbidity) is cost-effective with lower costs and QALYs. Results are highly sensitive to the usage of robotic hardware with higher usage increasing the probability of cost-effectiveness. Non-inferiority randomised controlled trial would be of benefit to decision-makers to provide further evidence on the cost-effectiveness of RALS versus CLS but may not be practical due to surgical preferences of surgeons and the extensive roll out of RALS.

Wittich, Walter; Kröger, Edeltraut; Aubin, Gabrielle; Fadhlaoui, Asma; Anderson, Nicole D; Ben Gaied, Nouha; Itzhak, Inbal; Belleville, Sylvie

doi: 10.1136/bmjopen-2023-074555pmid: 37709333

ObjectivesTo adapt the content and functionalities of Brain Health PRO, a web-based multidomain program designed to increase dementia literacy, to the context and needs of users, providers and community organisations across Québec, Canada.DesignFive consecutive qualitative co-creation focus group sessions 30–90 min in duration each, exploring potential barriers and facilitators to usability, accessibility, comprehensibility, participant recruitment and retention.SettingVirtual meetings.ParticipantsA 15-member team based in Québec and Ontario, Canada, consisting of 9 researchers (including a graduate student and the project coordinator), representing occupational therapy, sensory rehabilitation, neuropsychology, psychology, health science and research methods, 3 informal caregivers of older adults living with cognitive decline and 3 members of the Federation of Quebec Alzheimer Societies.Data analysisSession recordings were summarised through both qualitative description and thematic analysis.ResultsThe synthesised recommendations included adjustments around diversity, the complexity and presentation styles of the materials, suggestions on refining the web interface and the measurement approaches; it influenced aspects of participant recruitment, retention efforts and engagement with the content of Brain Health PRO.ConclusionsCo-creation in dementia prevention research is important because it involves collaboration between researchers, community support and service providers, and persons with lived experience as care providers, in the design and implementation of clinical studies. This approach helps to ensure that the content and presentation of educational material is relevant and meaningful to the target population and those involved in its delivery, and it leads to a greater understanding of their needs and perspectives.

Hackett, Ruth A; Jackson, Sarah E; Corker, Elizabeth; Steptoe, Andrew

doi: 10.1136/bmjopen-2023-072043pmid: 37709322

ObjectiveTo examine the role of stress and health-risk behaviours in relationships between weight discrimination and health and well-being.DesignSecondary data analysis of an observational cohort study.SettingThe English Longitudinal Study of Ageing.ParticipantsData were from 4341 adults (≥50 years) with overweight/obesity.Primary outcome measuresWe tested associations between perceived weight discrimination at baseline (2010/2011) and self-rated health, limiting long-standing illness, depressive symptoms, quality of life and life satisfaction over 4-year follow-up (2010/2011; 2014/2015). Potential mediation by stress exposure (hair cortisol) and health-risk behaviours (smoking, physical inactivity, alcohol consumption) was assessed.ResultsCross-sectionally, perceived weight discrimination was associated with higher odds of fair/poor self-rated health (OR=2.05 (95% CI 1.49 to 2.82)), limiting long-standing illness (OR=1.76 (95% CI 1.29 to 2.41)) and depressive symptoms (OR=2.01 (95% CI 1.41 to 2.85)) and lower quality of life (B=−5.82 (95% CI −7.01 to −4.62)) and life satisfaction (B=−2.36 (95% CI −3.25 to −1.47)). Prospectively, weight discrimination was associated with higher odds of fair/poor self-rated health (OR=1.63 (95% CI 1.10 to 2.40)) and depressive symptoms (OR=2.37 (95% CI 1.57 to 3.60)) adjusting for baseline status. Those who reported discrimination had higher hair cortisol concentrations (B=0.14 (95% CI 0.03 to 0.25)) and higher odds of physical inactivity (OR=1.90 (95% CI 1.18 to 3.05)). These variables did not significantly mediate associations between discrimination and health outcomes.ConclusionsWeight discrimination is associated with poor health and well-being. While this discrimination is associated with stress exposure and physical inactivity, these variables explain little of the association between discrimination and poorer outcomes.

Hughes, Luke; Fern, Lorna A; Whelan, Jeremy S; Taylor, Rachel M; Study Group, BRIGHTLIGHT

doi: 10.1136/bmjopen-2022-069910pmid: 37730384

ObjectivesThe BRIGHTLIGHT cohort study was the national evaluation of cancer services for teenager and young adults (TYA). This was analysis of free-text survey data to better understand their experiences of cancer care.DesignCohort studySettingNational Health Service hospitals delivering cancer care in EnglandParticipants830 young people newly diagnosed with cancer.InterventionsExposure to specialist care in the first 6 months after diagnosis defined as care in a TYA Principal Treatment Centre (PTC). This was categorised as follows: all care in a TYA-PTC (ALL-TYA-PTC), no care in a TYA-PTC (NO-TYA-PTC) so care delivered in a children/adult unit only and some care in a TYA-PTC with additional care in a children’s/adult unit (SOME-TYA-PTC).Primary outcomeData were collected through the BRIGHTLIGHT survey included free-text questions which asked patients ‘what was the best aspects of their experiences of care’ and ‘what aspects could be improved’. These comments were analysed using content analysis. Themes were compared between categories of care, then ranked in order of frequency, ranging from the most endorsed to the least.ResultsOverall, young people were most positive about their healthcare team, while the area highlighted for improvement was diagnostic experience. Differences between the three groups suggested those who had some or all treatment in a TYA-PTC valued the place of care. Regardless of where TYA were treated their healthcare teams were favourably viewed. Age appropriate place of care was highlighted to be of value for those in PTCs.ConclusionsThese data show the value young people placed on the care they received in TYA specific wards. Young people who accessed some or all of their care in a TYA-PTC highly endorsed their place of care as one of the best elements of their care, and it is further emphasised by those who had shared care who experienced difficulty with lack of age-appropriate care when treated outside the TYA-PTC.

Croke, Sarah; Volkmann, Anna-Maria; Perry, Catherine; Atkinson, Ross A; Pruneddu, Alessio; Morris, Lydia; Bower, Peter

doi: 10.1136/bmjopen-2022-068765pmid: 37730399

ObjectivesDelivered as part of the global assessment of diabetes in urban settings, this study explores different aspects of living with type 2 diabetes, for adults aged 18–40. Primary questions were as follows: (1) can we identify subgroups of adults under 40 years old sharing specific perspectives towards health, well-being and living with type 2 diabetes and (2) do these perspectives reveal specific barriers to and opportunities for better type 2 diabetes prevention and management and improved well-being?DesignThe study employed a mixed-method design with data collected through demographic questionnaires, Q-sort statement sorting exercises, focus groups discussions and individual interviews.SettingPrimary care across Greater Manchester, UK.ParticipantsThose aged between 18 and 40, with a confirmed type 2 diabetes diagnosis, and living in Greater Manchester were eligible to participate. A total of 46 people completed the Q-sort exercise and 43 were included in the final analysis. Of those, 29 (67%) identified as female and 32 (75%) as white. Most common time since diagnosis was between 5 and 10 years.ResultsThe Q-sort analysis categorised 35 of the 43 participants (81%) into five subgroups. Based on average statement sorts for each subgroup, perspectives were characterised as: (1) stressed and calamity coping (n=13), (2) financially disadvantaged and poorly supported (n=12), (3) well-intentioned but not succeeding (n=5), (4) withdrawn and worried (n=2) and (5) young and stigmatised (n=3). Holistic analysis of our qualitative data also identified some common issues across these subgroups.ConclusionsAdults under 40 with type 2 diabetes are not a homogeneous group, but fall into five identifiable subgroups. They also experience issues specific to this age group that make it particularly difficult for them to focus on their own health. More tailored support could help them to make the necessary lifestyle changes and manage their type 2 diabetes better.

Gosse, Philippe; Sentilhes, Loïc; Boulestreau, Romain; Doublet, Julien; Gaudissard, Julie; Azizi, Michel; Cremer, Antoine

doi: 10.1136/bmjopen-2022-071164pmid: 37775290

IntroductionA major issue confronting clinicians treating hypertension in pregnancy is the limited number of pharmacological options. Endovascular catheter-based renal denervation (RDN) is a new method to lower blood pressure (BP) in patients with hypertension by reducing the activity of the renal sympathetic nervous system. Drugs that affect this system are safe in pregnant women. So there is reasonable evidence that RDN performed before pregnancy should not have deleterious effects for the fetus. Because the efficacy of RDN may be greater in younger patients and in women, we may expect a larger proportion of BP normalisation in young hypertensive women, but this remains to be proven. Our primary objective is to quantify the proportion of BP normalisation with RDN in this population.Methods and analysisWHY-RDN is a multicentre randomised sham-controlled trial conducted in six French hypertension centres that will include 80 women with essential hypertension treated or untreated, who are planning a pregnancy in the next 2 years and will be randomly assigned to RDN or classic renal arteriography and sham RDN in a ratio of 1:1. The primary outcome is the normalisation of 24-hour BP (<130/80 mm Hg) at 2-month post procedure off treatment. Sample size is calculated with the following assumptions: 5% one-sided significance level (α), 80% power (1-β), expected responder rates of 24% and 3% in the treatment and control group, respectively. Secondary outcomes include the absence of adverse outcomes for a future pregnancy, the variations of BP in ambulatory and home BP measurements and the evaluation of treatment prescribed.Ethics and disseminationWHY-RDN has been approved by the French Ethics Committee (Tours, Region Centre, Ouest 1- number 2021T1-28 HPS). This project is being carried out in accordance with national and international guidelines. The findings of this study will be disseminated by publication.Trial registration numberClinicalTrials.gov, NCT05563337.

Arefhosseini, Sara; Tutunchi, Helda; Tavakkoli, Shahrzad; Arefhosseini, Seyed Rafie; Ebrahimi-Mameghani, Mehrangiz

doi: 10.1136/bmjopen-2023-073452pmid: 37699622

ObjectiveThe present study aimed to establish the association of neck circumference (NC)-related indices with metabolic, atherogenic and liver function biomarkers in patients with non-alcoholic fatty liver disease (NAFLD).DesignCross-sectional study.SettingOutpatient clinics of Tabriz University of Medical Sciences.ParticipantsA total of 175 adult patients with NAFLD diagnosed by abdominal ultrasonography were included in this study. Sociodemographic characteristics, anthropometric measures and metabolic, atherogenic and liver function biomarkers were assessed.ResultsResults on 107 women and 68 men with NAFLD showed that 52%, 45.1% and 2.9% of patients had mild, moderate and severe NAFLD, respectively. There were significant differences in most of the anthropometric indices, serum levels of ferritin, creatinine and uric acid as well as liver enzymes, and Aspartate Aminotransferase (AST) to Platelet Ratio Index (APRI) between the genders (p<0.01). However, no significant differences were found in the glycaemic, lipid profile and atherogenic biomarkers. Both NC and neck-to-height ratio (NHtR) were significantly associated with body mass index (BMI) (p=0.018, p<0.001, respectively), waist circumference (WC) (p<0.001, p=0.044, respectively) and waist-to-hip ratio (WHR) (p<0.001, p=0.026, respectively) while results showed only a significant relationship between neck-to-waist ratio (NWR) with BMI (p<0.001) and WC (p<0.001). Among metabolic factors, there were significant and positive correlations between NC and serum haemoglobin A1c (r=0.198, p<0.001), AST (r=0.300, p<0.001), alanine aminotransferase (ALT) (r=0.348, p<0.001), ferritin (r=0.403, p<0.001) and uric acid (r=0.347, p=0.003) while AST/ALT ratio was inversely related to NC (r=−0.226, p=0.003). APRI, Lipid Accumulation Product Index and also Hepatic Steatosis Index were significantly correlated with NC, NHtR and NWR (p<0.01).Conclusions and relevanceNC-related indices, particularly NC and NHtR, were correlated with some metabolic and liver function biomarkers (apart from lipid profile and atherogenic factors) in patients with NAFLD.

Pathmanathan, Arin; Snelling, Iain

doi: 10.1136/bmjopen-2022-068202pmid: 37739470

BackgroundThe retention of doctors is an important issue for the National Health Service; yet evidence suggests that the proportion of doctors wanting to leave UK medicine is increasing. Some of these doctors chose to continue their medical careers in other countries, however, some decided to leave the profession entirely.ObjectivesThis was the first study to interview a cohort of UK doctors who have left the medical profession to embark on alternative careers. Participants were asked about the reasoning behind their decision to leave medicine.DesignQualitative study using one-to-one, semi-structured virtual interviews.Participants17 participants, recruited via purposive sampling.SettingZoom interviews with 17 former UK doctors who had left medicine to pursue alternative careers were conducted between February and July 2021.FindingsData were analysed using thematic analysis and the theory of work adjustment was applied to findings. The most frequently discussed reasons for leaving were associated with factors preventing participants from providing a desired level of patient care, work-life balance, a lack of support, a lack of control over working lives and the pull of alternative careers. While reasons for leaving varied between participants, all participants reported greater satisfaction in their new careers.ConclusionNew careers were able to address many of the issues that caused participants to leave UK medicine. Consequently, it is important that some of the key issues raised in this study are addressed to retain more doctors in the UK medical workforce.

Luo, Yingxian; Wu, Qiong; Meng, Runtang; Lian, Fuzhi; Jiang, Chen; Hu, Meiyu; Wang, Yaxin; Ma, Haiyan

doi: 10.1136/bmjopen-2023-073930pmid: 37758669

ObjectiveTo evaluate the associations between serum uric acid (SUA) levels and cardiovascular disease (CVD) risk factors, focusing on potential sex-specific differences.DesignA retrospective cohort study.SettingA large community-based survey was conducted every two years from 2010 to 2018 in Hangzhou, Zhejiang Province, outheastern China.Participants6119 participants aged 40 years and above who underwent at least three times of physical examinations were enrolled.MethodsParticipants were categorised into four groups (Q1–Q4) based on baseline SUA quartiles within the normal range, with hyperuricaemia (HUA) as the fifth group. The Q1 was the reference. By stratifying participants by gender, the relationships between SUA levels and systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood glucose (FBG) and total cholesterol (TC) were investigated using linear regression models in the generalised estimating equation. Additionally, the associations of elevated SUA levels and HUA with hypertension, hyperglycaemia and dyslipidaemia were correspondingly examined using multivariate logistic regression models.ResultsAfter adjusting for confounding variables, we found positive associations between SUA levels and SBP, DBP, FBG and TC in women, and with TC in men (p<0.01). Likewise, elevated SUA quartiles and HUA were linked to increased dyslipidaemia risk in both sexes, and increased hyperglycaemia risk only in women, with HRs (95% CI) of 1.64 (1.05 to 2.55) and 2.37 (1.47 to 3.81) in the Q4 and HUA group, respectively. Women with HUA had higher hypertension risk (HR=1.45, 95% CI 1.21 to 1.73), while no such association was observed in men. Stratified analyses revealed significant associations between elevated SUA levels and CVD risk factors in postmenopausal and non-obese women.ConclusionsElevated SUA levels increase the risk of dyslipidaemia in both sexes. SUA levels within normal range and HUA are positively associated with hyperglycaemia and hypertension in postmenopausal women, but not in men.

Aryastami, Ni Ketut; Mubasyiroh, Rofingatul

doi: 10.1136/bmjopen-2022-067959pmid: 37666563

ObjectiveThis paper analyses the optimal utilization of maternal health services in Indonesia from 2015 to 2018.DesignNational cross-sectional study.SettingThis study takes place in 34 provinces in Indonesia.ParticipantsThe population in this study were mothers in all household members in Basic Health Research of Riskesdas 2018. The sample was all mothers who had a live birth within 5 years before data collection (1 January 2013 to July 2018) and had complete data. The number of samples analysed was 70 878.Primary outcomeWe developed a scoring for the optimal utilization of maternal health services as the outcome variable.ResultsThis analysis involved 70 787 mothers. The utilization of maternal care was not optimal. Mothers who delivered in health facilities achieved 83.3% of services. Better care is experienced more by mothers who live in urban areas. Mothers who delivered at health facilities significantly used threefold optimal care (ORa=3.15; 95% CI 3.00 to 3.30; p<0001). A statistically significant difference of optimal maternal care was found in mothers with better education (ORa=1.22; 95% CI 1.18 to 1.27; p=0.001); holding health insurance (ORa=1.25; 95% CI 1.21 to 1.30; p<0001), having more access to health facilities (ORa=1.13; 95% CI 1.09 to 1.17); p<0.001), less parity (ORa=1.16; 95% CI 1.11 to 1.20; p<0.001).ConclusionThe optimal utilization of MHS is independent of the free services delivery, but having health insurance and less parity brought about a better optimal score for MHS. Mothers in rural areas were more protective of optimal utilization. Finally, the eastern region used more optimal health services.