Critical Evidence Gaps Research Articles

Emissions of NOx from blending of hydrogen and natural gas in space heating boilers

As part of climate change commitments, the United Kingdom is considering an incremental transition from natural gas to hydrogen for domestic heating, blending up to 20% of hydrogen (by volume) into the national gas network. We consider the possible impacts of this policy on nitrogen oxides (NOx) emissions, a minor waste by-product from combustion. A meta-analysis of changes in NOx emissions from hydrogen/natural gas blends used in gas burners is undertaken, with focus on mixtures between 5% and 20% v/v. Literature reports are highly variable: for a 5% hydrogen blend, changes in NOx emissions, when compared to burning pure natural gas, vary over the range –12% to +39%, with a mean change across 14 studies of +8%. These estimates required an important assumption to be made that, when not explicitly described, all literature data on changes in NOx emissions and/or concentrations were suitably corrected for the reduced energy density and heat output arising once hydrogen is added. A NOx increase can be rationalized through the increased adiabatic flame temperature generated from hydrogen combustion. The associated range of plausible damage costs of a 5% hydrogen blend is estimated to fall within the range –117 million GBP to +362 million GBP per year; 20% hydrogen (the maximum that could be accommodated with existing infrastructure) would lead to a change in emissions in the range –50 to +154% with a change in damage costs of between –467 million GBP and +1,146 million GBP per year. The mean change is estimated at 292 million GBP per year. For existing poor performing boilers, an economic case can be made for scrappage and replacement based primarily on NOx damage costs avoided. The response of older boilers to added hydrogen is a critical evidence gap that needs filling before further decisions on hydrogen as a heating fuel are made.

Adolescent parenthood and HIV-infection in South Africa-Associations with child cognitive development.

HIV, both directly and indirectly, impacts child development outcomes. The most severe impacts are for children infected with HIV, and those exposed but uninfected are also shown to have challenges-though less severe. However, little is known regarding the development of children born to adolescent mothers affected by HIV. This study aims to examine cognitive development for children born to adolescent mothers, comparing those children living with HIV, those HIV exposed and uninfected (HEU) and those HIV unexposed (HU). Analyses utilise cross-sectional data from 920 adolescent mother (10-19 years)-first born child dyads residing in the Eastern Cape Province, South Africa. Participants completed detailed study questionnaires inclusive of validated and study specific measures relating to sociodemographic characteristics, HIV, and maternal and child health. Trained assessors administered standardised child development assessments (using the Mullen Scales of Early Learning) with all children. Chi-square tests and ANOVA tests were used to explore maternal and child characteristics according to child HIV status (HIV, HEU, HU) on cognitive development. Linear regression models were used to explore the cross-sectional associations between child HIV status and child cognitive development. 1.2% of children were living with HIV, 20.5% were classified as being HEU and, 78.3% were classified as HU. Overall, children living with HIV were found to perform lower across developmental domains compared to both HEU and HU groups (composite score of early learning: 73.0 vs 91.2 vs. 94.1, respectively: F = 6.45, p = 0.001). HEU children on average scored lower on all developmental domains compared to HU children, reaching significance on the gross motor domain (p<0.05). Exploratory analyses identified maternal education interruption as a potential risk factor for lower child cognitive development scores and, higher maternal age to be protective of child cognitive development scores. These exploratory findings address a critical evidence gap regarding the cognitive development of children born to adolescent mothers affected by HIV in South Africa. Analyses identify stepwise differences in the average scoring on child cognitive development domains according to child HIV status among children born to adolescent mothers affected by HIV; with children living with HIV performing worse overall. Young mothers and their children may benefit from adapted interventions aimed at bolstering child development outcomes. Targeted programming particularly among younger adolescent mothers and those experiencing education interruption may identify those families, particularly in need. Attention to maternal continuity of education and age of conception may be interventions to consider.

PD26-10 COMPARISON OF INTRAVESICAL THERAPY AND SURGERY AS TREATMENT OPTIONS FOR RECURRENT BLADDER CANCER (CISTO): UPDATE ON AN ONGOING MULTICENTER PRAGMATIC STUDY

You have accessJournal of UrologyCME1 May 2022PD26-10 COMPARISON OF INTRAVESICAL THERAPY AND SURGERY AS TREATMENT OPTIONS FOR RECURRENT BLADDER CANCER (CISTO): UPDATE ON AN ONGOING MULTICENTER PRAGMATIC STUDY John Gore, Erika Wolff, Bryan Comstock, Kristin Follmer, Michael Nash, On Ho, Stephanie Chisolm, Doug MacLean, Jenney Lee, Sarah Lawrence, Danielle Lavallee, Yair Lotan, Gary Steinberg, Sima Porten, Larry Kessler, Angela Smith, and CISTO Collaborative John GoreJohn Gore More articles by this author , Erika WolffErika Wolff More articles by this author , Bryan ComstockBryan Comstock More articles by this author , Kristin FollmerKristin Follmer More articles by this author , Michael NashMichael Nash More articles by this author , On HoOn Ho More articles by this author , Stephanie ChisolmStephanie Chisolm More articles by this author , Doug MacLeanDoug MacLean More articles by this author , Jenney LeeJenney Lee More articles by this author , Sarah LawrenceSarah Lawrence More articles by this author , Danielle LavalleeDanielle Lavallee More articles by this author , Yair LotanYair Lotan More articles by this author , Gary SteinbergGary Steinberg More articles by this author , Sima PortenSima Porten More articles by this author , Larry KesslerLarry Kessler More articles by this author , Angela SmithAngela Smith More articles by this author , and CISTO Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002574.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with non-muscle-invasive bladder cancer (NMIBC) that recurs after treatment with intravesical Bacillus Calmette-Guerin (BCG) must weigh the risk of progression of bladder cancer and loss of a window of potential cure with medical therapy against the risk of morbidity and loss of quality of life (QOL) with radical cystectomy. The CISTO Study (NCT03933826) is a pragmatic, prospective observational cohort study comparing medical therapy (i.e., intravesical therapy or systemic immunotherapy) with radical cystectomy for recurrent high-risk NMIBC. Here we report on the design and progress of the CISTO Study. METHODS: 900 patients with recurrent high-risk NMIBC that has failed first-line BCG and who have chosen to undergo standard of care treatment will be enrolled. Patient stakeholders helped determine the primary outcome: 12-month patient-reported QOL using the EORTC QLQ-C30. Secondary outcomes include urinary and sexual function, decisional regret, financial distress, healthcare utilization, return to work/normal activities, progression, and recurrence-free, metastasis-free, and overall survival. Participants will be followed for up to 3 years. RESULTS: Enrollment is active at 32 sites across the US, including 23 university-based centers and 9 community sites. As of November 1, 2021, 173 participants have been enrolled, 104 of whom chose medical therapy and 69 of whom chose radical cystectomy. The completion rate for the primary outcome of QOL at 12 months is 94% (15 out of 16 participants to date). The inclusion of electronic consent and collection of PROs allowed recruitment and follow-up to continue remotely during the COVID-19 pandemic. Significant pandemic-related challenges have included slow study start-up at sites, staffing, periods of suspension, and delays in patients obtaining care. Strategies to address these challenges include improved methods for onboarding and training sites, all-site communication, confirming study eligibility, abstracting EHR data, and remote monitoring while adhering to the highest study standards. CONCLUSIONS: The CISTO Study will compare patient reported outcomes for those undergoing medical therapy with radical cystectomy for recurrent high-risk NMIBC. The CISTO Study has the potential to fill critical evidence gaps and provide for personalized, patient-centered care. Source of Funding: This work was supported through a Patient-Centered Outcomes Research Institute (PCORI) Award (PCS-2017C3-9380) © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e491 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Gore More articles by this author Erika Wolff More articles by this author Bryan Comstock More articles by this author Kristin Follmer More articles by this author Michael Nash More articles by this author On Ho More articles by this author Stephanie Chisolm More articles by this author Doug MacLean More articles by this author Jenney Lee More articles by this author Sarah Lawrence More articles by this author Danielle Lavallee More articles by this author Yair Lotan More articles by this author Gary Steinberg More articles by this author Sima Porten More articles by this author Larry Kessler More articles by this author Angela Smith More articles by this author CISTO Collaborative More articles by this author Expand All Advertisement PDF DownloadLoading ...

Advancing Social Mission Research: A Call to Action.

Social mission efforts in health professions education are designed to advance health equity and address the health disparities of the society in which they exist. While there is growing evidence that social mission-related interventions are associated with intended outcomes such as practice in underserved communities, student diversity, and students graduating with skills and knowledge that prepare them to address societal needs, critical evidence gaps remain that limit the possibility of generalizing findings and using social mission strategically to advance health equity. At a time when COVID-19 has been laying bare health disparities related to systemic racism and maldistribution of resources, understanding how health professions training can produce the workforce needed to advance health equity becomes even more imperative. Yet, data and methods limitations are hindering progress in this critical research. The authors present an overview of the social mission research landscape; their review of the research led them to conclude that more rigorous research and data collection are needed to determine the link between social mission activities in health professions education and advances in health equity. To accelerate understanding of how health professions education and training can advance health equity, the authors propose a social mission research road map that includes (1) creating a social mission research community by consolidating stakeholders, (2) building a solid foundation for the research through development of a consensus-driven logic framework and research agenda, and (3) laying out the data and methodological needs that are imperative to strengthening the social mission evidence base and identifying opportunities to address these needs. Core to achieving these milestones is leadership from an organizing body that can serve as a hub for social mission research and engage stakeholder groups in building the evidence base for social mission strategies that will ultimately advance health equity.

Ending the evidence gap for pregnancy, HIV and co-infections: ethics guidance from the PHASES project.

IntroductionWhile pregnant people have been an important focus for HIV research, critical evidence gaps remain regarding prevention, co‐infection, and safety and efficacy of new antiretroviral therapies in pregnancy. Such gaps can result in harm: without safety data, drugs used may carry unacceptable risks to the foetus or pregnant person; without pregnancy‐specific dosing data, pregnant people face risks of both toxicity and undertreatment; and delays in gathering evidence can limit access to beneficial next‐generation drugs. Despite recognition of the need, numerous barriers and ethical complexities have limited progress. We describe the process, ethical foundations, recommendations and applications of guidance for advancing responsible inclusion of pregnant people in HIV/co‐infections research.DiscussionThe 26‐member international and interdisciplinary Pregnancy and HIV/AIDS: Seeking Equitable Study (PHASES) Working Group was convened to develop ethics‐centred guidance for advancing timely, responsible HIV/co‐infections research with pregnant people. Deliberations over 3 years drew on extensive qualitative research, stakeholder engagement, expert consultation and a series of workshops. The guidance, initially issued in July 2020, highlights conceptual shifts needed in framing research with pregnant people, and articulates three ethical foundations to ground recommendations: equitable protection from drug‐related risks, timely access to biomedical advances and equitable respect for pregnant people's health interests. The guidance advances 12 specific recommendations, actionable within the current regulatory environment, addressing multiple stakeholders across drug development and post‐approval research, and organized around four themes: building capacity, supporting inclusion, achieving priority research and ensuring respect. The recommendations describe strategies towards ethically redressing the evidence gap for pregnant people around HIV and co‐infections. The guidance has informed key efforts of leading organizations working to advance needed research, and identifies further opportunities for impact by a range of stakeholder groups.ConclusionsThere are clear pathways towards ethical inclusion of pregnant people in the biomedical research agenda, and strong agreement across the HIV research community about the need for – and the promise of – advancing them. Those who fund, conduct, oversee and advocate for research can use the PHASES guidance to facilitate more, better and earlier evidence to optimize the health and wellbeing of pregnant people and their children.

Adolescent Motherhood and HIV in South Africa: Examining Prevalence of Common Mental Disorder

The mental health of adolescents (10–19 years) remains an overlooked global health issue, particularly within the context of syndemic conditions such as HIV and pregnancy. Rates of pregnancy and HIV among adolescents within South Africa are some of the highest in the world. Experiencing pregnancy and living with HIV during adolescence have both been found to be associated with poor mental health within separate explorations. Yet, examinations of mental health among adolescents living with HIV who have experienced pregnancy/parenthood remain absent from the literature. As such, there exists no evidence-based policy or programming relating to mental health for this group. These analyses aim to identify the prevalence of probable common mental disorder among adolescent mothers and, among adolescents experiencing the syndemic of motherhood and HIV. Analyses utilise data from interviews undertaken with 723 female adolescents drawn from a prospective longitudinal cohort study of adolescents living with HIV (n = 1059) and a comparison group of adolescents without HIV (n = 467) undertaken within the Eastern Cape Province, South Africa. Detailed study questionnaires included validated and study specific measures relating to HIV, adolescent motherhood, and mental health. Four self-reported measures of mental health (depressive, anxiety, posttraumatic stress, and suicidality symptomology) were used to explore the concept of likely common mental disorder and mental health comorbidities (experiencing two or more common mental disorders concurrently). Chi-square tests (Fisher’s exact test, where appropriate) and Kruskal Wallis tests were used to assess differences in sample characteristics (inclusive of mental health status) according to HIV status and motherhood status. Logistic regression models were used to explore the cross-sectional associations between combined motherhood and HIV status and, likely common mental disorder/mental health comorbidities. 70.5% of participants were living with HIV and 15.2% were mothers. 8.4% were mothers living with HIV. A tenth (10.9%) of the sample were classified as reporting a probable common mental disorder and 2.8% as experiencing likely mental health comorbidities. Three core findings emerge: (1) poor mental health was elevated among adolescent mothers compared to never pregnant adolescents (measures of likely common mental disorder, mental health comorbidities, depressive, anxiety and suicidality symptoms), (2) prevalence of probable common mental disorder was highest among mothers living with HIV (23.0%) compared to other groups (Range:8.5–12.8%; Χ2 = 12.54, p = 0.006) and, (3) prevalence of probable mental health comorbidities was higher among mothers, regardless of HIV status (HIV & motherhood = 8.2%, No HIV & motherhood = 8.2%, Χ2 = 14.5, p = 0.002). Results identify higher mental health burden among adolescent mothers compared to never-pregnant adolescents, an increased prevalence of mental health burden among adolescent mothers living with HIV compared to other groups, and an elevated prevalence of mental health comorbidities among adolescent mothers irrespective of HIV status. These findings address a critical evidence gap, highlighting the commonality of mental health burden within the context of adolescent motherhood and HIV within South Africa as well as the urgent need for support and further research to ensure effective evidence-based programming is made available for this group. Existing antenatal, postnatal, and HIV care may provide an opportunity for mental health screening, monitoring, and referral.

Child mortality in Bangladesh - why, when, where and how? A national survey-based analysis.

BackgroundUpdated information on the cause of childhood mortality is essential for developing policies and designing programmes targeting the major burden of disease. There is a paucity of evidence regarding the current estimates of the cause of death in Bangladesh, which is essential for reinvigorating the current policies and reshaping existing strategies to avert preventable deaths. This paper aims to address this critical evidence gap and report the cause, timing and place of death among children under-five years of age using a nationally representative sample.MethodsThe present study was undertaken to provide updated estimates of causes of death among children under-five years of age using data from the 2017-18 round of the Bangladesh Demographic and Health Survey (BDHS). The verbal autopsy (VA) questionnaire of the 2017-18 BDHS was adapted from the standardised WHO 2016 instruments. Specially trained physicians reviewed the responses of the VA questionnaire and assigned the cause of death based on the online-2016-version of the International Classification of Diseases (ICD-10). We included 456 deaths among children under-five years of age in our analysis. Descriptive statistics were used to present the causes, timing and places of death with uncertainty ranges (UR).ResultsPneumonia is the major killer (19%), accounting for approximately 24 268 (UR = 21 626-26 695) under-five deaths per-year. It is followed by birth asphyxia (16%), prematurity and low-birth-weight (11%), serious infections including sepsis (8%) causing 20 882 (UR = 18 608-22 970), 14 956 (UR = 13 327-16,452), and 10 723 (UR = 9555-11,795) deaths per-year, respectively. Drowning (8%) caused 10 441 (UR = 9304-11 485) deaths and congenital anomaly (7%) resulted in d 8748 (UR = 7795-9623) deaths per-year. Around 29% of all deaths occurred on the first day, 52% within the first week, and 66% within the first month of life. Around 70% of birth asphyxia, prematurity, and low birth weight-related deaths happen on the day of birth. Approximately 43% of pneumonia-related deaths occur in age 1-11 months, and around 51% of drowning-related deaths happen in age 12-23 months.ConclusionsPneumonia with other serious infections, birth asphyxia, prematurity and low-birth-weight are responsible for more than half of all deaths among children under-five years of age. Strengthening the existing maternal, neonatal and child health programmes may be helpful in averting the majority of these preventable deaths. A multisectoral approach is required for the prevention of childhood deaths, especially drowning-related fatalities. Special measures need to be taken to prevent and control emerging public health challenges like birth defects and congenital anomalies.

Response strategies for promoting gender equality in public health emergencies: a rapid scoping review

ObjectivesThe COVID-19 pandemic threatens to widen existing gender inequities worldwide. A growing body of literature assesses the harmful consequences of public health emergencies (PHEs) for women and girls; however, evidence...

An Umbrella Review of the Work and Health Impacts of Working in an Epidemic/Pandemic Environment.

This umbrella review of reviews examined the evidence on the work and health impacts of working in an epidemic/pandemic environment, factors associated with these impacts, and risk mitigation or intervention strategies that address these factors. We examined review articles published in MEDLINE, PsycINFO and Embase between 2000 and 2020. Data extracted from the included reviews were analyzed using a narrative synthesis. The search yielded 1524 unique citations, of which 31 were included. Included studies were focused on health care workers and the risk of infection to COVID-19 or other respiratory illnesses, mental health outcomes, and health care workers’ willingness to respond during a public health event. Reviews identified a variety of individual, social, and organizational factors associated with these work and health outcomes as well as risk mitigation strategies that addressed study outcomes. Only a few reviews examined intervention strategies in the workplace such as physical distancing and quarantine, and none included long-term outcomes of exposure or work during an epidemic/pandemic. Findings suggest a number of critical research and evidence gaps, including the need for reviews on occupational groups potentially exposed to or impacted by the negative work and health effects of COVID-19 in addition to health care workers, the long-term consequences of transitioning to the post-COVID-19 economy on work and health, and research with an equity or social determinants of health lens.

To What Extent Is Trust a Prerequisite for Charitable Giving? A Systematic Review and Meta-Analysis

Trust is assumed to be important for charitable giving. However, disparate associations have been found, and recent theoretical approaches emphasize motives for giving that do not rely on trust. To resolve this tension, we conducted a systematic review of evidence generated between 1988 and 2020. A meta-analysis of 69 effect sizes from 42 studies sampling 81,604 people in 31 countries confirmed a positive association between trust and giving across diverse measures, r = .22. Meta-regressions showed that organizational ( r = .35) and sectoral trust ( r = .27) were more strongly associated with giving than were generalized ( r = .11) or institutional trust ( r = .14). The relationship was also stronger in non-western (vs Western) countries and in nonrepresentative (vs nationally representative) samples. All evidence was correlational, and few studies measured actual behavior. We discuss implications for theories of trust and for fundraising practice, and highlight critical gaps in evidence.

Introducing PIONEER: a project to harness big data in prostate cancer research.

Prostate Cancer Diagnosis and Treatment Enhancement Through the Power of Big Data in Europe (PIONEER) is a European network of excellence for big data in prostate cancer, consisting of 32 private and public stakeholders from 9 countries across Europe. Launched by the Innovative Medicines Initiative 2 and part of the Big Data for Better Outcomes Programme (BD4BO), the overarching goal of PIONEER is to provide high-quality evidence on prostate cancer management by unlocking the potential of big data. The project has identified critical evidence gaps in prostate cancer care, via a detailed prioritization exercise including all key stakeholders. By standardizing and integrating existing high-quality and multidisciplinary data sources from patients with prostate cancer across different stages of the disease, the resulting big data will be assembled into a single innovative data platform for research. Based on a unique set of methodologies, PIONEER aims to advance the field of prostate cancer care with a particular focus on improving prostate-cancer-related outcomes, health system efficiency by streamlining patient management, and the quality of health and social care delivered to all men with prostate cancer and their families worldwide.

ASSESSMENT OF COMPARATIVE EFFECTIVENESS RESEARCH GAPS TO PROMOTE AGING IN PLACE: A STAKEHOLDER-DRIVEN APPROACH

A priority for many older adults is to remain in their homes and communities. This paper describes the Patient-Centered Outcomes Research Institute’s (PCORI) review of our investment in comparative effectiveness research (CER) that will advance the field of “aging in place.” To inform our systematic evaluation, we first engaged our multi-stakeholder advisory panel of patients/caregivers, clinicians, health systems leaders, and payers to develop and refine a conceptual framework for research focused on aging in place among older adults. Key themes from stakeholders were: aging in place interventions should be patient-centered and align with the patients’ needs and goals, studies should include individuals 55+ years who may be at risk for institutionalization, relevant interventions go beyond environmental modifications and include social support, healthcare (inclusive of palliative care), and personal care services. In addition, aging in place services should focus more on informal caregiver interventions and outcomes since informal caregivers play a major role in enabling older adults to age in place. We identified 14 PCORI-funded CER projects that will provide evidence on the most effective interventions to promote aging in place among older adults; the total investment is $113.4 million dollars. The portfolio is addressing decisional dilemmas faced by multiple stakeholders on a variety of topics including falls prevention, home-based palliative care, and community-based care models; however, several critical CER evidence gaps remain that need to be addressed in future funding investments and will be discussed during the presentation.

Advancing Nutrition in the International Food Assistance Agenda: Progress and Future Directions Identified at the 2018 Food Assistance for Nutrition Evidence Summit

Global food insecurity persists despite continued international attention, necessitating evidence-based food assistance interventions that adequately address nutritional concerns. In June 2018, the US Agency for International Development's Office of Food for Peace through the Food Aid Quality Review (FAQR) project sponsored a "Food Assistance for Nutrition Evidence Summit" to share evidence relevant to policy and programmatic decision-making and to identify critical evidence gaps. This article presents 4 priority areas to advance nutrition in the international food assistance agenda generated through presentations and discussions with the food assistance community at the Evidence Summit. Priority areas were identified after the Evidence Summit using a combination of FAQR team discussions, review of presentations and official notes, and supporting literature. Key priority areas to advance nutrition in the international food assistance agenda are as follows: (1) increase research funding for food assistance in all contexts, paying particular attention to emergency settings; (2) research and adopt innovative ingredients, technology, and delivery strategies in food assistance products and programs that encourage long-term well-being; (3) redefine and expand indicators of nutritional status to capture contextual information about the outcomes of food assistance interventions; and (4) augment communication and collaboration across the food assistance ecosystem. These priorities are critical in a time of increased humanitarian need and will be key to fostering long-term resilience among vulnerable groups.

A Novel Method for Categorizing the Magnitude of Dietary Nutrient Gaps Among Children 6–23 Months and Rating the Quality of Evidence Using Data from Tanzania (P11-051-19)

ObjectivesExisting data on nutrient intake and status among infants and young children in low- and middle-income countries comes from disparate sources of varying quality and representativeness. Decision-makers are further challenged by incomplete guidance on how to interpret the heterogenous data for program and policy planning. This study describes results of testing a novel method for categorizing the magnitude of dietary nutrient gaps among children 6–23 months at the national level and rating the quality of evidence using data from Tanzania. MethodsWe reviewed scientific articles and grey literature containing information on biochemical nutrient status and dietary intake of children 6–23 months and broader population groups as well as food availability data and household consumption and expenditure surveys and summarized the evidence in a detailed report. Three independent reviewers, one from Tanzania, with expertise in child nutrition and complementary feeding use pre-specified criteria and a scoring template to review the evidence report and rank the magnitude of the gap (none, small, moderate, large, or unknown) and quality of the evidence (none, suggestive, or clear) for 13 common problem nutrients. Scores were combined to produce a simple evidence gap chart to aid decision-makers. ResultsPreliminary findings from the evidence report suggest iron, vitamin A, and calcium are clearly lacking in the complementary feeding diet nationally with suggestive evidence for inadequate energy and quality protein. Evidence for other common problem nutrients is low in quality or missing. Final rankings and concordance of the reviewers of the magnitude of each nutrient gap and quality of the evidence will be presented at Nutrition 2019. ConclusionsReviewing the literature on complementary feeding nutrient gaps from a range of sources and providing a scoring template allows nutrition experts to easily quantify gaps of common problem nutrients and rank the quality of evidence. The combined scoring charts provide robust but clear and simple guidance to inform program design and identify critical evidence gaps. Funding SourcesMinistry of the Foreign Affairs of the Netherlands.

Biomechanical factors related to clinical vs. structural progression of knee OA

Purpose: The purpose of this presentation is to provide an overview of the in vivo human gait studies investigating biomechanical factors related to clinical (i.e. evidence of structural damage and symptoms) versus structural severity/progression in knee osteoarthritis (OA). Background: Biochemical responses, commonly triggered by biomechanical factors, are related to changes in the homeostatic balance of articular cartilage synthesis and degradation associated with OA. Historically, cartilage degradation has been the hallmark for OA; however, its effects on other structures such as muscles, ligaments, synovium and nerves are gaining recognition. The presence of symptoms is also fundamental in diagnosing OA (e.g. pain, stiffness, swelling, etc.), with pain as the most common symptom for seeking clinical care. Importantly, the level of pain and degree of structural damage are not well correlated in individuals with knee OA and suggest that each component may progress using different pathways. Much of our existing knowledge about OA mechanisms comes from fundamental in vitro or animal model studies that link biomechanical loading to biochemical responses related to OA processes (i.e. cartilage damage, inflammation and pain). In human models, gait (i.e. walking) studies have been the primary source of information for understanding knee joint-level loading in knee OA, and much of the work to date has examined joint moments from biomechanical models. Over the past 10 years an increasing number of studies have examined muscle activation patterns, including the contribution of muscles when modelling joint contact loads associated with OA processes. Summary: Differences in joint moment and muscle activation patterns have been associated with the level of structural severity, and evidence exists that associates specific pattern features with increased risk of structural progression defined using radiography and magnetic resonance imaging. Although fewer studies have focused on biomechanical and muscle activation patterns associated with clinical severity and risk of clinical progression, interesting trends are emerging and differ from features observed for structural outcomes. These gait studies provide information related to the magnitude, distribution, pattern and duration of joint loading. Features associated with the magnitude of joint moments are related to structural processes, whereas muscle function features and patterns of loading are linked with clinical outcomes such as joint replacement surgery. A critical evidence gap exists among these human studies related to the effect of loading frequency on OA progression. Aerobic exercise, particularly increasing walking frequency, is recommended across international non-surgical, non-pharmacological knee OA management guidelines based on pain relief, improved general health (i.e. cardiovascular outcomes), and the response of healthy cartilage to physical activity and exercise, but less on the effects on damaged tissue. The few human studies that link joint loading features during locomotion to biomarkers related to cartilage damage and pain processes in individuals with knee OA provide early evidence of a causal effect. Conclusions: Collectively, the work to date suggests that different biomechanical targets exist for structural versus clinical OA processes and should be considered when tailoring person-specific interventions.

A Novel Just-in-Time Contextual Mobile App Intervention to Reduce Sodium Intake in Hypertension: Protocol and Rationale for a Randomized Controlled Trial (LowSalt4Life Trial).

BackgroundHigh sodium intake is a significant public health problem in the United States. Interventions that lower sodium intake can decrease blood pressure and improve cardiovascular outcomes. Restaurants and grocery stores are prime targets for intervention with about 77% of all sodium intake in the average US diet coming from processed and restaurant foods.ObjectiveThis study proposes that a mobile app intervention that promotes low-sodium alternatives at grocery stores and restaurants will reduce dietary intake of sodium and improve confidence following a low-sodium diet in hypertension.MethodsIn this single-center, prospective, open-label study, patients will be randomized to a mobile app or usual care for 8 weeks. We will randomize 50 patients (age>18 years) diagnosed with hypertension and on antihypertensive therapy for at least 3 months in a 1:1 manner stratified by gender. Study subjects will receive the mobile app, LowSalt4Life, or usual dietary advice for 8 weeks. LowSalt4Life provides a multifaceted intervention based on just-in-time contextual tailored messages at grocery stores and restaurants. The primary endpoint is the change in the estimated 24-hour urinary excretion of sodium from spot urine. Secondary outcomes include change in the sodium content of the food frequency questionnaire, confidence in following a low-sodium diet, urine chloride and creatinine dipsticks, and blood pressure.ResultsThe project was funded in May 2016 until April 2018. This trial is currently enrolling patients. To date, 26 of the 50 patients needed have been enrolled. Results will be available in the Spring of 2019.ConclusionsThis randomized controlled trial will test the efficacy of just-in-time contextual tailored messages through a novel mobile app 8-week intervention on urinary sodium excretion in patients with hypertension. We will address a critical evidence gap in the care of patients with hypertension. If effective, this intervention could be scaled to assess effects on blood pressure and cardiovascular events in hypertension.Trial RegistrationClinicalTrials.gov NCT03099343; https://clinicaltrials.gov/ct2/show/NCT03099343 (Archived by WebCite at http://www.webcitation.org/735HNzKlQ)International Registered Report Identifier (IRRID)PRR1-10.2196/11282

Fluid administration for acute circulatory dysfunction using basic monitoring: narrative review and expert panel recommendations from an ESICM task force.

An international team of experts in the field of fluid resuscitation was invited by the ESICM to form a task force to systematically review the evidence concerning fluid administration using basic monitoring. The work included a particular emphasis on pre-ICU hospital settings and resource-limited settings. The work focused on four main questions: (1) What is the role of clinical assessment to guide fluid resuscitation in shock? (2) What basic monitoring is required to perform and interpret a fluid challenge? (3) What defines a fluid challenge in terms of fluid type, ranges of volume, and rate of administration? (4) What are the safety endpoints during a fluid challenge? The expert panel found insufficient evidence to provide recommendations according to the GRADE system, and was only able to make recommendations for basic interventions, based on the available evidence and expert opinion. The panel identified significant gaps in the scientific evidence on fluid administration outside the ICU (excluding the operating theater). Globally, scientific communities and health care systems should address these critical gaps in evidence through research on how basic fluid administration in resource-rich and resource-limited settings can be improved for the benefit of patients and societies worldwide.

Understanding and Improving the Health of People Who Experience Incarceration: An Overview and Synthesis.

The world prison population is growing at a rate that exceeds the rate of population growth. This issue of Epidemiologic Reviews comprises articles in which researchers summarize what is known about some of the key health issues facing people in prison, particularly in relation to human immunodeficiency virus and other blood-borne viral infections. A key recurring theme is that addressing the health needs of people in prison is important to reducing health inequalities at the population level—that prisoner health is public health. The reviews also highlight some critical evidence gaps, notably the lack of evidence from low- and middle-income countries, and the limited number of longitudinal studies in which health behaviors, health outcomes, or health service experiences after release from prison are documented. Despite growing evidence of the poor health of detained adolescents, none of the included reviews considered this population. Further research on the health of young people who cycle through juvenile detention should be a priority. Despite a rapidly growing literature on the health of people who experience incarceration, some critical health issues remain poorly understood, and there has been insufficient attention devoted to co-occurring health conditions and the consequent need for coordinated care. Key populations in custodial settings remain understudied, limiting capacity to develop targeted, evidence-based responses to their health needs. The quality of many studies is suboptimal, and although rigorous, independent research in correctional settings can be challenging, it is not impossible and is critical to laying the groundwork for evidence-based reform.

New Advances in Acute Postoperative Pain Management.

Postoperative pain remains one of the most common challenges following inpatient and outpatient surgeries. With our advances in modern medicine, pain following surgical procedures still remains a challenge, though significant accomplishments have been made over the past few decades. This article highlights some of the promising new advances and approaches in postoperative pain management. Over the last decade, Enhanced Recovery after Surgery (ERAS) pathways and protocols are becoming the benchmark standards for enhancing postoperative recovery. Multimodal analgesia (MMA) is an essential component of such care. Further, in the wake of serious and persistent concern on the opioid epidemic in the USA, there has been a recent renewal of interest in non-opioid alternatives or adjuncts in controlling postoperative pain, often in the context of MMA. Intravenous (IV) acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), magnesium, ketamine, dexmedetomidine, liposomal bupivacaine, and newer neuraxial and peripheral regional techniques as well as patient-controlled modalities are gaining importance. Gabapentinoids have become popular but recent meta-analytic reviews have cast doubt on their routine use in perioperative settings. Among opioids, sublingual sufentanil, IV oxycodone, and iontophoretic transdermal fentanyl hold promise. Acupuncture and transcutaneous electrical nerve stimulation may be useful as adjuncts in MMA packages. Genetic testing, derivatives of herbal preparations, and an extended role of acute pain services may emerge as potential areas of importance in the future. There are, however, critical gaps in good quality evidence in many of the practice guideline recommendations. In the era of opioid epidemic, several lines of evidence have emerged to support non-opioid-based drugs and approaches along with a few newer opioid formulations for postoperative pain management, although more research is needed to find the right balance of efficacy and safety.

Gaps in evidence regarding iron deficiency anemia in pregnant women and young children: summary of US Preventive Services Task Force recommendations

The US Preventive Services Task Force (USPSTF) makes recommendations to primary care providers regarding preventive services for asymptomatic patients. Recommendations are based on the scientific evidence that the delivery of the preventive service leads to improvements in meaningful patient outcomes. After a review of the available evidence, the USPSTF found insufficient evidence to recommend routine iron supplementation for pregnant women or routine screening for iron deficiency anemia in pregnant women or young children. The USPSTF identified a critical evidence gap that is related to whether changing hematologic indexes in otherwise asymptomatic pregnant women or in infants within populations who are reflective of the United States leads to an improvement in maternal or child health outcomes. Future research opportunities are described to address these important evidence gaps.