Garden-based interventions and early childhood health: a protocol for an umbrella review

BACKGROUND

Garden-based interventions have the potential to impact young children's health in a number of ways, including enhancing dietary intake, increasing outdoor physical activity, diversifying the gut microbiome, and promoting general wellbeing. A number of recent systematic reviews have either included or focused on garden-based interventions for young children. However, most prior reviews including young children only focus on one health outcome or one setting, making a full summary of prior research assessing the impact of garden-based interventions nonexistent. As such, this umbrella systematic review aims to synthesize the literature on health outcomes of garden-based interventions for young children.

METHODS

This protocol outlines the systematic steps we will take to conduct an umbrella review on health-related outcomes of garden-based interventions in children younger than 6 years of age. We will systematically search PubMed, PsycINFO, ERIC, CINAHL, Embase, Scopus, OVID-Agricola, and CAB Direct, including all systematic reviews and meta-analyses fitting the pre-determined inclusion/exclusion criteria. We will double screen at each phase of the review: title/abstract, full text, data extraction, and quality appraisal. We will assess the quality of included reviews using A Measurement Tool to Assess Systematic Reviews (AMSTAR 2). Based on the potential for stark variability in what how reviews report child health outcomes, we will analyze the reviews both narratively and quantitatively, reporting summary of findings tables and iteratively mapping the results. This protocol aligns with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols statement (PRISMA-P).

DISCUSSION

This umbrella review aims to summarize the role that garden-based interventions play in health promotion for young children. We will focus on a number of diverse child health outcomes in an effort to comprehensively synthesize the evidence to inform future garden-based interventions, research, and policy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019106848.

Population trends in emergency cancer diagnoses: The role of changing patient case-mix

BACKGROUND

Diagnosis of cancer through an emergency presentation is associated with worse clinical and patient experience outcomes. The proportion of patients with cancer who are diagnosed through emergency presentations has consequently been introduced as a routine cancer surveillance measure in England. Welcome reductions in this metric have been reported over more than a decade but whether reductions reflect true changes in how patients are diagnosed rather than the changing case-mix of incident cohorts in unknown.

METHODS

We analysed 'Routes to Diagnosis' data on cancer patients (2006-2015) and used logistic regression modelling to determine the contribution of changes in four case-mix variables (sex, age, deprivation, cancer site) to time-trends in emergency presentations.

RESULTS

Between 2006 and 2015 there was an absolute 4.7 percentage point reduction in emergency presentations (23.8%-19.2%). Changing distributions of the four case-mix variables explained 19.0% of this reduction, leaving 81.0% unexplained. Changes in cancer site case-mix alone explained 16.0% of the total reduction.

CONCLUSION

Changes in case-mix (particularly that of cancer sites) account for about a fifth of the overall reduction in emergency presentations. This would support the use of adjustment/standardisation of reported statistics to support their interpretation and help appreciate the influence of case-mix, particularly regarding cancer sites with changing incidence. However, most of the reduction in emergency presentations remains unaccounted for, and likely reflects genuine changes during the study period in how patients were being diagnosed.

Use of Ultrasound Localization to Improve Results of Fine Needle Aspiration Cytology of Breast Masses

A prospective randomized controlled trial of 116 patients with breast masses was conducted to compare the accuracy of ‘blind’ aspiration cytology performed in the clinic with aspiration cytology using ultrasound localization. The unsatisfactory aspiration cytology rate was significantly reduced by ultrasound localization (P=0.028). This was mainly due to an improvement in the unsatisfactory rate for tumours less than 3 cm in diameter (P=0.036). The results were influenced by the number of needle manoeuvres performed, < 10 needle manoeuvres being associated with a 54% unsatisfactory aspiration rate compared with 25% when > 10 manoeuvres were performed (P= <0.02). One experienced aspirator in the clinic had results comparable to those achieved with ultrasound localization.

It is concluded that experience and technique are the most important factors in obtaining a satisfactory aspirate from breast masses. Routine ultrasound localization prior to aspiration confers some benefit. Consideration should be given to the use of the ultrasound-assisted technique following a previous unsatisfactory aspiration, particularly if the tumour is less than 3 cm in diameter.

"Let Me Help You Help Me": Church-Based HIV Prevention for Young Black Men Who Have Sex With Men

The goal of this study was to identify strategies that could yield more inclusive church-based HIV prevention efforts. In-depth interviews were conducted with 30 young Black men who have sex with men (YBMSM) living in Baltimore, Maryland. The sample had an equal number of regular and infrequent church attendees. Nearly one-fourth of the sample was HIV-positive. Interviews were transcribed verbatim and analyzed inductively using a qualitative content analytic approach. Two main recommendations emerged for churches to offer more inclusive HIV prevention efforts: (1) reduce homosexuality stigma by increasing interpersonal and institutional acceptance, and (2) address the sexual health needs of all congregants by offering universal and targeted sexual health promotion. Thus, results support a tiered approached to providing more inclusive church-based HIV prevention efforts. We conclude that Black churches can be a critical access point for HIV prevention among YBMSM and represent an important setting to intervene.

Primary HPV testing: a proposal for co-testing in initial rounds of screening to optimise sensitivity of cervical cancer screening

As explained by Kitchener in a previous issue of Cytopathology (2015;26:4-6), primary human papillomavirus (HPV) testing is likely to be introduced in the UK for all women aged 25-64 years following pilot site studies already in place. This will be necessary when the prevalence of cervical cancer and its precursors declines when vaccination takes effect but there is a risk in abandoning cytology as a primary test: a risk that would be most apparent in the present unvaccinated population in which the prevalence of cervical cancer and its precursors is exceptionally high. HPV testing is more sensitive than cytology but has a significant false-negative rate that could be detrimental to a successful screening programme if introduced without cytology backup. Accurate cytology would be needed for triage and could be compromised if HPV-negative tests were excluded from examination. This article proposes a compromise: cytology and HPV co-testing for the first two screening tests to optimise the sensitivity of the test as a whole. Registrations of invasive and in situ carcinoma of the uterine cervix in England indicate that the prevalence of the disease is highest in young women in the early rounds of screening. Calculations of the likely impact on the workload of this proposal have been based on a service evaluation of 295 cytology tests received at St Thomas' Hospital, which suggests that the volume of cytology tests would be reduced by approximately 60% compared with 80% for primary HPV testing alone. This proposal should be debated openly before irrevocable changes are made to a skilled workforce.

Nasseem Husain: homage to a pioneer of cytology automation

Dr Oliver Anthony Nasseem Husain, who died on 22 September 2014, aged 90 years, was one of the great names of European cytology, a pioneer of automated cervical screening and a founding member of both the British Society for Clinical Cytology (BSCC) and the European Federation of Cytology Societies (EFCS). The life of this one remarkable man involved much of the pioneering work, which is reviewed in this article, that has brought conventional cytology to the complex multimodal discipline it is today.

Arterial stiffness as a cause of cognitive decline and dementia: a systematic review and meta-analysis

BACKGROUND

Although arterial stiffness has recently been confirmed as a predictor of cardiovascular disease, the association between arterial stiffness and cognitive decline is less clear.

AIM

We performed a systematic review and meta-analysis to examine the evidence for large artery stiffness as a cause of cognitive decline and dementia.

METHOD

Electronic databases were systematically searched until September 2011 for studies reporting on the longitudinal relationship between any validated measure of large artery stiffness and cognitive decline or dementia. Meta-analysis was performed on four studies investigating the association between aortic pulse wave velocity and a decline in Mini-Mental State Examination scores.

RESULTS

Six relevant longitudinal studies were located, conducted over an average of 5 years follow up. Arterial stiffness was predictive of cognitive decline in five/six studies. In meta-analysis, higher aortic stiffness predicted lower Mini-Mental State Examination scores within the sample (β=-0.03, 95% confidence interval (CI): -0.06 to 0.01, n= 3947), although studies were not all homogeneous, and statistical heterogeneity was present (I(2) = 71.9%, P= 0.01). Removal of one study with a relatively younger cohort and lower median aortic stiffness found higher aortic stiffness to significantly predict cognitive decline (β=-0.04, 95% CI: -0.07 to -0.01, n= 3687) without evidence of heterogeneity (I(2) = 9.5%, P= 0.33). There was little research investigating the effects of aortic stiffness on the development of dementia.

CONCLUSION

Aortic stiffness was found to predict cognitive decline in both qualitative review and quantitative analysis.

Are significant numbers of abnormal cells lost on the discarded ThinPrep® broom when used for cervical cytology?

Are significant numbers of abnormal cells lost on the discarded ThinPrep® broom when used for cervical cytology?

BACKGROUND

  In view of a study with SurePath® showing that cells were lost on the broom if it was discarded, we decided to investigate whether cells were lost on the ThinPrep® (TP) broom, which is discarded according to the manufacturer's protocol.

AIM

  To determine whether significant amounts of cellular material are lost on the discarded TP broom, and whether the loss is operator dependent.

METHODS

  Three hundred and six women attending the Guy's Hospital Colposcopy Unit gave their consent for TP liquid-based cytology samples to be taken and the broom immersed in a second vial instead of being discarded. The cellularity of the first and second vials was compared by counting cells in 10 ×40 high-power fields (HPFs). The significance of cell loss was ascertained by correlating the likelihood of abnormal cells and transformation zone (TZ) material being present with the degree of cellularity of the two vials.

RESULTS

  More than 10 cells per HPF were seen in 3.2%, 19.4% and 35.8% of slides from the second vial taken by three experienced colposcopists, which was significantly different between them (P < 0.001); cellularity of the first vial was not significantly different between colposcopists but the one with highest cellularity in the first vial discarded most in the second. Abnormal cells were more likely to be seen in slides with more than 10 cells per HPF (P < 0.001) and with evidence of TZ sampling (P < 0.001), but there was no preferential loss of TZ material in the second vial. Of 126 slides with abnormal cells on the slides from the second vial, 113 (89.7%) were also present on the significantly more cellular first vial (P < 0.001).

CONCLUSION

  Abnormal cells were potentially lost on the broom, but were usually represented in the first vial. The likelihood of abnormal cells being discarded was operator dependent in this small study, but this did not affect the quality of the initial preparation. The likelihood of abnormal cells being seen on TP slides was dependent on their cellularity, which provided our laboratory with a criterion for the assessment of sample adequacy.

Opinions of general medical registrars on HIV teaching and their competence in HIV-related clinical issues

More HIV-positive patients are living longer and presenting to non-infection specialties with non-HIV-related issues (eg diabetes, heart disease). National recommendations advise routinely offering HIV testing to all new registrants to primary care and all general medical admissions where community prevalence exceeds 2:1000. It is, therefore, imperative that all physicians are educated and competent in HIV infection, counselling and testing. This study aimed to establish regional medical registrars' opinions on teaching provision, and confidence in, HIV medicine. The results indicated a lack of confidence in HIV medicine and, in those without postgraduate rotations in HIV medicine or infectious diseases, a perception that HIV and infection-related teaching provision is inadequate.

Corneal confocal microscopy detects improvement in corneal nerve morphology with an improvement in risk factors for diabetic neuropathy

AIM

We have assessed whether corneal confocal microscopy can be used to detect alterations in nerve morphology following an improvement in risk factors associated with diabetic neuropathy.

METHODS

Twenty-five patients with diabetes with mild to moderate neuropathy and 18 control subjects underwent corneal confocal microscopy to quantify corneal nerve fibre (density, branch density, length and tortuosity) at baseline and after 24 months from first visit. This was not planned as an intervention trial and was simply an observational follow-up.

RESULTS

At baseline, nerve fibre density (18.8 ± 2.1 vs. 46.0 ± 3.8 number/mm(2), P = 0.001), nerve branch density (6.9 ± 1.5 vs. 35.6 ± 6.7 number/mm(2), P < 0.0001), nerve fibre length (8.3 ± 0.9 vs. 13.5 ± 0.8 mm/mm(2), P < 0.0001) and nerve fibre tortuosity (19.8 ± 1.6 vs. 22.7 ± 2.2, P < 0.05) were significantly lower in patients with diabetes than in control subjects. At follow-up, glycaemic control (HbA(1c) 64 ± 3 to 58 ± 2 mmol/mol, P = 0.08), total cholesterol (4.9 ± 0.2 to 4.2 ± 0.2 mmol/l, P = 0.01), systolic blood pressure (145.8 ± 4.9 to 135.9 ± 3.7 mmHg, P = 0.09) and diastolic blood pressure (77.8 ± 2.7 to 70.8 ± 2.5, P = 0.03) improved. Nerve fibre density (24.1 ± 2.0, P = 0.05), nerve branch density (11.1 ± 1.3, P < 0.01) and nerve fibre tortuosity (22.6 ± 1.5, P = 0.05) increased significantly, with no change in nerve fibre length (8.4 ± 0.5). Improvement in nerve fibre density correlated significantly with the improvement in HbA(1c) (r = -0.51, P = 0.008). Via four multifactorial regressions, this confirms the negative association between HbA(1c) and nerve fibre density (P = 0.02).

CONCLUSIONS

This study shows that corneal confocal microscopy may be employed in longitudinal studies to assess progression of human diabetic neuropathy and also supports the hypothesis that improvements in risk factors for diabetic neuropathy, in particular HbA(1c) , may lead to morphological repair of nerve fibres.

Changes in arterial stiffness but not carotid intimal thickness in acromegaly

CONTEXT

Acromegaly increases cardiovascular morbidity. We tested the hypothesis that increased arterial stiffness together with left ventricular hypertrophy may be a contributory factor.

PATIENTS AND DESIGN

Fifty-six patients (40 males, 54 ± 13 yr; 25 active disease, 31 in remission) and 46 healthy controls (30 males, 52 ± 13 yr) underwent measurements of aortic pulse wave velocity (PWV), carotid Doppler (IMT), echocardiography, and cardiovascular risk factors.

RESULTS

Mean serum IGF-I was 323 ± 286 ng/ml (sd score 1.8 ± 1.9) in all patients. Age, body mass index, diastolic blood pressure (BP), and lipid levels were similar comparing patients and controls. Systolic BP (130.8 ± 19.9 vs. 122 ± 14 mm Hg controls, P < 0.01) and PWV (11.7 ± 3.8 vs. 9.7 ± 2.8 m/sec, 95% confidence interval -3.4 to -0.7, P <0.01) were higher in patients than controls. Regression analysis revealed age, presence of acromegaly, systolic BP, and body mass index, inversely, as significantly and independently associated with PWV. No difference in carotid IMT was seen (0.8 ± 0.2 patients vs. 0.7 ± 0.2 mm controls, P = 0.5) or between active/controlled disease. In the subset of participants with echocardiography (n = 32), left ventricular mass was higher by a mean of 38.2 g (95% confidence interval -80.9 to +4.6, P = 0.08).

CONCLUSION

In summary, patients with acromegaly had independently and significantly increased aortic PWV as evidence of arterial stiffening but unaltered carotid IMT compared with controls, also influenced by age and systolic BP. Premature cardiovascular disease in patients with acromegaly is likely related to pressure-related arterial and left ventricular stiffening rather than atherosclerotic disease.

Replication of genome-wide association studies (GWAS) loci for fasting plasma glucose in African-Americans

AIMS/HYPOTHESIS

Chronically elevated blood glucose (hyperglycaemia) is the primary indicator of type 2 diabetes, which has a prevalence that varies considerably by ethnicity in the USA, with African-Americans disproportionately affected. Genome-wide association studies (GWASs) have significantly enhanced our understanding of the genetic basis of diabetes and related traits, including fasting plasma glucose (FPG). However, the majority of GWASs have been conducted in populations of European ancestry. Thus, it is important to conduct replication analyses in populations with non-European ancestry to identify shared loci associated with FPG across populations.

METHODS

We used data collected from non-diabetic unrelated African-American individuals (n = 927) who participated in the Howard University Family Study to attempt to replicate previously published GWASs of FPG. Of the 29 single nucleotide polymorphisms (SNPs) previously reported, we directly tested 20 in this study. In addition to the direct test, we queried a 500 kb window centred on all 29 reported SNPs for local replication of additional markers in linkage disequilibrium (LD).

RESULTS

Using direct SNP and LD-based comparisons, we replicated multiple SNPs previously associated with FPG and strongly associated with type 2 diabetes in populations with European ancestry. The replicated SNPs included those in or near TCF7L2, SLC30A8, G6PC2, MTNR1B, DGKB-TMEM195 and GCKR. We also replicated additional variants in LD with the reported SNPs in ZMAT4 and adjacent to IRS1.

CONCLUSIONS/INTERPRETATION

We identified multiple GWAS variants for FPG in our cohort of African-Americans. Using an LD-based strategy we also identified SNPs not previously reported, demonstrating the utility of using diverse populations for replication analysis.

European Guidelines for Quality Assurance in Cervical Cancer Screening. Second edition--summary document

European Guidelines for Quality Assurance in Cervical Cancer Screening have been initiated in the Europe Against Cancer Programme. The first edition established the principles of organised population-based screening and stimulated numerous pilot projects. The second multidisciplinary edition was published in 2008 and comprises ∼250 pages divided into seven chapters prepared by 48 authors and contributors. Considerable attention has been devoted to organised, population-based programme policies which minimise adverse effects and maximise benefits of screening. It is hoped that this expanded guidelines edition will have a greater impact on countries in which screening programmes are still lacking and in which opportunistic screening has been preferred in the past. Other methodological aspects such as future prospects of human papillomavirus testing and vaccination in cervical cancer control have also been examined in the second edition; recommendations for integration of the latter technologies into European guidelines are currently under development in a related project supported by the European Union Health Programme. An overview of the fundamental points and principles that should support any quality-assured screening programme and key performance indicators are presented here in a summary document of the second guidelines edition in order to make these principles and standards known to a wider scientific community.

Survey of medical training in cytopathology carried out by the journal Cytopathology

This report of the Editorial Advisory Board of Cytopathology gives the results of a survey of medical practitioners in cytopathology, which aimed to find out their views on the current situation in undergraduate and postgraduate training in their institutions and countries. The results show that training in cytopathology and histopathology are largely carried out at postgraduate level and tend to be organized nationally rather than locally. Histopathology was regarded as essential for training in cytopathology by 89.5% of respondents and was mandatory according to 83.1%. Mandatory cytopathology sections of histopathology were reported by 67.3% and specific examinations in cytopathology by 55.4%. The main deficiencies in training were due to its variability; there were insufficient numbers of pathologists interested in cytology and a consequent lack of training to a high level of competence. Pathologists without specific training in cytopathology signed out cytology reports according to 54.7% of responses, more often in centres where training was 3-6 months or less duration. Although 92.2% of respondents thought that specialist cytology should not be reported by pathologists without experience in general cytopathology, that practice was reported by 30.9%, more often in centres with small workloads. The survey report recommends that 6-12 months should be dedicated to cytopathology during histopathology training, with optional additional training for those wanting to carry out independent practice in cytopathology. Formal accreditation should be mandatory for independent practice in cytopathology. When necessary, temporary placements to centres of good practice should be available for trainees intending to practise independently in cytopathology. There should be adequate numbers of pathologists trained in cytopathology to a high level of competence; some of their time could be released by training cytotechnologists and trainee pathologists to prescreen cytology slides and assess adequacy of fine-needle aspiration samples when immediate diagnosis was not required. The survey demonstrated a clear need for European and international guidelines for training in cytopathology.

BSCC Code of Practice--fine needle aspiration cytology

The British Society for Clinical Cytology Code of Practice on fine needle aspiration cytology complements that on exfoliative cytopathology, which was published in the last issue (Cytopathology 2009;20:211-23). Both have been prepared with wide consultation within and outside the BSCC and have been endorsed by the Royal College of Pathologists. A separate code of practice for gynaecological cytopathology is in preparation. Fine needle aspiration (FNA) cytology is an accepted first line investigation for mass lesions, which may be targeted by palpation or a variety of imaging methods. Although FNA cytology has been shown to be a cost-effective, reliable technique its accurate interpretation depends on obtaining adequately cellular samples prepared to a high standard. Its accuracy and cost-effectiveness can be seriously compromised by inadequate samples. Although cytopathologists, radiologists, nurses or clinicians may take FNAs, they must be adequately trained, experienced and subject to regular audit. The best results are obtained when a pathologist or an experienced and trained biomedical scientist (cytotechnologist) provides immediate on-site assessment of sample adequacy whether or not the FNA requires image-guidance. This COP provides evidence-based recommendations for setting up FNA services, managing the patients, taking the samples, preparing the slides, collecting material for ancillary tests, providing rapid on-site assessment, classifying the diagnosis and providing a final report. Costs, cost-effectiveness and rare complications are taken into account as well as the time and resources required for quality control, audit and correlation of cytology with histology and outcome. Laboratories are expected to have an effective quality management system conforming to the requirements of a recognised accreditation scheme such as Clinical Pathology Accreditation (UK) Ltd.

Self-reported bladder function five years post-hysterectomy

We have examined the contribution of hysterectomy, compared with less invasive surgery, for dysfunctional uterine bleeding (DUB) on the prevalence of bladder problems five years after surgery. We report a prospective cohort study of over 25,000 women treated for benign cause menorrhagia by three types of surgery - transcervical endometrial resection/ablation and hysterectomy with or without bilateral oophorectomy. Postal questionnaires were sent five years after surgery investigating satisfaction with surgery and bladder function. When adjusted for confounders the odds of severe urinary incontinence (OR = 1.59, CI 95%, 1.35 - 1.87), urinary frequency (1.23 (1.04 - 1.45)), and nocturia (1.19, (1.03 - 1.38)) - were increased for women who had a hysterectomy compared with endometrial ablation. Hysterectomy with bilateral oophorectomy was not as strongly associated with severe bladder problems. Women who had the LAVH were most likely to report severe urinary incontinence (2.02, CI 95% 1.32 - 3.07), but not severe frequency or nocturia.