On the use of the not‐at‐random fully conditional specification (NARFCS) procedure in practice

The not‐at‐random fully conditional specification (NARFCS) procedure provides a flexible means for the imputation of multivariable missing data under missing‐not‐at‐random conditions. Recent work has outlined difficulties with eliciting the sensitivity parameters of the procedure from expert opinion due to their conditional nature. Failure to adequately account for this conditioning will generate imputations that are inconsistent with the assumptions of the user. In this paper, we clarify the importance of correct conditioning of NARFCS sensitivity parameters and develop procedures to calibrate these sensitivity parameters by relating them to more easily elicited quantities, in particular, the sensitivity parameters from simpler pattern mixture models. Additionally, we consider how to include the missingness indicators as part of the imputation models of NARFCS, recommending including all of them in each model as default practice. Algorithms are developed to perform the calibration procedure and demonstrated on data from the Avon Longitudinal Study of Parents and Children, as well as with simulation studies.     

A comparison of seven random‐effects models for meta‐analyses that estimate the summary odds ratio

Comparative trials that report binary outcome data are commonly pooled in systematic reviews and meta‐analyses. This type of data can be presented as a series of 2‐by‐2 tables. The pooled odds ratio is often presented as the outcome of primary interest in the resulting meta‐analysis. We examine the use of 7 models for random‐effects meta‐analyses that have been proposed for this purpose. The first of these models is the conventional one that uses normal within‐study approximations and a 2‐stage approach. The other models are generalised linear mixed models that perform the analysis in 1 stage and have the potential to provide more accurate inference. We explore the implications of using these 7 models in the context of a Cochrane Review, and we also perform a simulation study. We conclude that generalised linear mixed models can result in better statistical inference than the conventional 2‐stage approach but also that this type of model presents issues and difficulties. These challenges include more demanding numerical methods and determining the best way to model study specific baseline risks. One possible approach for analysts is to specify a primary model prior to performing the systematic review but also to present the results using other models in a sensitivity analysis. Only one of the models that we investigate is found to perform poorly so that any of the other models could be considered for either the primary or the sensitivity analysis.     

The combination of cardiorespiratory fitness and muscle strength,and mortality risk

Little is known about the combined associations of cardiorespiratory fitness (CRF) and hand grip strength (GS) with mortality in general adult populations. The purpose of this study was to compare the relative risk of mortality for CRF, GS, and their combination. In UK Biobank, a prospective cohort of >?0.5 million adults aged 40–69 years, CRF was measured through submaximal bike tests; GS was measured using a hand-dynamometer. This analysis is based on data from 70,913 men and women (832 all-cause, 177 cardiovascular and 503 cancer deaths over 5.7-year follow-up) who provided valid CRF and GS data, and with no history of heart attack/stroke/cancer at baseline. Compared with the lowest CRF category, the hazard ratio (HR) for all-cause mortality was 0.76 [95% confidence interval (CI) 0.64–0.89] and 0.65 (95% CI 0.55–0.78) for the middle and highest CRF categories, respectively, after adjustment for confounders and GS. The highest GS category had an HR of 0.79 (95% CI 0.66–0.95) for all-cause mortality compared with the lowest, after adjustment for confounders and CRF. Similar results were found for cardiovascular and cancer mortality. The HRs for the combination of highest CRF and GS were 0.53 (95% CI 0.39–0.72) for all-cause mortality and 0.31 (95% CI 0.14–0.67) for cardiovascular mortality, compared with the reference category of lowest CRF and GS: no significant association for cancer mortality (HR 0.70; 95% CI 0.48–1.02). CRF and GS are both independent predictors of mortality. Improving both CRF and muscle strength, as opposed to either of the two alone, may be the most effective behavioral strategy to reduce all-cause and cardiovascular mortality risk.     

Supporting nursing students with dyslexia in clinical practice

AIMS: To determine whether pre-registration nursing students with dyslexia experience specific problems in developing clinical competence, identify what strategies they use and how they may be supported in clinical practice. METHOD: Qualitative case study methodology was used. Stage 1 involved semi-structured interviews with seven students, three support and eight teaching staff, postal questionnaires from nine mentors, in addition to a review of policy documentation. Stage 2 involved a two-year study of four students on their branch programme and included semi-structured interviews with seven mentors. FINDINGS: The students' difficulties in clinical practice fell into three categories: dealing with information; performing the role; and administering drugs. Specific supporting measures included: informal and formal support networks; portable information technology equipment; and personal strategies, for example, rehearsing difficult tasks such as the handover report. The students' relationships with their mentors and the type of environment they were working in were key to the successful development of clinical competence. CONCLUSION: Nursing students who have dyslexia have specific learning difficulties in practice. Their response to these difficulties is individual and support needs to be tailored to meet their specific needs.     

Ginger: an overview

Ginger (Zingiber officinale) is one of the more commonly used herbal supplements. Although often consumed for culinary purposes, it is taken by many patients to treat a variety of conditions. Ginger has been shown to be effective for pregnancy-induced and postoperative nausea and vomiting. There is less evidence to support its use for motion sickness or other types of nausea and vomiting. Mixed results have been found in limited studies of ginger for the treatment of arthritis symptoms.     

Effect of a stannous fluoride dentifrice on plaque formation and removal: a digital plaque imaging study

OBJECTIVE: A repeated measures digital imaging technique (Digital Plaque Image Analysis-DPIA) was used to assess the antiplaque effectiveness of a 0.454% stannous fluoride dentifrice. METHODOLOGY: Subjects were qualified to enter the study based upon a previous assessment of dental plaque accumulation while brushing with a standard (non-antimicrobial) fluoridated dentifrice. Fourteen qualifying subjects were entered into a cross-over study design, including the use of a standard 0.243% sodium fluoride (NaF) dentifrice, or a 0.454% stannous fluoride (SnF,) dentifrice. Cross-over periods were separated by a one-week washout. During the assigned treatments, subjects visited the imaging laboratory on six separate days over two weeks, reporting each day for three separate assessments of plaque accumulation, as assessed by DPIA. On each "grading day," subjects entered for plaque assessments prior to morning tooth brushing, and without consuming any food or beverages. Following this morning "pre-brushing" assessment, subjects brushed with the assigned dentifrice and then had plaque immediately reassessed (morning post-brushing). Subjects also reported to the imaging clinic for an afternoon plaque regrowth assessment. Subjects were again required to avoid food and drink for one hour prior to this measurement. RESULTS: The SnF2 dentifrice was observed to produce statistically significant reductions in dental plaque, measuring 24.4% in the morning pre-brushing, and 27.9% in the afternoon assessment. Tooth brushing was observed to significantly reduce plaque on the teeth in the morning post-brushing for subjects using either the standard NaF or the SnF2 dentifrice. There were no statistically significant differences in plaque coverage on teeth following tooth brushing with the NaF (6.3% coverage) or SnF2 (6.2% coverage) dentifrices. CONCLUSION: Use of a 0.454% SnF2 dentifrice produced statistically significant reductions in dental plaque formation as compared to the similar use of a standard 0.243% NaF dentifrice.     

Lip impressions: a new method for monitoring morphological changes in orofacial granulomatosis

AIM: To develop and evaluate an objective method for assessing lip size and treatment-related morphological changes in orofacial granulomatosis (OFG) patients. MATERIALS AND METHODS: Patients with swollen lips because of OFG (n=21) were enrolled. A light-body polyvinylsiloxane material was used to take lip impressions before and after treatment (n=10), or during treatment (n=11). Plaster models were cast from the impressions and the lips were measured using callipers. The intra-examiner and inter-examiner reproducibility of the technique were assessed. RESULTS: OFG patients had significantly larger lips than controls (P<0.0001). The coefficient of variation on repeated measurements of the same impression was 1.6% and for duplicate impressions was 2.6%. Significant reduction in lip size was shown in all 10 patients after diet restriction (P<0.002). Seven of 11 patients whose impressions were taken at least 3 months after the initiation of cinnamon- and benzoate-free diet also showed reduction in lip size during follow up (P<0.002). CONCLUSIONS: Serial lip impressions appear to be reliable for routine quantification of morphological changes of the lips in OFG patients. We present a new reproducible and sensitive method for assessing changes in lip size in response to treatment in OFG.     

Community-dwelling stroke survivors: function is not the whole story with quality of life

OBJECTIVE: To compare function and quality of life in community-dwelling stroke survivors at 1, 3, and 5 years after stroke. DESIGN: A community-based, cross-sectional study of 3 retrospective cohorts. SETTING: Community-dwelling stroke survivors in Australia. PARTICIPANTS: The 3 cohorts comprised 30 participants each at 1, 3, and 5 years poststroke discharge from a tertiary referral hospital. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Stroke severity, comorbidity, medications used, and demographic information were recorded. Poststroke function was assessed using the Modified Rankin Scale, Mini-Mental State Examination, Stroke Impact Scale, and Multidimensional Scale of Perceived Social Support. RESULTS: This cross-sectional study provides insights into trends in stroke survivors over time. A high proportion of stroke survivors use community services, even those who are independent with activities of daily living. Although there was little attrition in medication use over time except for warfarin, this was from a baseline of suboptimal compliance and adherence with stroke preventive therapies. Stroke survivors report high levels of perceived social support; however, emotional well-being was low overall. The data suggest that those who are independent at 1 year tend to remain independent, although this was an extrapolation from serial cross-sections and needs to be explored in a longitudinal study. CONCLUSIONS: Stroke survivors' function does not change significantly over time. A high proportion of survivors require community services. The development of needs-related effective long-term service delivery models is required.