Health Benefits of Different Sports: a Systematic Review and Meta-Analysis of Longitudinal and Intervention Studies Including 2.6 Million Adult Participants

BACKGROUND

Several reviews have examined the health benefits of participation in specific sports, such as baseball, cricket, cross-country skiing, cycling, downhill skiing, football, golf, judo, rugby, running and swimming. However, new primary studies on the topic have recently been published, and the respective meta-analytic evidence needs to be updated.

OBJECTIVES

To systematically review, summarise and appraise evidence on physical health benefits of participation in different recreational sports.

METHODS

Searches for journal articles were conducted in PubMed/MEDLINE, Scopus, SpoLit, SPORTDiscus, Sports Medicine & Education Index and Web of Science. We included longitudinal and intervention studies investigating physical health outcomes associated with participation in a given sport among generally healthy adults without disability.

RESULTS

A total of 136 papers from 76 studies conducted among 2.6 million participants were included in the review. Our meta-analyses of available evidence found that: (1) cycling reduces the risk of coronary heart disease by 16% (pooled hazard ratio [HR] = 0.84; 95% confidence interval [CI]: 0.80, 0.89), all-cause mortality by 21% (HR = 0.79; 95% CI: 0.73, 0.84), cancer mortality by 10% (HR = 0.90; 95% CI: 0.85, 0.96) and cardiovascular mortality by 20% (HR = 0.80; 95% CI: 0.74, 0.86); (2) football has favourable effects on body composition, blood lipids, fasting blood glucose, blood pressure, cardiovascular function at rest, cardiorespiratory fitness and bone strength (p < 0.050); (3) handball has favourable effects on body composition and cardiorespiratory fitness (p < 0.050); (4) running reduces the risk of all-cause mortality by 23% (HR = 0.77; 95% CI: 0.70, 0.85), cancer mortality by 20% (HR = 0.80; 95% CI: 0.72, 0.89) and cardiovascular mortality by 27% (HR = 0.73; 95% CI: 0.57, 0.94) and improves body composition, cardiovascular function at rest and cardiorespiratory fitness (p < 0.010); and (5) swimming reduces the risk of all-cause mortality by 24% (HR = 0.76; 95% CI: 0.63, 0.92) and improves body composition and blood lipids (p < 0.010).

CONCLUSIONS

A range of physical health benefits are associated with participation in recreational cycling, football, handball, running and swimming. More studies are needed to enable meta-analyses of health benefits of participation in other sports. PROSPERO registration number CRD42021234839.

The overlap of accessory virulence factors and multidrug resistance among clinical and surveillance Klebsiella pneumoniae isolates from a neonatal intensive care unit in Nepal: a single-centre experience in a resource-limited setting

BACKGROUND

There is a lack of data on the characteristics of overlap between acquired antimicrobial resistance and virulence factors in Klebsiella pneumoniae in high-risk settings, especially with the inclusion of surveillance isolates along with the clinical. We investigated K. pneumoniae isolates, from a neonatal intensive care unit (NICU) in Nepal, for the presence of both accessory virulence factors and acquired antimicrobial resistance.

METHODS

Thirty-eight clinical and nineteen surveillance K. pneumoniae isolates obtained between January 2017 and August 2022 in the NICU of Siddhi Memorial Hospital, Bhaktapur, Nepal were investigated with antimicrobial susceptibility testing, PCR-based detection of β-lactamases and virulence factors, and genetic similarity by ERIC-PCR.

RESULTS

K. pneumoniae was found positive in 37/85 (43.5%) blood culture-positive neonatal bloodstream infections, 34/954 (3.6%) patient surveillance cultures, and 15/451 (3.3%) environmental surveillance samples. Among 57 isolates analyzed in this study, we detected multidrug resistance in 37/57 (64.9%), which was combined with at least one accessory virulence factor in 21/37 (56.8%). This overlap was mostly among β-lactamase producing isolates with accessory mechanisms of iron acquisition. These isolates displayed heterogenous ERIC-PCR patterns suggesting genetic diversity.

CONCLUSIONS

The clinical significance of this overlap between acquired antimicrobial resistance and accessory virulence genes in K. pneumoniae needs further investigation. Better resource allocation is necessary to strengthen infection prevention and control interventions in resource-limited settings.

The causes of bacterial bloodstream infections and antimicrobial resistance patterns in children attending a secondary care hospital in Bhaktapur, Nepal, 2017-2022: a retrospective study

Objectives

Data on antimicrobial resistance (AMR) among children in Nepal are limited. Here we have characterized the causes of bacterial bloodstream infections (BSIs), antimicrobial resistance patterns and the mechanisms of β-lactamase production in Enterobacterales among children attending outpatient and inpatient departments of a secondary care paediatric hospital in Nepal.

Methods

We retrospectively collected demographic and clinical data of culture-proven bacterial BSIs between January 2017 and December 2022 among children <18 years attending a 50-bedded paediatric hospital. Stored isolates were subcultured for antimicrobial susceptibility testing against commonly used antimicrobials. Enterobacterales displaying non-susceptibility to β-lactams were phenotypically and genotypically investigated for ESBLs, plasmid-mediated AmpC (pAmpC) β-lactamases and carbapenemases.

Results

A total of 377 significant bacteria were isolated from 27 366 blood cultures. Among 91 neonates with a BSI, Klebsiella pneumoniae (n = 39, 42.4%), Pseudomonas aeruginosa (n = 15, 16.3%) and Acinetobacter baumannii complex (n = 13, 14.1%) were most common. In the non-neonates, 275/285 (96.5%) infections were community-acquired including Staphylococcus aureus (n = 89, 32.4%), Salmonella Typhi (n = 54, 19.6%) and Streptococcus pneumoniae (n = 32, 11.6%). Among the 98 S. aureus, 29 (29.6%) were methicillin-resistant Staphylococcus aureus. K. pneumoniae and Escherichia coli demonstrated non-susceptibility to extended-spectrum cephalosporins and carbapenems in both community and hospital-acquired cases. For E. coli and K. pneumoniae, blaCTX-M (45/46), blaEBC (7/10) and blaOXA-48 (5/6) were common among their respective groups.

Conclusions

We determined significant levels of AMR among children attending a secondary care paediatric hospital with BSI in Nepal. Nationwide surveillance and implementation of antimicrobial stewardship policies are needed to combat the challenge imposed by AMR.

Community-based mental health interventions in low- and middle-income countries: a qualitative study with international experts

BACKGROUND

Mental health services are scarce in low- and middle-income countries (LMICs), and designing and implementing effective interventions can be difficult. The aim of this international study was to explore the key lessons for developing, implementing, and evaluating community-based mental health and well-being interventions in LMICs, with an additional focus on older adults.

METHODS

Research and clinical experts in developing and implementing psychosocial community-based interventions in LMICs were interviewed remotely between October 2021 and January 2022. Participants were recruited via existing global health networks and via published literature searches. Participants were asked about their experiences of developing and implementing interventions, and about key barriers and facilitators during the process. Interviews lasted up to 45 min, and data were analysed using combined inductive and deductive thematic analysis.

RESULTS

Sixteen global mental health experts participated. Five themes with different sub-themes were generated: Mechanisms and contexts; Barriers; Facilitators; Public and stakeholder involvement; Looking through an ageing lens. The development and delivery of mental health interventions in LMICs are facilitated through integration into existing health infrastructures and working with existing job roles as delivery agents. Public and stakeholder involvement are crucial at all stages of development through to implementation to focus on meeting local needs and sustaining participant motivation. Logistical barriers of transport, resources, and location need to be addressed, emphasising local sustainability.

CONCLUSIONS

This study provides important insights for how the development, implementation, and evaluation of community-based mental health and well-being interventions in LMICs can be optimised, and can complement general guidance into complex interventions developments.

Cecal volvulus following appendectomy in a teenage patient: A case report

Patients mimicking appendicitis symptoms in a rural setting or those post-appendectomy, indicating cecal volvulus, should always be considered. Swift action can prevent catastrophic consequences.

Abstract

We present a case of a 14-year-old female who initially underwent open appendectomy for acute appendicitis and subsequently experienced symptoms of abdominal distention, vomiting, and fever. Her condition deteriorated following the appendectomy, despite a prior appendectomy for similar symptoms at a different facility. A computed tomography (CT) scan identified cecal volvulus as the underlying issue. This led to the performance of a laparotomy, cecopexy, and decompressive ileostomy. After six weeks, ileostomy closure was successfully carried out, and the patient currently enjoys good health. This case highlights the significance of considering uncommon factors as potential contributors to postoperative complications in young patients.

Deferred cord clamping, cord milking, and immediate cord clamping at preterm birth: a systematic review and individual participant data meta-analysis

BACKGROUND

Umbilical cord clamping strategies at preterm birth have the potential to affect important health outcomes. The aim of this study was to compare the effectiveness of deferred cord clamping, umbilical cord milking, and immediate cord clamping in reducing neonatal mortality and morbidity at preterm birth.

METHODS

We conducted a systematic review and individual participant data meta-analysis. We searched medical databases and trial registries (from database inception until Feb 24, 2022; updated June 6, 2023) for randomised controlled trials comparing deferred (also known as delayed) cord clamping, cord milking, and immediate cord clamping for preterm births (<37 weeks' gestation). Quasi-randomised or cluster-randomised trials were excluded. Authors of eligible studies were invited to join the iCOMP collaboration and share individual participant data. All data were checked, harmonised, re-coded, and assessed for risk of bias following prespecified criteria. The primary outcome was death before hospital discharge. We performed intention-to-treat one-stage individual participant data meta-analyses accounting for heterogeneity to examine treatment effects overall and in prespecified subgroup analyses. Certainty of evidence was assessed with Grading of Recommendations Assessment, Development, and Evaluation. This study is registered with PROSPERO, CRD42019136640.

FINDINGS

We identified 2369 records, of which 48 randomised trials provided individual participant data and were eligible for our primary analysis. We included individual participant data on 6367 infants (3303 [55%] male, 2667 [45%] female, two intersex, and 395 missing data). Deferred cord clamping, compared with immediate cord clamping, reduced death before discharge (odds ratio [OR] 0·68 [95% CI 0·51-0·91], high-certainty evidence, 20 studies, n=3260, 232 deaths). For umbilical cord milking compared with immediate cord clamping, no clear evidence was found of a difference in death before discharge (OR 0·73 [0·44-1·20], low certainty, 18 studies, n=1561, 74 deaths). Similarly, for umbilical cord milking compared with deferred cord clamping, no clear evidence was found of a difference in death before discharge (0·95 [0·59-1·53], low certainty, 12 studies, n=1303, 93 deaths). We found no evidence of subgroup differences for the primary outcome, including by gestational age, type of delivery, multiple birth, study year, and perinatal mortality.

INTERPRETATION

This study provides high-certainty evidence that deferred cord clamping, compared with immediate cord clamping, reduces death before discharge in preterm infants. This effect appears to be consistent across several participant-level and trial-level subgroups. These results will inform international treatment recommendations.

FUNDING

Australian National Health and Medical Research Council.

Short, medium, and long deferral of umbilical cord clamping compared with umbilical cord milking and immediate clamping at preterm birth: a systematic review and network meta-analysis with individual participant data

BACKGROUND

Deferred (also known as delayed) cord clamping can improve survival of infants born preterm (before 37 weeks of gestation), but the optimal duration of deferral remains unclear. We conducted a systematic review and individual participant data network meta-analysis with the aim of comparing the effectiveness of umbilical cord clamping strategies with different timings of clamping or with cord milking for preterm infants.

METHODS

We searched medical databases and trial registries from inception until Feb 24, 2022 (updated June 6, 2023) for randomised controlled trials comparing cord clamping strategies for preterm infants. Individual participant data were harmonised and assessed for risk of bias and quality. Interventions were grouped into immediate clamping, short deferral (≥15 s to <45 s), medium deferral (≥45 s to <120 s), long deferral (≥120 s), and intact cord milking. The primary outcome was death before hospital discharge. We calculated one-stage, intention-to-treat Bayesian random-effects individual participant data network meta-analysis. This study was registered with PROSPERO, CRD42019136640.

FINDINGS

We included individual participant data from 47 trials with 6094 participants. Of all interventions, long deferral reduced death before discharge the most (compared with immediate clamping; odds ratio 0·31 [95% credibility interval] 0·11-0·80; moderate certainty). The risk of bias was low for 10 (33%) of 30 trials, 14 (47%) had some concerns, and 6 (20%) were rated as having a high risk of bias. Heterogeneity was low, with no indication of inconsistency.

INTERPRETATION

This study found that long deferral of clamping leads to reduced odds of death before discharge in preterm infants. In infants assessed as requiring immediate resuscitation, this finding might only be generalisable if there are provisions for such care with the cord intact. These results are based on thoroughly cleaned and checked individual participant data and can inform future guidelines and practice.

FUNDING

Australian National Health and Medical Research Council.

Characterization of Transferrable Mechanisms of Quinolone Resistance (TMQR) among Quinolone-resistant Escherichia coli and Klebsiella pneumoniae causing Urinary Tract Infection in Nepalese Children

BACKGROUND

Transferrable mechanisms of quinolone resistance (TMQR) can lead to fluoroquinolone non-susceptibility in addition to chromosomal mechanisms. Some evidence suggests that fluoroquinolone resistance is increasing among the pediatric population. We sought to determine the occurrence of TMQR genes among quinolone-resistant E. coli and K. pneumoniae causing urinary tract infections among Nepalese outpatient children (< 18 years) and identify molecular characteristics of TMQR-harboring isolates.

METHODS

We performed antimicrobial susceptibility testing, phenotypic extended-spectrum β-lactamase (ESBL) and modified carbapenem inactivation method tests, and investigated the presence of six TMQR genes (qnrA, qnrB, qnrS, aac(6')-Ib-cr, oqxAB, qepA), three ESBL genes (blaCTX-M, blaTEM, blaSHV), and five carbapenemase genes (blaNDM, blaOXA-48, blaKPC, blaIMP, blaVIM). The quinolone resistance-determining region (QRDR) of gyrA and parC were sequenced for 35 TMQR-positive isolates.

RESULTS

A total of 74/147 (50.3%) isolates were TMQR positive by multiplex PCR [aac(6')-Ib-cr in 48 (32.7%), qnrB in 23 (15.7%), qnrS in 18 (12.3%), qnrA in 1 (0.7%), and oqxAB in 1 (0.7%) isolate]. The median ciprofloxacin minimum inhibitory concentration of TMQR-positive isolates (64 µg/mL) was two-fold higher than those without TMQR (32 µg/mL) (p = 0.004). Ser-83→Leu and Asp-87→Asn in GyrA and Ser-80→Ile in ParC were the most common QRDR mutations (23 of 35). In addition, there was a statistically significant association between TMQR and two β-lactamase genes; blaCTX-M (p = 0.037) and blaTEM (p = 0.000).

CONCLUSION

This study suggests a high prevalence of TMQR among the quinolone-resistant E. coli and K. pneumoniae isolates causing urinary tract infection in children in this area of Nepal and an association with the carriage of ESBL gene. This is a challenge for the management of urinary infections in children. Comprehensive prospective surveillance of antimicrobial resistance in these common pathogens will be necessary to devise strategies to mitigate the emergence of further resistance.

Association between hearing aid use and all-cause and cause-specific dementia: an analysis of the UK Biobank cohort

BACKGROUND

Dementia and hearing loss are both highly prevalent conditions among older adults. We aimed to examine the association between hearing aid use and risk of all-cause and cause-specific dementia among middle-aged and older-aged adults, and to explore the roles of mediators and moderators in their association.

METHODS

We used data from the UK Biobank, a population-based cohort study, which recruited adults aged 40-69 years between 2006 and 2010 across 22 centres in England, Scotland, and Wales. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% CIs between self-reported hearing aid use status (hearing loss with or without hearing aids) at baseline and risk of dementia (all-cause dementia, Alzheimer's disease, vascular dementia, and non-Alzheimer's disease non-vascular dementia). Dementia diagnoses were ascertained using hospital records and death-register data. We also analysed the roles of mediators (self-reported social isolation, loneliness, and mood) and moderators (self-reported education and income, smoking, morbidity, and measured APOE allele status).

FINDINGS

After the exclusion of people who did not answer the question on hearing difficulties (n=25 081 [5·0%]) and those with dementia at baseline visit (n=283 [0·1%]), we included 437 704 people in the analyses. Compared with participants without hearing loss, people with hearing loss without hearing aids had an increased risk of all-cause dementia (HR 1·42 [95% CI 1·29-1·56]); we found no increased risk in people with hearing loss with hearing aids (1·04 [0·98-1·10]). The positive association of hearing aid use was observed in all-cause dementia and cause-specific dementia subtypes (Alzheimer's disease, vascular dementia, and non-Alzheimer's disease non-vascular dementia). The attributable risk proportion of dementia for hearing loss was estimated to be 29·6%. Of the total association between hearing aid use and all-cause dementia, 1·5% was mediated by reducing social isolation, 2·3% by reducing loneliness, and 7·1% by reducing depressed mood.

INTERPRETATION

In people with hearing loss, hearing aid use is associated with a risk of dementia of a similar level to that of people without hearing loss. With the postulation that up to 8% of dementia cases could be prevented with proper hearing loss management, our findings highlight the urgent need to take measures to address hearing loss to improve cognitive decline.

FUNDING

National Natural Science Foundation of China and Shandong Province, Taishan Scholars Project, China Medical Board, and China Postdoctoral Science Foundation.

Number of Live Births, Age at the Time of Having a Child, Span of Births and Risk of Dementia: A Population-Based Cohort Study of 253,611 U.K. Women

Objectives: The association between birth-related factors and dementia is unclear. We aimed to investigate their association and subsequent risk of dementia in a large-scale follow-up prospective study. Materials and Methods: This population-based cohort study used data from U.K. Biobank (2006-2010), and the median follow-up was 12.0 years. Multivariable-adjusted Cox proportional hazard models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) between number of children, age of first live birth, age of last live birth, span of births, and dementia. Restricted cubic spline models were used to quantify dose-response relationships. Results: A total of 253,611 women with mean age (standard deviation) of 56.3 (8.0) years were included. Compared with women with no child, women who had three or more children and first birth at age before 25 years, had elevated risk of all-cause dementia (HR: 1.30, 95% CI: 1.10-1.54), Alzheimer's disease (AD; 1.21, 1.00-1.46), and vascular dementia (VD; 1.59, 1.19-2.13). Also, women with three or more children and the last birth at age before 30 years, had increased risk of all-cause dementia (1.33, 1.11-1.59), AD (1.27, 1.03-1.57), and VD (1.55, 1.12-2.13). Moreover, women who had three or more children in <7 years, had an increased risk of all-cause dementia (1.25, 1.04-1.49). Dose-response relationship showed a lowest risk of dementia at having two children, and having three or more children in 7-9 years. Conclusions: Number of children, age of births, and span of births were all related to risk of dementia. These findings may help developing fertility policies or dementia prevention programs.

COVID 19 Vaccine Breakthrough Infection among Health Care Workers

Background Mass vaccination is considered the primary strategy for reducing the impact of COVID-19, and it has been implemented globally. Objective To study the extent of SARS-CoV-2 infection and breakthrough infection among the HCWs who were fully vaccinated for at least 14 days and investigated the relation between neutralizing antibody response and breakthrough infection. Method This study was a retrospective cohort study among health care workers at Dhulikhel Hospital Kathmandu University Hospital from December 2021 to October 2022. The interviews with semi structured questionnaire were conducted in person or over phone. Out of 1450 participants 137 fully vaccinated HCWs without breakthrough infection were randomly selected for the prospective serological cohort. Result Out of 1079 participants' majority (51.8%) were of age 25-34 years. Two thirds (66.7%) were females. More than half of participant (54.7%) had infection with SARS-CoV-2 at least once whereas more than one third people (35%) had reported SARS-CoV-2 infection 14 days after receiving full vaccination. Infection after vaccination had less moderate and sever/critical illness and less need for hospitalization as compared to infection before vaccination. Staffs who were directly involved in patient care had higher chance of breakthrough infection compared to those not involved directly in patient care. Those who had prior infection or booster dose had relatively higher antibody level and participants with low level of antibody had higher chance for breakthrough infection (35.3%) than participants with moderate to high level of antibody (11.9%). Conclusion Vaccinations significantly decreased severe diseases and the need for hospitalizations. Breakthrough infection was higher among the health care workers involved in direct patient care and with low level of antibody.

Optimizing cord management for each preterm baby - Challenges of collating individual participant data and recommendations for future collaborative research

The optimal cord management strategy at birth for each preterm baby is still unknown, despite more than 100 randomized controlled trials (RCTs) undertaken on this question. To address this, we brought together all RCTs examining cord management strategies at preterm birth in the iCOMP (individual participant data on COrd Management at Preterm birth) Collaboration, to perform an individual participant data network meta-analysis. In this paper, we describe the trials and tribulations around obtaining individual participant data to resolve controversies around cord clamping, and we derive key recommendations for future collaborative research in perinatology. To reliably answer outstanding questions, future cord management research needs to be collaborative and coordinated, by aligning core protocol elements, ensuring quality and reporting standards are met, and carefully considering and reporting on vulnerable sub-populations. The iCOMP Collaboration is an example of the power of collaboration to address priority research questions, and ultimately improve neonatal outcomes worldwide.

Cross-cultural Adaptation and Psychometric Properties of Nepali Version of Developmental Coordination Disorder Questionnaire

Background Revised developmental coordination disorder questionnaire (DCDQ'07) is the best available population-based screening tool to identify developmental coordination disorder and being a parent reported tool, it needs to be available in Nepali language for its application in Nepali population. Objective The objective of this study was to cross-culturally adapt developmental coordination disorder questionnaire into Nepali (DCDQ-NP). The psychometric properties of Nepali version of Developmental coordination disorder questionnaire were established. Method The adaptation was done following Beaton's guideline and the psychometric properties was studied in the community sample of 165 parents of school going children of 5-15 years. Fifty parents were asked to refill the questionnaire after the two weeks period. The study determines internal consistency, test retest reliability, floor and ceiling effect and construct validity. Result Significant cultural adaptation was required to obtain relevant Nepali version. The Nepali version of Developmental coordination disorder questionnaire demonstrates high internal consistency (α = 0.912), excellent test-retest reliability (IC = 0.901) and the floor and ceiling effect were acceptable. Principal component analysis showed three factor structure accounting 62% of variance. Conclusion The developmental coordination disorder questionnaire into Nepali were successfully translated and culturally adapted preserving its original concept. It showed good psychometric properties in a Nepali population. The adapted questionnaire shall be of significance in carry out further research in developmental coordination disorder in Nepal.

Post-tonsillectomy Hemorrhage in Patients Receiving Ketorolac Analgesic

Background Ketorolac, the non-steroidal anti-inflammatory drug, is thought to have less sedation as well as postoperative nausea and vomiting in comparison to opioids, but with higher risk of post-tonsillectomy hemorrhage as reported in some of the literatures. There is no consensus till date in the use of ketorolac in the management of pain following tonsil and adenoid related surgeries. Objective To find out the incidence of hemorrhage following tonsil and adenoid related surgeries in patients receiving ketorolac in postoperative period. Method This is a retrospective chart review of patients undergoing tonsil and adenoid related surgeries who had received ketorolac during April, 2013 to May, 2019 at department of ENT-HNS, Patan Academy of Health Sciences (PAHS), Lalitpur, Nepal. Post-tonsillectomy hemorrhage rate was calculated in pediatric and adult patients. Result During the study period, 103 patients (male - 50 and female - 53) received ketorolac in postoperative period. Tonsillectomy and adenotonsillectomy were performed in 71and 32 patients respectively. Forty-five patients were < 18 years whereas 58 were ≥ 18 years. Most common indication for surgery was recurrent tonsillitis (66/103) followed by adenotonsillar hypertrophy (31/103). Post-tonsillectomy hemorrhage was observed in 15 patients; among them, four out 45 were < 18 years and 11 out of 58 ≥ 18 years. All five patients out of 15, who required surgical intervention for post-tonsillectomy hemorrhage, were ≥ 18 years and were operated for recurrent tonsillitis. Rest of the patients (10/15) were managed conservatively. None of the patients required blood transfusion. Conclusion Ketorolac is not associated with increased risk of post-tonsillectomy hemorrhage in children and can safely be administered. Whereas in adults, recurrent tonsillitis being the most common indication for tonsillectomy, it should be used cautiously.

Knowledge, Attitude and Practice of Medical Ethics among Doctors and Nurses in Pokhara Valley, Nepal

Background Medical ethics is defined as the ethical obligations of medical professionals towards their patients, colleagues, and society. The inadequacy and non-uniformity of this topic has been associated with rising cases of professional misconduct and medical negligence all over the world. Objective To assess and compare the status of knowledge, attitude and practice of medical ethics among medical doctors and nurses in three major hospitals of Pokhara valley. Method This was a cross-sectional study conducted from 15th Mar 2018 to 13th Apr 2018; in which 124 doctors and 103 nurses were asked to fill up medical ethics related questionnaire. The data was entered in SPSS file and the association of variables was determined by Chi-square and statistical significance was considered if the p-value < 0.05. Result The study showed that 56.5%, 8.1%, and 13.7% of doctors were aware of the Hippocratic oath, Nuremberg Code, and Helsinki declaration respectively compared to only 1% of nurses. There was a significant difference in opinions on various questions related to medical ethics with p-value < 0.05 in 12 out of 22 questions. Only a few (12.1% doctors vs. 25.2% nurses) stood in support of the physicianassisted dying. Conclusion The study showed that there was inadequate as well as a non-uniform level of knowledge of three major codes of medical ethics and principles related to it which resulted in significant disparity in the attitude and practice of medical ethics among doctors and nurses in Pokhara valley.

Community-based mental health and well-being interventions for older adults in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Mental health support is often scarce in low- and middle-income countries (LMIC), with mental health stigmatised. Older adults are some of the most vulnerable members of society and may require specific types of mental health support. The aim of this mixed-methods systematic review and meta-analysis was to explore the types, components, and efficacy of psychosocial community-based mental health interventions for older adults (aged 60 + years) residing in LMIC.

METHODS

Six databases were searched in August 2021. Studies published since 2000 were included if they collected primary quantitative or qualitative data on community-based interventions for improving mental health for older adults residing in LMICs, focusing on improving mental health and well-being outcomes. Full texts were screened by two researchers.

RESULTS

From 24,378 citations identified, 40 studies met eligibility criteria. Across 12 countries, interventions were categorised into those focusing on (1) Established forms of psychological therapy; (2) Exercise; (3) Education; (4) Social engagement; (5) Multi-component. Most interventions were effective in reducing levels of depression, anxiety, and improving well-being, including reminiscence therapy, different types of socialising, and breathing and laughter exercises. Some interventions reported no benefits and those that did at times failed to report continued benefits at follow-up. Given the variations in intervention type and delivery, cultures, and outcome measures used, underpinning factors of intervention success or failure were difficult to establish.

CONCLUSIONS

Psychosocial interventions for older adults in LMIC need to be adapted to local contexts depending on culture and population needs. Existing interventions and their components can be used as a foundation to produce adapted and multi-component interventions, to tackle growing and inadequate mental health care provision in LMIC.

TRIAL REGISTRATION

The review protocol was registered on PROSPERO [CRD42021271404].

Effects of high-intensity interval training (HIIT) and sprint interval training (SIT) on fat oxidation during exercise: a systematic review and meta-analysis

OBJECTIVE

To investigate the effects of high-intensity interval training (HIIT) and sprint interval training (SIT) on fat oxidation during exercise (FatOx) and how they compare with the effects of moderate-intensity continuous training (MICT).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Academic Search Ultimate, CINAHL, Networked Digital Library of Theses and Dissertations, Open Access Theses and Dissertations, OpenDissertations, PubMed/MEDLINE, Scopus, SPORTDiscus and Web of Science.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies using a between-group design, involving adult participants who were not trained athletes, and evaluating effects of HIIT or SIT on FatOx (vs no exercise or MICT) were included.

RESULTS

Eighteen studies of fair-to-good quality were included; nine comparing HIIT or SIT with no exercise and eleven comparing HIIT or SIT with MICT. A significant pooled effect of these types of interval training on FatOx was found (mean difference in g/min (MD)=0.08; 95% confidence interval (CI) 0.04 to 0.12; p<0.001). Significant effects were found for exercise regimens lasting ≥4 weeks, and they increased with every additional week of training (β=0.01; 95% CI 0.00 to 0.02; p=0.003). HIIT and/or SIT were slightly more effective than MICT (MD=0.03; 95% CI 0.01 to 0.05; p=0.005). The effects on FatOx were larger among individuals with overweight/obesity.

CONCLUSION

Engaging in HIIT or SIT can improve FatOx, with larger effects expected for longer training regimens and individuals with overweight/obesity. While some effects seem small, they may be important in holistic approaches to enhance metabolic health and manage obesity.

Sex differences in the association between cardiovascular diseases and dementia subtypes: a prospective analysis of 464,616 UK Biobank participants

BACKGROUND

Whether the association of cardiovascular diseases (CVDs) with dementia differs by sex remains unclear, and the role of socioeconomic, lifestyle, genetic, and medical factors in their association is unknown.

METHODS

We used data from the UK Biobank, a population-based cohort study of 502,649 individuals. We used Cox proportional hazards models to estimate sex-specific hazard ratios (HRs) and 95% confidence intervals (CI), and women-to-men ratio of HRs (RHR) for the association between CVD (coronary heart diseases (CHD), stroke, and heart failure) and incident dementia (all-cause dementia, Alzheimer's Disease (AD), and vascular dementia (VD)). The moderator roles of socioeconomic (education, income), lifestyle (smoking, BMI, leisure activities, and physical activity), genetic factors (APOE allele status), and medical history were also analyzed.

RESULTS

Compared to people who did not experience a CVD event, the HRs (95%CI) between CVD and all-cause dementia were higher in women compared to men, with an RHR (Female/Male) of 1.20 (1.13, 1.28). Specifically, the HRs for AD were higher in women with CHD and heart failure compared to men, with an RHR (95%CI) of 1.63 (1.39, 1.91) and 1.32 (1.07, 1.62) respectively. The HRs for VD were higher in men with heart failure than women, with RHR (95%CI) of 0.73 (0.57, 0.93). An interaction effect was observed between socioeconomic, lifestyle, genetic factors, and medical history in the sex-specific association between CVD and dementia.

CONCLUSION

Women with CVD were 1.5 times more likely to experience AD than men, while had 15% lower risk of having VD than men.

Demographics and Awareness of Diabetic Retinopathy among Diabetic Patients Attending Department of Ophthalmology at Dhulikhel Hospital

Background Diabetes mellitus is considered as a major public health concern globally. Poor management of diabetes may lead to several serious complications including endstage renal disease, diabetic retinopathy, diabetic neuropathy, and cardiovascular complications. Among them diabetic retinopathy is one of the leading causes of visual impairment and blindness in Nepal. Objective To assess the demographics and level of awareness among individuals with diabetes about diabetic retinopathy during their visit to Department of Ophthalmology at Dhulikhel Hospital. Method A descriptive cross-sectional study was conducted involving all consecutive cases of diabetes mellitus who attended eye clinic with the principal investigator and co-investigator from March 2021 to August 2021. Detailed demographics of the participants, their level of awareness regarding diabetic retinopathy and associated complications were documented. This was followed by a detailed ocular examination intending to screen for the presence of features of diabetic retinopathy. Result A total of 260 patients with a mean age of 54 years ± 12.20 (range of 24 - 85 years) were included. The male to female ratio was 2.2:1. Among them, 65.4% of the patients had diabetes mellitus for less than 5 years duration. Diabetic retinopathy was found in 18.46% of the cases. Awareness of diabetic ocular complications was significantly higher among literate population (p = 0.054), among those who have positive family history of diabetes mellitus (p = 0.529) and those who had undergone prior fundus evaluation (p = 0.000). Conclusion From result of this study, we can emphasize that there is a necessity for health education in order to increase the awareness and knowledge about diabetic retinopathy to lower the burden of sight threatening complications related with the issue.

Improving Practices of Mental Health Professionals in Recommending More Physical Activity and Less Sedentary Behaviour to Their Clients: An Intervention Trial

We investigated the effects of increasing physical activity (PA) and reducing sedentary behaviour (SB) of mental health professionals on their attitudes towards and practices in recommending more PA and less SB to their clients. A 4-week pre-post intervention trial was conducted involving 17 mental health professionals. The participants who increased their own physical activity during the intervention increased the frequency of recommending more PA (p = 0.009) and less SB (p = 0.005) to their clients. A relatively simple, low-cost intervention, consisting of group behaviour change counselling, goal setting and positive feedback, may improve the practices of mental health professionals.Supplemental data for this article is available online at https://doi.org/10.1080/01612840.2021.1972189 .

Association of reproductive factors with dementia: A systematic review and dose-response meta-analyses of observational studies

BACKGROUND

Associations between endogenous estrogen exposure indicators and risk of subtypes of dementia have been unclear.

METHODS

Databases (PubMed, EMBASE and Web of Science) were searched electronically on 1st July and updated regularly until 12nd November 2021. Observational studies of English language were selected if reported an effect estimate [e.g., odds ratio (OR), rate ratio (RR) or hazard ratio (HR)] and 95% CI for the association between any exposure (age of menarche, age at menopause, reproductive period, estradiol level) and any endpoint variable [all-cause dementia, Alzheimer's disease (AD), vascular dementia (VD), cognitive impairment (CI)]. Random-effects models and dose-response meta-analyses were used to calculate estimates and to show the linear/nonlinear relationship. PROSPERO CRD42021274827.

FINDINGS

We included 22 studies (475 9764 women) in this analysis. We found no clear relationship between late menarche (≥14 vs <14 years) and dementia, CI in categorical meta-analysis compared to a J-shape relationship in dose-response meta-analyses. Later menopause (≥45 vs <45 years) was consistently associated with a lower risk of all-cause dementia (pooled RR: 0.87, 95%CI: 0.78-0.97, I²=56.0%), AD (0.67, 0.44-0.99, I²=78.3%), VD (0.87, 0.80-0.94) and CI (0.82, 0.71-0.94, I²=19.3%) in categorical meta-analysis, showing similar results in dose-response meta-analyses. An inverse relationship between longer reproductive duration (≥35 vs <35 years) and dementia was observed in dose-response meta-analysis. In addition, estradiol levels after menopause were inversely correlated with the risk of AD and CI.

INTERPRETATION

In this study, later menopause and longer reproductive period were associated with a lower risk of dementia, while the relationship for menarchal age was J-shaped. There was an inverse relationship between higher postmenopausal estrogen levels and risk of AD and CI. Longitudinal study are needed to further explore the association between life-time estrogen exposure and risk of subtypes of dementia.

FUNDING

Start-up Foundation for Scientific Research in Shandong University.

Nepal Paediatric Society Guideline for use of Antibiotics in Critically ill Children in the Pediatric Intensive Care Unit

Justification: Overuse and administration of unnecessary and inappropriate antibiotics are the leading causes for the increased antimicrobial resistance worldwide. Judicious use of antimicrobials can prevent this phenomenon.  Objective: Create a collaborative outline for the use of antibiotics in the paediatric intensive care unit for various infections, based on evidence, taking into consideration local antimicrobial susceptibility patterns.  Process / Methods: Under the aegis of Nepal Paediatric Society, this guideline has been developed after several meetings of paediatricians working in various hospitals in different parts of Nepal, looking into the prevalent diseases and local sensitivity patterns of antibiotics.   Recommendations: This guideline will help standardize the treatment protocol in paediatric intensive care units in Nepal and help paediatricians decide the appropriate use of antibiotics promptly while managing critically ill children.  Keywords: Antibiotics; antibiotic sensitivity; antimicrobial resistance; critically ill child; Paediatric Intensive Care Unit 

Barriers, Enablers and Strategies for the Treatment and Control of Hypertension in Nepal: A Systematic Review

Background: Understanding country-specific factors influencing hypertension care is critical to address the gaps in the management of hypertension. However, no systematic investigation of factors influencing hypertension treatment and control in Nepal is available. This study aimed to systematically review the published literature and synthesise the findings on barriers, enablers, and strategies for hypertension treatment and control in Nepal.

Methods: Embase, PubMed, Web of Science, CINAHL, ProQuest and WorldCat, and Nepali journals and government websites were searched for qualitative, quantitative, and mixed-methods studies on factors or strategies related to hypertension treatment and control in Nepal. Information from qualitative studies was analysed using template analysis, while results from quantitative studies were narratively synthesised. Summary findings were framed under “health system”, “provider”, and “patient” domains. The protocol was registered in PROSPERO (registration number: CRD42020145823).

Results: We identified 15 studies; ten related to barriers and enablers and five to strategies. The identified barriers associated with the health system were: lack of affordable services and lack of resources. The barriers at the provider's level were: communication gaps, inadequate counselling, long waiting hours for appointments, lack of national guidelines for hypertension treatment, and provider's unsupportive behaviours. Non-adherence to medication, irregular follow-up visits, lack of awareness on blood pressure target, poor help-seeking behaviours, reluctance to change behaviours, perceived side-effects of anti-hypertensive medication, self-medication, lack of family support, financial hardship, lack of awareness on blood pressure complications, and comorbidity were barriers identified at patient level. The following enablers were identified: free essential health care services, family support, positive illness perception, and drug reminders. Strategies implemented at the health system, provider and patient levels were: establishing digital health records at health centres, health worker's capacity development, and health education.

Conclusion: There is a range of barriers for hypertension treatment and control in Nepal pertaining to the health system, health providers, and patients. Comprehensive interventions are needed at all three levels to further improve management and control of hypertension in Nepal.

Burden of chronic kidney disease in the general population and high-risk groups in South Asia: A systematic review and meta-analysis

BACKGROUND

Chronic kidney disease (CKD) is an emerging public health issue globally. The prevalence estimates on CKD in South Asia are however limited. This study aimed to examine the prevalence of CKD among the general and high-risk population in South Asia.

METHODS

We conducted a systematic review and meta-analysis of population-level prevalence studies in South Asia (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka). Three databases namely PubMed, Scopus and Web of Science were systematically searched for published reports of kidney disease in South Asia up to 28 October 2020. A random-effect model for computing the pooled prevalence was used.

RESULTS

Of the 8749 identified studies, a total of 24 studies were included in the review. The pooled prevalence of CKD among the general population was 14% (95% CI 11-18%), and 15% (95% CI 11-20%) among adult males and 13% (95% CI 10-17%) in adult females. The prevalence of CKD was 27% (95% CI 20-35%) in adults with hypertension, 31% (95% CI 22-41%) in adults with diabetes and 14% (95% CI 10-19%) in adults who were overweight/obese. We found substantial heterogeneity across the included studies in the pooled estimates for CKD prevalence in both general and high-risk populations. The prevalence of CKD of unknown origin in the endemic population was 8% (95% CI 3-16%).

CONCLUSION

Our study reaffirms the previous reports that CKD represents a serious public health challenge in South Asia, with the disease prevalent among 1 in 7 adults in South Asian countries.

Physical activity and sedentary behaviour counselling: Attitudes and practices of mental health professionals

Background

Despite recent interest in the mental health benefits of increasing physical activity (PA) and reducing sedentary behaviour (SB), little is known about PA and SB counselling provided by mental health professionals. Therefore, the aim of this study was to explore the attitudes and practices of mental health professionals in recommending more PA and less SB to their clients.

Methods

Quantitative data were collected using a modified version of the Exercise in Mental Illness Questionnaire in a sample of 17 Australian mental health professionals. The collected data were reported using percentages (for categorical data) and means and standard deviations (for numerical data). Additionally, in focus group discussions, 10 mental health professionals provided in-depth information about their clinical practice, facilitators, and perceived barriers in recommending more PA and less SB. They also provided suggestions on how to potentially improve their PA and SB counselling practices. The focus groups were audio-recorded, transcribed and analysed using thematic analysis.

Results

Only 35.3% of participants have undergone formal training in recommending PA in the treatment of mental illness. Most participants (64.7%) ranked PA counselling among the top three types of mental health treatment. All participants reported recommending PA to their clients at least “occasionally”, while 88% of them also provided SB counselling. However, the recommendations provided were usually not specific. The most commonly reported barriers for providing PA and SB counselling were a lack of knowledge and confidence. Participants also believed that, if they were more active themselves, they would be in a better position to recommend PA to their clients, by sharing their own experience of evidence-informed strategies designed to increase PA and reduce SB.

Conclusion

The findings of this study indicate that mental health professionals commonly provide generic PA and SB counselling to their clients. PA and SB counselling in the mental health setting could be improved by: including training on PA and SB counselling in formal education and continued professional training for mental health professionals; implementing interventions to increase PA and reduce SB among mental health professionals themselves; and ensuring support from an exercise or PA promotion specialist as a part of a multi-disciplinary approach to mental health care.

Health System Preparedness for COVID-19 and Its Impacts on Frontline Health-Care Workers in Nepal: A Qualitative Study Among Frontline Health-Care Workers and Policy-Makers

BACKGROUND

Rapidly growing coronavirus disease 2019 (COVID-19) pandemic has brought unprecedented challenges to the health system in Nepal. The main objective of this study was to explore the health system preparedness for COVID-19 and its impacts on frontline health-care workers in Nepal.

METHODS

Semi-structured interviews were conducted among 32 health-care workers who were involved in clinical care of COVID-19 patients and four policy-makers who were responsible for COVID-19 control and management at central and provincial level. Interviews were conducted through telephone or Internet-based tools such as Zoom and Skype. All interviews were audio-recorded, transcribed into English, and coded using inductive and deductive approaches.

RESULTS

Both health-care workers and policy-makers reported failure to initiate pre-emptive control measures at the early stages of the outbreak as the pivot in pandemic control. Although several measures were rolled out when cases started to appear, the overall health system preparedness was low. The poor governance, and coordination between three tiers of government was compounded by the inadequate personal protective equipment for health-care workers, insufficient isolation beds for patients, and poor engagement of the private sector. Frontline health-care workers experienced various degrees of stigma because of their profession and yet were able to maintain their motivation to continue serving patients.

CONCLUSION

Preparedness for COVID-19 was affected by the poor coordination between three tiers of governance. Specifically, the lack of human resources, inadequate logistic chain management and laboratory facilities for testing COVID-19 appeared to have jeopardized the health system preparedness and escalated the pandemic in Nepal. Despite the poor preparedness, and health and safety concerns, health-care workers maintained their motivation. There is an urgent need for an effective coordination mechanism between various tiers of health structure (including private sector) in addition to incentivizing the health-care workers for the current and future pandemics.

Trends in the Prevalence, Awareness, Treatment, and Control of Hypertension in Nepal between 2000 and 2025: A Systematic Review and Meta-Analysis

BACKGROUND

Understanding the burden and trend of hypertension and the associated care cascade can provide direction to the development of interventions preventing and controlling hypertension. This study aimed to assess prevalence and trends of hypertension and its awareness, treatment, and control in Nepal.

METHODS

We systematically searched CINAHL, Embase, ProQuest, PubMed, Web of Science, WorldCat, and government and health agency-owned websites to identify studies reporting prevalence of hypertension, awareness, treatment, and control in Nepal between 2000 and 2020. We applied the random-effects model to compute the pooled prevalence in the overall population and among subgroups in each 5-year interval period between 2000 and 2020. We used linear meta-regression analysis to predict hypertension from 2000 to 2025.

RESULTS

We identified 23 studies having a total of 84,006 participants. The pooled prevalence of hypertension, awareness, treatment, and control for 2016-2020 was 32% (95% CI: 23-40%), 50% (95% CI: 30-69%), 27% (95% CI: 19-34%), and 38% (95% CI: 28-48%), respectively. The prevalence of hypertension varied by age, gender, education, and geographical area. Hypertension increased by 6 percentage points (pp), awareness increased by 12 pp, treatment increased by 11 pp, and control increased by 3 pp over the 20 years studied. Since 2000, the rate of increment of hypertension has been 3.5 pp per decade, where 44.7% of men are expected to suffer from hypertension by 2025.

CONCLUSION

The markedly increased prevalence of hypertension and relatively poor progress in hypertension awareness, treatment, and control in Nepal suggest that there is a need for hypertension preventive approaches as well as strategies to optimize hypertension care cascade.

Association of altitude and urbanization with hypertension and obesity: analysis of the Nepal Demographic and Health Survey 2016

BACKGROUND

Nepal's Himalayan range attracts mountaineers, climbers and tourists from all across the globe. Limited recent evidence suggests that exposure to hypoxia at a higher altitude may be a risk factor for hypertension and a protective factor for obesity. The existing urban-rural disparities in Nepal in health and economic resources may be anticipated in the burden of hypertension and obesity, two rapidly growing public health issues, but they remain largely unstudied. Therefore this study aims to assess the association of altitude and urbanization with hypertension and overweight/obesity in Nepal.

METHODS

Data on 10 473 participants from a nationally representative survey, the 2016 Nepal Demographic and Health Survey (NDHS), was used. The NDHS assessed/measured blood pressure, height, weight, urbanization and the altitude of participants' households by following standard procedures. Logistic and linear regression models were used to study the association of altitude (per 100 m increases) and urbanization with hypertension and obesity, or their continuous measurements (i.e. systolic and diastolic blood pressure [SBP and DBP, respectively] and body mass index [BMI]).

RESULTS

The prevalence of hypertension, overweight and obesity was 25.6%, 19.6% and 4.8%, respectively. After controlling for covariates, residents of metropolitan cities had a 30% higher prevalence of overweight/obesity (adjusted prevalence ratio 1.30 [95% confidence interval {CI} 1.11 to 1.52]) than their rural counterparts. For altitude, there was a marginally increased odds of hypertension and overweight/obesity with elevation. Consistently, DBP (β = 0.18 [95% CI 0.09 to 0.27]) and BMI increased with altitude (β = 0.11 [95% CI 0.08 to 0.13]).

CONCLUSION

Urbanization was positively associated with BMI, while altitude showed a marginally positive association with hypertension and overweight/obesity. Given the role of obesity and hypertension in the aetiology of other chronic diseases and subsequently associated mortality and health care costs, residents in urban areas and at higher altitudes may benefit from weight control interventions and BP monitoring, respectively.

Revisiting Strategies for Maternal Health Care in the Face of COVID-19 Pandemic

Novel coronavirus (SARS-CoV-2) is a new strain of coronavirus causing COVID-19, first identified in Wuhan City, China towards the end of 2019. At present, there is no evidence that pregnant women are more likely to be severely ill, need ICU care, or die from the illness in comparison to non-pregnant adults. Evidences suggest that vertical transmission, might be possible. We searched and retrieved the published literature from PubMed and Google Scholar using various keywords. We further searched the official webpages of various organizations for the updated information. Pregnant individuals in particular are encouraged to take all available precautions to optimize health and avoid exposure to COVID-19. Adequate Testing should be prioritized in pregnant women admitted with suspected COVID-19. When a pregnancy is complicated by critical illness, the pregnant patient should ideally be cared for at a Level III or IV hospital. In the face of COVID-19, antenatal fetal surveillance and ultrasonography should continue as medically indicated when possible and elective ultrasound examinations should not be performed. Maternal immunizations continue to be an essential component of prenatal care and Obgyns should screen all pregnant individuals for mental health issues. Although the most commonly reported sign in COVID-19 is fever, nevertheless, other causes of intrapartum fever should not be overlooked. Cesarean delivery should be based on obstetric indications and not COVID-19 status alone. Infants born to patients with known COVID-19 should be considered infants with suspected COVID-19. The suspected or confirmed COVID-19 mother and infant can be allowed to remain together with enhanced precautions and suspected or confirmed maternal COVID-19 is not a contraindication to breastfeeding. If both the mother and the infant are healthy, it may be prudent to expedite discharge, so as to limit the risk of inadvertent exposure and infection. The Ob-gyns should commit to providing necessary care, although modifications to health care delivery approaches may be necessary.

Gaming Disorder among Medical College Students during COVID-19 Pandemic Lockdown

Background The frequent lockdown in Nepal during COVID-19 pandemic had brought various kinds of complexities such as stress among college students. This situation had created uncertainty of future academic career of undergraduate students in medical colleges. Some previously published literature showed gaming as a coping mechanism against stress. Objective To assess the gaming behavior of Medical college students during lockdown in COVID-19 pandemic. Method A cross-sectional study was conducted during lockdown period of July to August 2020. A total of 412 college students were enrolled. Online Google forms were shared to all the eligible students through email, viber and messenger with the help of class representative. Collected data were analyzed in SPSS version 20.0. Result The prevalence of gaming disorder was 8.5% among 260 internet gaming users. About 69.2% of the participants reported that their gaming behavior had increased due to stress of COVID-19 pandemic. Gender and spending more time online per day showed significant associations with greater scores on the internet gaming disorder. Conclusion During lockdown period of COVID-19 pandemic, the gaming behavior of medical college students has increased.

Online Learning in the Face of COVID-19 Pandemic: Assessment of Students' Satisfaction at Chitwan Medical College of Nepal

Background Online learning can play a vital role in the process of teaching and learning during Corona Virus Disease 2019 (COVID-19) pandemic. However, learners' satisfaction is extremely important in effective implementation of the online learning, especially at institutions where it is newly adopted. Objective To assess satisfaction towards online learning and its predictors among students at Chitwan Medical College, Bharatpur. Method A web-based cross-sectional survey was undertaken among 434 undergraduate and postgraduate students from various academic programs who had participated in the online classes started during this COVID-19 pandemic. A structured questionnaire consisting of 31 items (5-point Likert scale) covering four major student satisfaction domains (learners' dimensions, technological characteristics, instructors' characteristics and course management and coordination) was distributed to the students using Google Form. Result More than half (53.5%) of the students were satisfied with the online learning, while 29.7% gave neutral views. Bivariate analyses found that all four domains scores were positively correlated with each other as well as with the students' overall satisfaction towards learning. In multivariate analysis, female gender [aOR: 2.72, p = 0.013], WiFi as internet modality for learning [aOR: 3.36, p = 0.001) and learners' dimension score [aOR: 1.27, p<0.001] were the significant predictors of students' satisfaction. Conclusion Although recently adopted, the satisfaction of the students towards online classes appears good, and prioritizing the identified predictors and working on the weak links could assist in enhancing students' satisfaction and better outcomes.

Diabetes among tuberculosis patients and its impact on tuberculosis treatment in South Asia: a systematic review and meta-analysis

The escalating burden of diabetes is increasing the risk of contracting tuberculosis (TB) and has a pervasive impact on TB treatment outcomes. Therefore, we conducted this systematic review and meta-analysis to examine the burden of diabetes among TB patients and assess its impact on TB treatment in South Asia (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka). PubMed, Excerpta Medica Database (EMBASE), and CINAHL databases were systematically searched for observational (cross-sectional, case-control and cohort) studies that reported prevalence of diabetes in TB patients and published between 1 January 1980 and 30 July 2020. A random-effect model for computing the pooled prevalence of diabetes and a fixed-effect model for assessing its impact on TB treatment were used. The review was registered with PROSPERO number CRD42020167896. Of the 3463 identified studies, a total of 74 studies (47 studies from India, 10 from Pakistan, four from Nepal and two from both Bangladesh and Sri-Lanka) were included in this systematic review: 65 studies for the prevalence of diabetes among TB patients and nine studies for the impact of diabetes on TB treatment outcomes. The pooled prevalence of diabetes in TB patients was 21% (95% CI 18.0, 23.0; I2 98.3%), varying from 11% in Bangladesh to 24% in Sri-Lanka. The prevalence was higher in studies having a sample size less than 300 (23%, 95% CI 18.0, 27.0), studies conducted in adults (21%, 95% CI 18.0, 23.0) and countries with high TB burden (21%, 95% CI 19.0, 24.0). Publication bias was detected based on the graphic asymmetry of the funnel plot and Egger's test (p < 0.001). Compared with non-diabetic TB patients, patients with TB and diabetes were associated with higher odds of mortality (Odds Ratio (OR) 1.7; 95% CI 1.2, 2.51; I2 19.4%) and treatment failure (OR 1.7; 95% CI 1.1, 2.4; I2 49.6%), but not associated with Multi-drug resistant TB (OR 1.0; 95% CI 0.6, 1.7; I2 40.7%). This study found a high burden of diabetes among TB patients in South Asia. Patients with TB-diabetes were at higher risk of treatment failure and mortality compared to TB alone. Screening for diabetes among TB patients along with planning and implementation of preventive and curative strategies for both TB and diabetes are urgently needed.

Indoor Air Pollution (IAP) Traceable to Household Fuel Consumption and its Impact on Health

Energy is an essential and obligatory prerequisite of life. Indoor air pollution is one of the biggest environmental problems in the world being specifically concentrated in resource limited settings. Inspite of the availability of cleaner fuel technologies, people in resource limited setting still depend on traditional fuel to meet their basic needs resulting even in premature deaths. In Nepal people in rural areas are the pre-dominant users of biomass fuel, there is limited research focusing on rural areas particularly; women as they spend most of their time in kitchen. Reports were extensively searched for literature using preset keywords in English language peer-reviewed journals databases PubMed and Google Scholar published between the years 2005 to 2020. Citation details were examined, titles and abstracts screened for eligibility and if relevant, full text was also reviewed in greater detail. Findings were then presented primarily under two bold themes: Household fuel consumption: existing theories and evidence; and health impact of indoor air pollution. Several health effects were reported of indoor air pollution including respiratory illnesses, cardiovascular diseases, cancer, endocrine system disruption and pregnancy complications. These exposures almost double the health risks predominantly among children and women of rural communities as they are directly involved in household activities causing air pollution. Based on our review of evidence, women and children of rural households were the major victims. Further, determinants of household fuel consumption and health effects should be considered while formulating policies in regard to promoting accessibility of clean fuels and reducing household air pollutants.

The effect of metformin in EML4-ALK+ lung cancer alone and in combination with crizotinib in cell and rodent models

Cell based studies have suggested that the diabetes drug metformin may combine with the anaplastic lymphoma kinase receptor (ALK) inhibitor crizotinib to increase ALK positive lung cancer cell killing and overcome crizotinib resistance. We therefore tested metformin alone and in combination with crizotinib in vivo, by employing a xenograft mouse model of ALK positive lung cancer. We found that 14 days of daily oral metformin (100 mg/kg) alone had a moderate but statistically significant effect on tumour growth suppression, but in combination with crizotinib, produced no greater tumour suppression than crizotinib (25 mg/kg) alone. We also reassessed the effect of metformin on EML₄-ALK positive lung cancer (H3122) cell viability. Although metformin alone did have a moderate effect on cell viability (30% suppression) this was only at a clinically irrelevant concentration (5 mM) and there was no additive effect with cytotoxic concentrations of crizotinib. Moreover, metformin did not overcome crizotinib resistance in our resistant cells. Nevertheless, we were able to show that metformin induces a G1-cell cycle arrest and apoptosis alone and in combination with crizotinib. Also, consistent with earlier work, the addition of insulin-like growth factor-1 (IGF-1) to EML₄-ALK positive cancer cells reduced cell killing by crizotinib. We therefore hypothesised that the effect of metformin in vivo was not due to direct cytotoxicity on cancer cells, but by modulation of IGF-1 expression. We therefore measured levels of IGF-1 in plasma taken from mice treated with metformin, but found no difference between the drug treatment and control groups. We further hypothesised that the effect of metformin could be due to modulation of thrombospondin 1 (TSP-1), which metformin has been proposed to regulatein vivo, but again we found no difference between the experimental groups. Finally, we investigated the potential for liver and kidney toxicity, as well as CYP3A based interactions, from the combination of metformin with crizotinib.

Meta-analysis of computed tomography and magnetic resonance imaging for diagnosing mycotic aneurysms

Background

Mycotic aneurysms are a serious complication of infective endocarditis and bloodstream infection with high mortality and morbidity. Computed tomography (CT) and magnetic resonance (MRI) play major roles in detecting mycotic aneurysms, but their accuracy is not well established warranting this meta-analysis.

Purpose

We aimed to assess the diagnostic performance of CT and MRI for mycotic aneurysms in this meta-analysis.

Methods

Pubmed, Cochrane and Embase were searched from 1 January 1980–30 June 2019 for diagnostic studies reporting both sensitivity and specificity of CT and/or MRI for detecting mycotic aneurysms, and pooled using random effects models and Meta-DiSc 1.4 software.

Results

Amongst 1507 articles searched, 15 studies with 622 scans for 249 mycotic aneurysms included. CT was performed in 13 studies and MRI in 5 studies, looking at aortic and cerebral mycotic aneurysm in 12 and 3 studies respectively. The pooled sensitivities and specificities for all mycotic aneurysms with 95% confidence intervals were for CT 0.82 (0.77–0.87) and 0.93 (0.89–0.95) respectively, and for MRI 0.79 (0.61–0.91) and 0.89 (0.81–0.95) (Figure). CT or MRI had pooled sensitivities and specificities of 0.84 (0.78–0.89) and 0.92 (0.89–0.95) for aortic and 0.71 (0.54–0.85) and 0.90 (0.83–0.95) for cerebral mycotic aneurysms. Heterogeneity and publication bias was observed in some pooled analysis.

Conclusion

CT and MRI had moderately high diagnostic accuracy for mycotic aneurysms. Sensitivity was numerically higher for detecting aortic than cerebral mycotic aneurysms, with similar specificity. Study heterogeneity, publication bias and modest sample size from the literature were important limitations, warranting larger and higher quality studies.

Forrest plots for CT and MRI pooled data

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): National Heart Foundation of New Zealand - Overseas Clinical and Research Fellowship

Burden of Diabetes and Prediabetes in Nepal: A Systematic Review and Meta-Analysis

BACKGROUND

Unhealthy behaviors, such as energy-dense food choices and a sedentary lifestyle, both of which are established risk factors for diabetes, are common and increasing among Nepalese adults. Previous studies have reported a wide variation in the prevalence of prediabetes and diabetes in Nepal, and thus a more reliable pooled estimate is needed. Furthermore, Nepal underwent federalization in 2015, and the province-specific prevalence, which is necessary for the de novo provincial government to formulate local health policies, is lacking. This study aims to provide a comprehensive summary of the current literature on various aspects of diabetes in Nepal, i.e., the prevalence of prediabetes and diabetes as well as of the awareness, treatment, and control of diabetes in Nepal.

METHODS

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched three electronic databases-PubMed, Scopus, and Web of Science-using a comprehensive search strategy to identify eligible studies published up to April 2, 2020. Data on prevalence estimates of prediabetes and diabetes were extracted and pooled in a meta-analysis using a random effect model. Subgroup analyses and meta-regression were conducted to assess heterogeneity across the studies. The quality of included studies was assessed using the New Castle-Ottawa scale.

RESULTS

We included 14 eligible studies that comprised a total of 44,129 participants and 3517 diabetes cases. Half of the included studies had good quality. Overall, the prevalence of prediabetes and diabetes was 9.2% (95% CI 6.6-12.6%) and 8.5% (95% CI 6.9-10.4%), respectively. Among the participants with diabetes, only 52.7% (95% CI 41.7-63.4%) were aware of their diabetes status, and 45.3% (95% CI 31.6-59.8%) were taking antidiabetic medications. Nearly one-third of those under antidiabetic treatment (36.7%; 95% CI 21.3-53.3%) had their blood glucose under control. The prevalence of prediabetes and diabetes gradually increased with increasing age and was more prevalent among males and urban residents. There was a wide variation in diabetes prevalence across the provinces in Nepal, the lowest 2% in Province 6 to the highest 10% in Province 3 and Province 4.

CONCLUSIONS

The prevalence of prediabetes and diabetes was high in Nepal, while its awareness, treatment, and control were low. Our findings call for urgent nationwide public health action in Nepal.

Diagnostic utility of ultrasonography and computerized tomography in gall bladder perforation: A case report

Gall bladder (GB) perforation can be misdiagnosed as any other more common cause of acute abdomen. We present a case of a 72-year-female who had presented to the emergency department with an acute abdomen. The clinical presentation and the biochemical markers had pointed towards acute pancreatitis. However, the ultrasonographic examination of the abdomen and the pelvis suggested GB perforation which was confirmed by the multislice computerized tomography scan. Following this the patient underwent open cholecystectomy and was successfully managed. The invaluable contributions from the radiological modalities led to the successful management of the patient.

Health system's readiness to provide cardiovascular, diabetes and chronic respiratory disease related services in Nepal: analysis using 2015 health facility survey

BACKGROUND

The burgeoning rise of non-communicable diseases (NCDs) is posing serious challenges in resource constrained health facilities of Nepal. The main objective of this study was to assess the readiness of health facilities for cardiovascular diseases (CVDs), diabetes and chronic respiratory diseases (CRDs) services in Nepal.

METHODS

This study utilized data from the Nepal Health Facility Survey 2015. General readiness of 940 health facilities along with disease specific readiness for CVDs, diabetes, and CRDs were assessed using the Service Availability and Readiness Assessment manual of the World Health Organization. Health facilities were categorized into public and private facilities.

RESULTS

Out of a total of 940 health facilities assessed, private facilities showed higher availability of items of general service readiness except for standard precautions for infection prevention, compared to public facilities. The multivariable adjusted regression coefficients for CVDs (β = 2.87, 95%CI: 2.42-3.39), diabetes (β =3.02, 95%CI: 2.03-4.49), and CRDs (β = 15.95, 95%CI: 4.61-55.13) at private facilities were higher than the public facilities. Health facilities located in the hills had a higher readiness index for CVDs (β = 1.99, 95%CI: 1.02-1.39). Service readiness for CVDs (β = 1.13, 95%CI: 1.04-1.23) and diabetes (β = 1.78, 95%CI: 1.23-2.59) were higher in the urban municipalities than in rural municipalities. Finally, disease-related services readiness index was sub-optimal with some degree of variation at the province level in Nepal. Compared to province 1, province 2 (β = 0.83, 95%CI: 0.73-0.95) had lower, and province 4 (β =1.24, 95%CI: 1.07-1.43) and province 5 (β =1.17, 95%CI: 1.02-1.34) had higher readiness index for CVDs.

CONCLUSION

This study found sub-optimal readiness of services related to three NCDs at the public facilities in Nepal. Compared to public facilities, private facilities showed higher readiness scores for CVDs, diabetes, and CRDs. There is an urgent need for policy reform to improve the health services for NCDs, particularly in public facilities.

Prevalence of American Heart Association defined ideal cardiovascular health metrics in Nepal: findings from a nationally representative cross-sectional study

BACKGROUND

The ever-increasing burden of non-communicable diseases (NCDs) is posing a serious health challenge for Nepal. This study examines the status of ideal cardiovascular health (ICH) and its associated determinants in Nepal using the American Heart Association (AHA) definition of ICH metrics.

METHODS

The AHA has defined ICH as having five to seven of the ideal health metrics. A representative sample from the NCD risk factors STEPS survey 2013 were drawn to analyse the prevalence and sociodemographic determinants of ideal, intermediate and poor cardiovascular health in Nepal. Multivariable logistic regression was used to measure the determinants of ICH.

RESULTS

More than half of the participants had ICH metrics (51.6%), with the 45-69 y age group having the lowest prevalence of ICH (28%) and females having better cardiovascular health compared with their male counterparts (60.6% vs 41.7%). The prevalence of low intake of fruit and vegetables, tobacco smoking and elevated blood pressure were quite high (99%, 18.8% and 31.4%, respectively). The status of ICH declined with age: individuals 15-29 y of age had 6 times (95% confidence interval [CI] 4.80-8.60) higher odds of having ICH compared with those who were 45-69 y, and it was low among urban residents (referent: rural; adjusted odds ratio 0.77 [95% CI 0.58-1.01]).

CONCLUSIONS

Nearly half of the participants had ICH, which declined with ageing. Further, urban residents had poor cardiovascular health. This highlights the need for a comprehensive population-based intervention targeting elderly and urban residents to improve overall cardiovascular health.

Translation with Cross-cultural Adaptation of Cerebral Palsy Quality of Life Questionnaire for Children into Nepali and its Psychometric Properties

Background Cerebral Palsy Quality of Life questionnaire for children primary caregiver version is the widely used condition specific outcome measure which assesses the wellbeing of the child. It has been translated to many languages and shows excellent psychometric properties. Availability in Nepali would facilitate the use in clinical practice and research in Nepali population. Objective The objective of this study was translation with cross-culturally adaption of Cerebral Palsy Quality of Life questionnaire for children primary caregiver version into Nepali and assess its psychometric properties. Method Cross-cultural adaptation was performed using forward and backward translation protocol. Pretesting was done on six participants to confirm that the original concept was preserved. The Nepali version of questionnaire was administered twice for data collection. The feasibility, sensitivity, internal consistency and test-retest reliability was determined. Result Culturally adapted Nepali version showed good feasibility only the domain "Access to service" had a highest missing score related to use of the special equipment, attending kindergarten and applying for respite care. Floor and ceiling effect were < 15% in all the domains except in few items of "Pain and impact of disability" and "Social well being and acceptance". Test retest reliability (0.82 - 0.91) and internal consistency (0.68 - 0.84) was good. There were weak association of domains with the gross motor functional classification system level. Conclusion Cross-culturally adapted Nepali Cerebral Palsy Quality of Life questionnaire for children primary caregiver was developed. It demonstrates good psychometric properties confirming to assess quality of life of children with Cerebral palsy in Nepal.

Inhibition of Mitogen-Activated Protein Kinase Kinase Alone and in Combination with Anaplastic Lymphoma Kinase (ALK) Inhibition Suppresses Tumor Growth in a Mouse Model of ALK-Positive Lung Cancer

Anaplastic lymphoma kinase (ALK)-positive non-small-cell lung cancer most commonly arises through EML4 (Echinoderm Microtuble Like 4)-ALK chromosomal fusion. We have previously demonstrated that combination of the ALK inhibitor crizotinib with the MEK inhibitor selumetinib was highly effective at reducing cell viability of ALK-positive non-small-cell lung cancer (H3122) cells. In this study, we further investigated the efficacy of crizotinib and selumetinib combination therapy in an in vivo xenograft model of ALK-positive lung cancer. Crizotinib decreased tumor volume by 52% compared with control, and the drug combination reduced tumor growth compared with crizotinib. In addition, MEK inhibition alone reduced tumor growth by 59% compared with control. Crizotinib and selumetinib alone and in combination were nontoxic at the dose of 25 mg/kg, with values for ALT (<80 U/l) and creatinine (<2 mg/dl) within the normal range. Our results support the combined use of crizotinib with selumetinib in ALK-positive lung cancer but raise the possibility that a sufficient dose of an MEK inhibitor alone may be as effective as adding an MEK inhibitor to an ALK inhibitor. SIGNIFICANCE STATEMENT: This study contains in vivo evidence supporting the use of combination MEK inhibitors in ALK+ lung cancer research, both singularly and in combination with ALK inhibitors. Contrary to previously published reports, our results suggest that it is possible to gain much of the benefit from combination treatment with an MEK inhibitor alone, at a tolerable dose.

Application of single-level and multi-level modeling approach to examine geographic and socioeconomic variation in underweight, overweight and obesity in Nepal: findings from NDHS 2016

Nepal's dual burden of undernutrition and over nutrition warrants further exploration of the population level differences in nutritional status. The study aimed to explore, for the first time in Nepal, potential geographic and socioeconomic variation in underweight and overweight and/or obesity prevalence in the country, adjusted for cluster and sample weight. Data came from 14,937 participants, including 6,172 men and 8,765 women, 15 years or older who participated in the 2016 Nepal Demography and Health Survey (NDHS). Single-level and multilevel multi-nominal logistic regression models and Lorenz curves were used to explore the inequalities in weight status. Urban residents had higher odds of being overweight and/or obese (OR: 1.89, 95% CI: 1.62-2.20) and lower odds of being underweight (OR: 0.81, 95% CI: 0.70-0.93) than rural residents. Participants from Provinces 2, and 7 were less likely to be overweight/obese and more likely to be underweight (referent: province-1). Participants from higher wealth quintile households were associated with higher odds of being overweight and/or obese (P-trend < 0.001) and lower odds of being underweight (P-trend < 0.001). Urban females at the highest wealth quintile were more vulnerable to overweight and/or obesity as 49% of them were overweight and/or obese and nearly 39% at the lowest wealth quintile were underweight.

Workplace interventions for increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers

BACKGROUND

The prevalence of musculoskeletal symptoms among sedentary workers is high. Interventions that promote occupational standing or walking have been found to reduce occupational sedentary time, but it is unclear whether these interventions ameliorate musculoskeletal symptoms in sedentary workers.

OBJECTIVES

To investigate the effectiveness of workplace interventions to increase standing or walking for decreasing musculoskeletal symptoms in sedentary workers.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, OSH UPDATE, PEDro, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal up to January 2019. We also screened reference lists of primary studies and contacted experts to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-randomised controlled trials (cluster-RCTs), quasi RCTs, and controlled before-and-after (CBA) studies of interventions to reduce or break up workplace sitting by encouraging standing or walking in the workplace among workers with musculoskeletal symptoms. The primary outcome was self-reported intensity or presence of musculoskeletal symptoms by body region and the impact of musculoskeletal symptoms such as pain-related disability. We considered work performance and productivity, sickness absenteeism, and adverse events such as venous disorders or perinatal complications as secondary outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts, and full-text articles for study eligibility. These review authors independently extracted data and assessed risk of bias. We contacted study authors to request additional data when required. We used GRADE considerations to assess the quality of evidence provided by studies that contributed to the meta-analyses.

MAIN RESULTS

We found ten studies including three RCTs, five cluster RCTs, and two CBA studies with a total of 955 participants, all from high-income countries. Interventions targeted changes to the physical work environment such as provision of sit-stand or treadmill workstations (four studies), an activity tracker (two studies) for use in individual approaches, and multi-component interventions (five studies). We did not find any studies that specifically targeted only the organisational level components. Two studies assessed pain-related disability. Physical work environment There was no significant difference in the intensity of low back symptoms (standardised mean difference (SMD) -0.35, 95% confidence interval (CI) -0.80 to 0.10; 2 RCTs; low-quality evidence) nor in the intensity of upper back symptoms (SMD -0.48, 95% CI -.096 to 0.00; 2 RCTs; low-quality evidence) in the short term (less than six months) for interventions using sit-stand workstations compared to no intervention. No studies examined discomfort outcomes at medium (six to less than 12 months) or long term (12 months and more). No significant reduction in pain-related disability was noted when a sit-stand workstation was used compared to when no intervention was provided in the medium term (mean difference (MD) -0.4, 95% CI -2.70 to 1.90; 1 RCT; low-quality evidence). Individual approach There was no significant difference in the intensity or presence of low back symptoms (SMD -0.05, 95% CI -0.87 to 0.77; 2 RCTs; low-quality evidence), upper back symptoms (SMD -0.04, 95% CI -0.92 to 0.84; 2 RCTs; low-quality evidence), neck symptoms (SMD -0.05, 95% CI -0.68 to 0.78; 2 RCTs; low-quality evidence), shoulder symptoms (SMD -0.14, 95% CI -0.63 to 0.90; 2 RCTs; low-quality evidence), or elbow/wrist and hand symptoms (SMD -0.30, 95% CI -0.63 to 0.90; 2 RCTs; low-quality evidence) for interventions involving an activity tracker compared to an alternative intervention or no intervention in the short term. No studies provided outcomes at medium term, and only one study examined outcomes at long term. Organisational level No studies evaluated the effects of interventions solely targeted at the organisational level. Multi-component approach There was no significant difference in the proportion of participants reporting low back symptoms (risk ratio (RR) 0.93, 95% CI 0.69 to 1.27; 3 RCTs; low-quality evidence), neck symptoms (RR 1.00, 95% CI 0.76 to 1.32; 3 RCTs; low-quality evidence), shoulder symptoms (RR 0.83, 95% CI 0.12 to 5.80; 2 RCTs; very low-quality evidence), and upper back symptoms (RR 0.88, 95% CI 0.76 to 1.32; 3 RCTs; low-quality evidence) for interventions using a multi-component approach compared to no intervention in the short term. Only one RCT examined outcomes at medium term and found no significant difference in low back symptoms (MD -0.40, 95% CI -1.95 to 1.15; 1 RCT; low-quality evidence), upper back symptoms (MD -0.70, 95% CI -2.12 to 0.72; low-quality evidence), and leg symptoms (MD -0.80, 95% CI -2.49 to 0.89; low-quality evidence). There was no significant difference in the proportion of participants reporting low back symptoms (RR 0.89, 95% CI 0.57 to 1.40; 2 RCTs; low-quality evidence), neck symptoms (RR 0.67, 95% CI 0.41 to 1.08; two RCTs; low-quality evidence), and upper back symptoms (RR 0.52, 95% CI 0.08 to 3.29; 2 RCTs; low-quality evidence) for interventions using a multi-component approach compared to no intervention in the long term. There was a statistically significant reduction in pain-related disability following a multi-component intervention compared to no intervention in the medium term (MD -8.80, 95% CI -17.46 to -0.14; 1 RCT; low-quality evidence).

AUTHORS' CONCLUSIONS

Currently available limited evidence does not show that interventions to increase standing or walking in the workplace reduced musculoskeletal symptoms among sedentary workers at short-, medium-, or long-term follow up. The quality of evidence is low or very low, largely due to study design and small sample sizes. Although the results of this review are not statistically significant, some interventions targeting the physical work environment are suggestive of an intervention effect. Therefore, in the future, larger cluster-RCTs recruiting participants with baseline musculoskeletal symptoms and long-term outcomes are needed to determine whether interventions to increase standing or walking can reduce musculoskeletal symptoms among sedentary workers and can be sustained over time.