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Chester Medical School
Chester Medical School run research programmes jointly with the Countess of Chester Hospital NHS Foundation Trust (COCH) and other hospital trusts that are relevant at regional, national and international level.
This collection is licenced under a Creative Commons licence. The collection may be reproduced for non-commerical use and without modification, providing that copyright is acknowledged.
Recent Submissions
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The efficacy and safety of Asciminib in the treatment of Chronic Myeloid Leukemia: A systematic review and meta-analysisChronic Myeloid Leukemia (CML) is a myeloproliferative neoplasm characterized by the presence of the BCR :ABL1 fusion gene, which drives leukemogenesis through aberrant tyrosine kinase activity. While first- and second-generation tyrosine kinase inhibitors (TKIs) have transformed the management of CML, treatment failure due to resistance or intolerance—especially in patients with the T315I mutation—remains a critical concern. Asciminib, a first-in-class STAMP inhibitor targeting the myristoyl pocket of ABL1, offers a novel therapeutic approach distinct from ATP-competitive TKIs. This systematic review summarizes current evidence on the efficacy and safety of Asciminib in adults with CML who have failed at least two prior TKIs. Data from eight clinical trials involving 1,093 patients revealed that Asciminib demonstrated superior major molecular response rates compared to Bosutinib and Ponatinib in patients without the T315I mutation, along with a favorable safety profile marked by fewer grade ≥3 adverse events and treatment discontinuations. However, its efficacy in T315I-mutant CML remains inconclusive and warrants further investigation. The unique mechanism of Asciminib and its tolerability profile support its clinical utility as a third-line agent in CML, with potential future applications in combination therapies and treatment-free remission strategies.
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florio HAEMO—A digital medical device for monitoring of treatment, symptoms and physical activities for people living with haemophiliaIntroduction: Despite therapeutic achievements in haemophilia care, there is still the need to monitor and define personal treatment outcomes and document results to achieve the best possible care. Hence, a need for unbiased, timely and comprehensive real‐world information exists to support informed shared decision‐making regarding treatment and care. Aim: To describe a medical device for people living with haemophilia (PLWH) supporting an active involvement to achieve a near to normal life. Methods: Florio HAEMO was developed as haemophilia monitoring platform to support PLWH and their care teams in documenting, interpreting and analysing personal reported outcomes. The tool was created partnering closely with PLWH and healthcare professionals to address previously unmet needs compared to existing applications. Results: Florio HAEMO was launched in March 2020. Currently, it is available in 25 countries and 24 languages; 1558 PLWH (86% with haemophilia A) are registered users in 121 treatment centres across 20 countries. All users included are on a prophylactic treatment regimen. Conclusion: Florio HAEMO allows the collection of contemporaneous data to monitor treatment, like factor level, adherence and consumption as well as monitoring treatment outcomes, including pain, bleeds, wellbeing and levels of physical activity to support self‐management, shared decision‐making and to enable better care for PLWH. Data collected over time may help to show the impact of individualised prophylaxis and may support the definition of factor levels required for good bleed and joint protection in a real world setting from daily life to physical activities.
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The Eat-Out-to-Help-Out incentive: A trigger for gastrointestinal infections in England, 2020?Our study assessed the link between gastrointestinal (GI) infections in England and the Eat Out to Help Out scheme (EOHO), a government subsidy created to encourage people to eat out during COVID-19 pandemic (03–30 August 2020). We studied national laboratory data between January 2015 and December 2020. We used time series change point analysis to see if there were shifts in reported cases of specific GI infections (Campylobacter spp., Escherichia coli O157, and non-typhoidal Salmonella spp.) associated with the timing of the scheme. Our analysis uniquely applied the Pruned Exact Linear Time method, with generalized linear models to a national dataset of GI infections. This revealed increases in cases closely aligned to the timing of the easing of COVID-19 restrictions, prior to the introduction of the EOHO scheme. Our study showed the scheme had no measurable impact, as there was no significant change on reported cases. Substantial reductions in cases after the first lockdown, followed by an increase as restrictions were phased out, show the wider impact of COVID-19 control measures, for example, public information campaigns aimed at improving hand-hygiene. These findings highlight the complicated interactions between COVID-19 control measures, the public’s behaviour, and the spread of GI infections.
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Impact of dietary patterns on skeletal health: A systematic review and meta-analysis of bone mineral density, fracture, bone turnover markers, and nutritional statusBackground/Objectives: Dietary patterns play a crucial role in musculoskeletal health; however, the effects of different diets on bone mineral density (BMD), fracture risk, and bone metabolism remain inconsistent across studies. This systematic review and meta-analysis aimed to evaluate the impact of Mediterranean, calorie restriction, high-protein, low-carbohydrate, and ketogenic diets on skeletal outcomes in adults. Methods: A comprehensive search of PubMed/MEDLINE, CENTRAL, and Web of Science was conducted for studies published between January 2000 and June 2025. Eligible randomised controlled trials (RCTs) and cohort studies involving adults (≥18 years) and reporting outcomes related to BMD, fractures, bone turnover markers, and vitamin D or calcium status were included. Risk of bias was assessed using the Cochrane’s Risk of Bias tool for RCTs and the Joanna Briggs Institute checklist for observational studies. Random-effects meta-analyses were performed for outcomes reported by ≥3 comparable studies, presenting standardised mean differences (SMDs) for BMD and hazard ratios (HRs) for fractures. Results: Thirty studies met inclusion criteria, comprising 14 RCTs and 16 observational studies with over 500,000 participants. Pooled analyses showed no significant differences in BMD at the femoral neck (SMD = 0.12, 95% CI −0.80 to 1.04), lumbar spine (SMD = 0.04, 95% CI: −1.12 to 1.03), total hip (SMD = −0.07, 95% CI −0.36 to 0.21), or whole body (SMD = 0.03, 95% CI −0.07 to 0.14) across diet categories. However, adherence to a Mediterranean diet was associated with a significantly reduced hazard of hip and overall fractures (pooled HR = 0.95, 95% CI 0.93–0.96). Calorie restriction consistently increased bone resorption markers, whereas Mediterranean and high-protein diets showed neutral or modestly favourable effects. Vitamin D and calcium status were minimally affected across interventions. Conclusions: While dietary patterns exert diverse effects on skeletal health, consistent evidence supports Mediterranean-style diets as protective against fractures. Calorie restriction may elevate bone turnover, whereas ketogenic and high-protein diets show mixed effects on bone. However, across all analyses, high heterogeneity was observed. Further high-quality RCTs are warranted to clarify these relationships and inform dietary guidance for bone health.
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Organisational contextual drivers of evidence-based practice across acute and primary careBackground: Evidence based practice (EBP) is widely recognised as fundamental to high quality nursing care, yet implementation remains uneven across healthcare settings in England. Attention has shifted from individual barriers to organisational context. Leadership, team dynamics, access to resources, and social capital shape how nurses engage with EBP. Despite national policies promoting research active environments, how these ambitions are realised at the frontline is unclear. This study examined how organisational factors influence nurses’ implementation of evidence across acute and primary care. Methods: A cross-sectional design was used with registered nurses working in acute and primary care settings. Two validated instruments, the Evidence Based Practice Implementation Scale and the Alberta Context Tool, were administered. A nonprobability sampling strategy targeted the acute and general practice nursing workforce. Response distributions were monitored across pre specified strata and fieldwork closed once coverage and precision criteria were met. Descriptive statistics summarised participant and organisational characteristics. Inferential analyses compared settings, mediation modelling tested the role of social capital in the leadership to EBP pathway, and cluster analysis identified implementation profiles. Results: Engagement with EBP was moderate overall (M = 3.16, SD = 0.88) with no significant difference between sectors (p = 0.38). Acute care nurses reported higher leadership support (M = 4.01 versus 3.78, p = 0.008) and better access to structural resources (M = 3.35 vs. 3.10, p = 0.004). Within acute care, leadership differed across specialties, with higher scores in ICU or CCU and general medicine, F (4, 636) = 4.12, p = 0.003. Social capital significantly mediated the association between leadership and EBP implementation (β = 0.15, 95% CI 0.10–0.21). Three engagement clusters were identified, high 32%, moderate 45%, and low 23%, each with distinct organisational profiles. Conclusion: Organisational context, particularly leadership and social capital, is central to nurses’ capacity to implement evidence. Variation across specialties and sectors indicates that a one size fits all approach is unlikely to succeed. Policy relevant levers include formalising protected time, resourcing embedded facilitation, investing in knowledge infrastructure, and expanding clinical academic pathways, to create environments where evidence use is routine and supported.
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A situation analysis of diagnostic and management strategies for gestational Urinary Tract Infections (UTIs) in Kisumu County, Kenya: Maternal health implications and opportunities for diagnostic improvementUrinary tract infections (UTIs) are linked to adverse pregnancy outcomes, yet epidemiological data on gestational UTIs in Kenya are limited. This study assessed diagnostic and management practices in Kisumu County to inform diagnostic and antimicrobial stewardship. A hospital-based retrospective study was conducted from February 2020 to February 2021 among 416 records of pregnant women at Chulaimbo and Nyahera Sub-County Hospitals. Socio-demographic, laboratory, and clinical history data were collected using structured forms and analysed in STATA 16.0. Statistical methods included chi-square, multivariate logistic regression, and Spearman’s rank correlation (p ≤ 0.05). Dipstick-based presumptive proportion of UTIs was 57.9% (241/416). Only 1.4% (6/416) had microbiological confirmation despite infections being recorded. The mean maternal age was 23.92 years, parity two, mean antenatal visits two, and mean haemoglobin 10.73 ± 1.8 g/dL. The first antenatal care attendance occurred at varying gestational ages in 56% (233/416). Antibiotics prescribed were 60% from WHO ‘Access’ group and 40% from ‘Watch’ group. Gestational UTI’s in Kisumu County were frequently managed without confirmatory diagnosis, increasing antimicrobial resistance risk. Strengthening management requires better laboratory capacity, sustained financial investment, improved antibiotic access, and adherence to WHO AWaRe guidelines to protect maternal and neonatal health.
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Cardiovascular disease in the context of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A comprehensive narrative reviewMetabolic dysfunction-associated steatotic liver disease (MASLD) is a chronic hepatic disease with a rising global prevalence (25–38% of the general population). As a new term, MASLD was introduced in 2023 to replace the previous nomenclature of non-alcoholic fatty liver disease (NAFLD) and metabolic dysfunction-associated fatty liver disease (MAFLD). This new term/definition introduced changes in the diagnostic criteria and underscores the direct link between cardio-metabolic risk and this prevalent liver disease. In this context, the present review examines the clinical and pathophysiological links between MASLD and cardiovascular disease (CVD), providing a robust evidence synthesis of primarily systematic review data on the association between MASLD and coronary artery disease (CAD), atrial fibrillation (AF), and heart failure (HF). This association appears to be not only synergistic, but also independent of other known CVD risk factors, highlighting MASLD as a key cardio-metabolic risk factor that merits prompt diagnosis and treatment. The development of MASLD-related cardiovascular morbidity increases with the severity of the underlying hepatic pathology, particularly with progression to steatohepatitis and fibrosis. Notably, growing evidence highlights the links between MASLD and CVD through cardiac structural, electrical, and functional alterations that can progress to CAD, AF, and new-onset HF. Recognizing these links in clinical practice underscores the importance of early detection and multi-disciplinary management of MASLD to prevent disease progression and CVD complications.
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Organ wide toxicological assessment of common edible herbs and their mixtures as used in home remediesThe use of home remedies for medicinal purposes, most of which are edible plants has continued to be a practice in many homes. However, there has been an increasing report of chronic use with lethal effect. Among the commonly used herbal/ medicinal plants were ginger, garlic and lemon. These were seen to be prevalent across continents with brewing and crude extraction being the most means of consumption. This study investigated the organ wide toxicity of this extract following chronic consumption of crude extract. Twenty-five albino Wister rats, five in each group were used for this experiment. Each animal received 0.5ml/kg body weight of either ginger extract, garlic extract, lemon juice, or a mixture of equal volumes of all three extract (v/v) respectively twice daily for seven (7) days. Statistics were represented as ±SE; P≤0.05 was considered significant. Previous studies have shown that moderate consumption of these medicinal plants were beneficial and have shown no deleterious effect. This study observed no change in the weight of the experimental animals. The weight of the animals continued to increase except for the group that received lemon and the mixture, but these were not significant. It was observed that chronic consumption induced organ wide toxicity to include the liver, kidney, intestinal epithelium, stomach, and pancreas. These were shown to alter tissue architecture and the cell morphology. Packed cell volume was reduced in the lemon and the group that received a combination of all extracts (p=o.03). Blood differentials showed changes in levels. An elevated basophil level was observed in ginger and garlic (p<0.0001; p=0.0006). Monocyte levels increased progressively across each group when compared to the control with the most elevated level seen in the group that received the mixture (p<0.0001). Lymphocyte count was reduced across all the groups that received the extract except for animals that received ginger. This study suggests the application of caution among users of these medicinal plants and continues to draw attention to the need for harmonization and standardization of safe use doses.
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Awareness and Knowledge of Antimicrobial Resistance, Antimicrobial Stewardship and Barriers to Implementing Antimicrobial Susceptibility Testing among Medical Laboratory Scientists in Nigeria: A Cross-Sectional StudyBackground: Antimicrobial resistance (AMR) is now considered one of the greatest global health threats. This is further compounded by a lack of new antibiotics in development. Antimicrobial stewardship programmes can improve and optimize the use of antibiotics, thereby increasing the cure rates of antibiotic treatment and decreasing the problem of AMR. In addition, diagnostic and antimicrobial stewardships in the pathology laboratories are useful tools to guide clinicians on patient treatment and to stop the inappropriate use of antibiotics in empirical treatment or narrow antibiotics. Medical Laboratory Scientists are at the forefront of performing antibiotics susceptibility testing in pathology laboratories, thereby helping clinicians to select the appropriate antibiotics for patients suffering from bacterial infections. Methods: This cross-sectional study surveyed personal antimicrobial usage, the knowledge and awareness on AMR, and antimicrobial stewardship, as well as barriers to antimicrobial susceptibility testing among medical laboratory scientists in Nigeria using pre-tested and validated questionnaires administered online. The raw data were summarized and exported in Microsoft Excel and further analyzed using IBM SPSS version 26. Results: Most of the respondents were males (72%) and 25–35 years old (60%). In addition, the BMLS degree was the highest education qualification most of the respondents (70%) achieved. Of the 59.2% of the respondents involved in antibiotics susceptibility testing, the disc diffusion method was the most commonly used (67.2%), followed by PCR/Genome-based detection (5.2%). Only a small percentage of respondents used the E-test (3.4%). The high cost of testing, inadequate laboratory infrastructure, and a lack of skilled personnel are the major barriers to performing antibiotics susceptibility testing. A higher proportion of a good AMR knowledge level was observed in male respondents (75%) than females (42.9%). The knowledge level was associated with the respondent’s gender (p = 0.048), while respondents with a master’s degree were more likely to possess a good knowledge level of AMR (OR: 1.69; 95% CI: 0.33, 8.61). Conclusion: The findings of this study indicate that Nigerian medical laboratory scientists had moderate awareness of AMR and antibiotic stewardship. It is necessary to increase investments in laboratory infrastructure and manpower training, as well as set up an antimicrobial stewardship programme to ensure widespread antibiotics susceptibility testing in hospitals, thereby decreasing empirical treatment and the misuse of antibiotics.
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Metabolic, androgenic, and physical activity profiles in women aged over 40 years with polycystic ovary syndrome: A comparative analysis using UK Biobank dataBackground: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive-aged women, linked to metabolic, hormonal, and psychological issues. Management typically involves lifestyle changes, including increased physical activity and reduced sedentary behaviour. Objectives: To compare the health profiles and behaviours of women with and without PCOS. Design: This study analysed data from the UK Biobank, which is a prospective cohort study. Methods: Women with PCOS in the UK Biobank were identified, while age- and body mass index (BMI)-matched controls were randomly selected. Data on factors associated with PCOS severity and self-reported lifestyle behaviours were analysed. Group differences were tested for significance, and participants were categorised by health behaviours to assess morbidity risk. Results: The study included 319 women with PCOS (mean age: 43.9 years) and 638 in each control group. Significant differences (p < 0.05) were observed in anthropometric (e.g. body weight, BMI, waist and hip circumference, and body fat), cardio-metabolic (e.g. blood pressure, triglycerides, and glycated haemoglobin), and androgenic (e.g. sex hormone-binding globulin) indices. Differences were most pronounced between PCOS and age-matched controls but remained when BMI was also considered. Women with PCOS engaged in less vigorous physical activity and had higher screen time and sedentary behaviours. Those with the lowest physical activity and highest sedentary time had the worst health profiles and highest morbidity risk, regardless of group. Conclusion: Women with PCOS exhibit poorer health despite only slight lifestyle differences. Across all participants, lower physical activity and higher sedentary behaviour were linked to increased health risks. Further research is needed to clarify causal relationships between lifestyle factors and PCOS.
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Loss of the RNA binding protein HuR in early murine limb mesenchyme does not affect development but leads to impaired bone homeostasis in adulthoodIn this study, we examined how a critical posttranscriptional regulator, the RNA‐binding protein HuR (gene name Elavl1), contributes to the development and maintenance of limb skeletal tissue. Using the Prx1‐Cre knockout model, we examined the effect of germline knockout (Elavl1KO) and limb mesenchyme‐specific knockout (MSC‐Elavl1KO) of HuR on limb development. We found that Elavl1KO disrupted the development of the limb skeleton and was associated with a loss of signaling from the apical ectodermal ridge (AER). In contrast, MSC‐Elavl1KO did not appear to affect skeletal development. Mature MSC‐Elavl1KO mice appeared healthy, but their limb skeleton exhibited abnormal bone structure in both males and females at 2.5 months of age. Osteoblasts isolated from MSC‐Elavl1KO mice exhibited lower expression of osteoblastic marker genes, and their ability to generate a mineralized matrix was markedly impaired. RNA‐Seq analysis of these osteoblasts demonstrated that loss of HuR substantially influenced their transcriptome, affecting genes associated with a wide range of cellular processes. Finally, using siRNA knockdown in the human MG63 cell line, we identified that loss of HuR leads to increased mRNA turnover of the osteoblastic transcription factor Runx2. Overall, the study has demonstrated a critical role for HuR‐mediated posttranscriptional control in skeletal development and homeostasis, but finds that its expression in mesenchyme‐derived cells only becomes critical in mature skeletal tissue.
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Erratum to: An interpretative phenomenological analysis (IPA) of coercion towards community dwelling older adults with dementia: findings from Mysore studies of natal effects on ageing and health (MYNAH)A co-author’s name was published incorrectly in the original publication of the article. The author name “Muffadal Bharmal” should be “Mufaddal Bharmal”. The original article has been updated accordingly.
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Mapping the age of autistic spectrum condition diagnosis, affected by sex and intellectual disabilityIntroduction/purpose: Autism is a complex neurodevelopmental condition thought to affect 1 in 100 children globally. More commonly diagnosed in males, and during childhood, diagnoses are increasingly being made throughout adulthood. Purpose: To establish what age autistic people receive their diagnosis, and whether the age of diagnosis was influenced by their sex and by the presence of intellectual disability. Design: A quantitative, cross-sectional, retrospective study. Data was collected from the Primary Care records of 6 GP Practices covering Ellesmere Port, a large town in Northwest England with 71,210 people registered. Mean age of diagnosis was calculated for the group then for each subgroup, to allow comparison between males and females, and those with and without a documented intellectual disability. Findings: Data from 1130 autistic participants were analysed. Age of participants was between 3 - 81 years with an age of autism diagnosis of 1 - 72 years. 85.6% of participants were diagnosed with autism by the age of 25 years, most commonly at 3 years of age (11.9%). The average age of diagnosis was 2.48 years later for females diagnosed across the lifespan. Average age of diagnosis was 5.05 years later for those with a learning disability. Practical implications: This study highlights the importance of healthcare professionals, educators and care givers recognising autistic traits in people across the lifespan, including the potential for diagnostic overshadowing. There are implications for commissioning autistic services, to ensure adequate assessment pathway capacity for adolescents and adults as well as children.
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Educational strategies for managing moral distress in student nurses: A scoping reviewAims: To explore what content, teaching and learning activities are advocated by nurse educators to mitigate moral distress and related concepts in student nurses. Review Methods: The review was conducted according to Joanna Briggs Institute guidelines. The search strategy adopted their three-step method for systematic reviews. The eligibility criteria reflected the Population, Concept, Context format. Results: Following searches, 3809 records were screened against eligibility criteria, resulting in 42 eligible papers being included; 29 research studies and 13 non-empirical papers. We identified 236 content suggestions, mapped to 70 subject codes. Also, 217 teaching and learning activities are suggested and mapped to 41 coded activities. Data is charted in tables and figures and results are discussed per related concept of moral distress. Conclusions: Educational content, and teaching and learning activities are heterogenous across the concepts influencing moral distress. There is overlap of content across different concepts. Moral sensitivity received the most publications. Development of research and educational strategies addressing other interrelated concepts would be advantageous for evidence-based curriculum development. Recommendations are made to develop evidence-based content and teaching and learning activities.
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Antibiotic use among university students in malaria therapy and its implications for antimicrobial resistance in Nigeria: a quantitative cross-sectional studyBackground: Antimicrobial resistance (AMR) is a global health crisis, driven partly by inappropriate antibiotic use. In Nigeria, malaria remains highly prevalent and often mismanaged with antibiotics, particularly in presumed malaria-typhoid co-infections. This study examined patterns of antibiotic use in malaria treatment among university students, highlighting implications for AMR. Methods: A cross-sectional survey was conducted among undergraduates purposively selected from 12 universities across Nigeria’s six geopolitical zones. Data were collected via validated online questionnaires (February–March 2025) and analysed using descriptive statistics, chi-square tests, logistic regression, and Spearman correlation (SPSS v26). Results: Of 646 respondents, > 97% demonstrated general antibiotic knowledge, yet 27.6% misidentified chloroquine as an antibiotic. While 94.6% correctly recognised antibiotics for bacterial infections, about one-fifth believed they were effective against fungal, parasitic, or viral diseases. Despite 84.7% AMR awareness, 49.1% reported using antibiotics for malaria treatment. Misuse was highest in the Northeast (62.3%), Northwest (63.7%), and South-South (32.9%). In the Northeast, key drivers included prior experience (35.4%), pharmacist advice (29.9%), and peer influence (28.0%), while only 6.7% followed physician prescriptions. Misuse correlated with the belief that antibiotics treat all illnesses (rs = 0.329, p < 0.001). Nearly half (49.5%) accessed antibiotics without prescriptions. Conclusions: High AMR awareness contrasts with persistent misuse of antibiotics for malaria, reflecting misconceptions, regional disparities, and weak regulation. Targeted education, stricter antibiotic controls, and improved diagnostics are urgently needed to curb AMR in Nigeria.
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Intermittent prophylactic antibiotics for bronchiectasisBACKGROUND: Bronchiectasis is a common but under-diagnosed chronic disorder characterised by permanent dilation of the airways arising from a cycle of recurrent infection and inflammation. Symptoms including chronic, persistent cough and productive phlegm are a significant burden for people with bronchiectasis, and the main aim of treatment is to reduce exacerbation frequency and improve quality of life. Prophylactic antibiotic therapy aims to break this infection cycle and is recommended by clinical guidelines for adults with three or more exacerbations a year, based on limited evidence. It is important to weigh the evidence for bacterial suppression against the prevention of antibiotic resistance and further evidence is required on the safety and efficacy of different regimens of intermittently administered antibiotic treatments for people with bronchiectasis. OBJECTIVES: To evaluate the safety and efficacy of intermittent prophylactic antibiotics in the treatment of adults and children with bronchiectasis. SEARCH METHODS: We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted searches on 6 September 2021, with no restriction on language of publication. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of at least three months' duration comparing an intermittent regime of prophylactic antibiotics with placebo, usual care or an alternate intermittent regimen. Intermittent prophylactic administration was defined as repeated courses of antibiotics with on-treatment and off-treatment intervals of at least 14 days' duration. We included adults and children with a clinical diagnosis of bronchiectasis confirmed by high resolution computed tomography (HRCT), plain film chest radiograph, or bronchography and a documented history of recurrent chest infections. We excluded studies where participants received high dose antibiotics immediately prior to enrolment or those with a diagnosis of cystic fibrosis, allergic bronchopulmonary aspergillosis (ABPA), primary ciliary dyskinesia, hypogammaglobulinaemia, sarcoidosis, or a primary diagnosis of COPD. Our primary outcomes were exacerbation frequency and serious adverse events. We did not exclude studies on the basis of review outcomes. DATA COLLECTION AND ANALYSIS: We analysed dichotomous data as odds ratios (ORs) or relative risk (RRs) and continuous data as mean differences (MDs) or standardised mean differences (SMDs). We used standard methodological procedures expected by Cochrane. We conducted GRADE assessments for the following primary outcomes: exacerbation frequency; serious adverse events and secondary outcomes: antibiotic resistance; hospital admissions; health-related quality of life. MAIN RESULTS: We included eight RCTs, with interventions ranging from 16 to 48 weeks, involving 2180 adults. All evaluated one of three types of antibiotics over two to six cycles of 28 days on/off treatment: aminoglycosides, ß-lactams or fluoroquinolones. Two studies also included 12 cycles of 14 days on/off treatment with fluoroquinolones. Participants had a mean age of 63.6 years, 65% were women and approximately 85% Caucasian. Baseline FEV<sub>1</sub> ranged from 55.5% to 62.6% predicted. None of the studies included children. Generally, there was a low risk of bias in the included studies. Antibiotic versus placebo: cycle of 14 days on/off. Ciprofloxacin reduced the frequency of exacerbations compared to placebo (RR 0.75, 95% CI 0.61 to 0.93; I<sup>2</sup> = 65%; 2 studies, 469 participants; moderate-certainty evidence), with eight people (95% CI 6 to 28) needed to treat for an additional beneficial outcome. The intervention increased the risk of antibiotic resistance more than twofold (OR 2.14, 95% CI 1.36 to 3.35; I<sup>2</sup> = 0%; 2 studies, 624 participants; high-certainty evidence). Serious adverse events, lung function (FEV<sub>1</sub>), health-related quality of life, and adverse effects did not differ between groups. Antibiotic versus placebo: cycle of 28 days on/off. Antibiotics did not reduce overall exacerbation frequency (RR 0.92, 95% CI 0.82 to 1.02; I<sup>2</sup> = 0%; 8 studies, 1695 participants; high-certainty evidence) but there were fewer severe exacerbations (OR 0.59, 95% CI 0.37 to 0.93; I<sup>2</sup> = 54%; 3 studies, 624 participants), though this should be interpreted with caution due to low event rates. The risk of antibiotic resistance was more than twofold higher based on a pooled analysis (OR 2.20, 95% CI 1.42 to 3.42; I<sup>2</sup> = 0%; 3 studies, 685 participants; high-certainty evidence) and consistent with unpooled data from four further studies. Serious adverse events, time to first exacerbation, duration of exacerbation, respiratory-related hospital admissions, lung function, health-related quality of life and adverse effects did not differ between study groups. Antibiotic versus usual care. We did not find any studies that compared intermittent antibiotic regimens with usual care. Cycle of 14 days on/off versus cycle of 28 days on/off. Exacerbation frequency did not differ between the two treatment regimens (RR 1.02, 95% CI 0.84 to 1.24; I<sup>2</sup> = 71%; 2 studies, 625 participants; moderate-certainty evidence) However, inconsistencies in the results from the two trials in this comparison indicate that the apparent aggregated similarities may not be reliable. There was no evidence of a difference in antibiotic resistance between groups (OR 1.00, 95% CI 0.68 to 1.48; I<sup>2</sup> = 60%; 2 studies, 624 participants; moderate-certainty evidence). Serious adverse events, adverse effects, lung function and health-related quality of life did not differ between the two antibiotic regimens. AUTHORS' CONCLUSIONS: Overall, in adults who have frequent chest infections, long-term antibiotics given at 14-day on/off intervals slightly reduces the frequency of those infections and increases antibiotic resistance. Intermittent antibiotic regimens result in little to no difference in serious adverse events. The impact of intermittent antibiotic therapy on children with bronchiectasis is unknown due to an absence of evidence, and further research is needed to establish the potential risks and benefits.
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The relationship between facilitating emotional cues and medical students’ clinical communication performance in qualifying examsA cross-sectional study design explored the relationship between medical students' Objective Structured Clinical Examination (OSCE) clinical communication ratings and their responsiveness to simulated patient (SP) verbal emotional cues in their qualifying OSCE. Data were collected from two cohorts of fourth-year medical students (n = 37), and responses to patient cues that facilitated further disclosure or related discussion - known as provide space responses - from two OSCE communication stations were measured by coding video footage with the Verona Coding Definition of Emotional Sequences (VR-CoDES). The 37 medical students were representative of the larger cohort (n = 508) in terms of age. A significant positive correlation with a medium effect was found between OSCE clinical communication ratings and provide space responses. OSCE clinical communication ratings could differentiate between students who adopted patient-centred facilitative behaviours and those who did not.
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“The perception of visiting Holocaust sites on undergraduate students learning process”This paper presents the main findings of a qualitative research project. The aim of the research was to explore undergraduate students’ perceived knowledge acquisition and awareness of the Holocaust, after visiting Auschwitz concentration camp in Poland. The qualitative study (focus groups & semi-structured questionnaires) involved three cohorts of students and lecturers from a university in the North West of England. The participants visited the Holocaust-related sites in Poland from 2016 to 2019. Findings indicate that students’ who actively engaged in visits to Holocaust related sites developed knowledge and awareness of the Holocaust. For many participants, this knowledge and awareness was facilitated via a reflective process that enabled empathic connection between these historical events and the students. The study also highlighted practical strategies that could be implemented to enhance the experience for future cohorts of undergraduate students visiting holocaust related sites. By adding to the limited literature on Holocaust education with undergraduate students, the study highlighted the importance and directions for future research in this area to inform future pedagogic practice.
