Yes / Background: Obesity interventions rely predominantly on managing dietary intake and/or increasing physical activity but sustained adherence to behavioural regimens is often poor. Avatar technology is well established within the computer gaming industry and evidence suggests that virtual representations of self may impact real-world behaviour, acting as a catalyst for sustained weight loss behaviour modification. However, the effectiveness of avatar technology in promoting weight loss is unclear. Aims: We aimed to assess the quantity and quality of empirical support for the use of avatar technologies in adult weight loss interventions. Method: A systematic review of empirical studies was undertaken. The key objectives were to determine if: (i) the inclusion of avatar technology leads to greater weight loss achievement compared to routine intervention; and (ii) whether weight loss achievement is improved by avatar personalisation (avatar visually reflects self). Results: We identified 6 papers that reported weight loss data. Avatar-based interventions for weight loss management were found to be effective in the short (4–6 weeks) and medium (3–6 months) term and improved weight loss maintenance in the long term (12 months). Only 2 papers included avatar personalisation, but results suggested there may be some added motivational benefit. Conclusions: The current evidence supports that avatars may positively impact weight loss achievement and improve motivation. However, with only 6 papers identified the evidence base is limited and therefore findings need to be interpreted with caution. / National Institute for Health Research (NIHR) [RfPB programme (project reference PB-PG-1215-20016)].

Yes / Implementation and uptake of novel and cost-effective medicines can improve patient health outcomes and healthcare efficiency. However, the uptake of new medicines into practice faces a wide range of obstacles. Earlier reviews provided insights into determinants for new medicine uptake (such as medicine, prescriber, patient, organization, and external environment factors). However, the methodological approaches used had limitations (e.g., single author, narrative review, narrow search, no quality assessment of reviewed evidence). This systematic review aims to identify barriers and facilitators affecting the uptake of new medicines into clinical practice and identify areas for future research. A systematic search of literature was undertaken within seven databases: Medline, EMBASE, Web of Science, CINAHL, Cochrane Library, SCOPUS, and PsychINFO. Included in the review were qualitative, quantitative, and mixed-methods studies focused on adult participants (18 years and older) requiring or taking new medicine(s) for any condition, in the context of healthcare organizations and which identified factors affecting the uptake of new medicines. The methodological quality was assessed using QATSDD tool. A narrative synthesis of reported factors was conducted using framework analysis and a conceptual framework was utilised to group them. A total of 66 studies were included. Most studies (n = 62) were quantitative and used secondary data (n = 46) from various databases, e.g., insurance databases. The identified factors had a varied impact on the uptake of the different studied new medicines. Differently from earlier reviews, patient factors (patient education, engagement with treatment, therapy preferences), cost of new medicine, reimbursement and formulary conditions, and guidelines were suggested to influence the uptake. Also, the review highlighted that health economics, wider organizational factors, and underlying behaviours of adopters were not or under explored. This systematic review has identified a broad range of factors affecting the uptake of new medicines within healthcare organizations, which were grouped into patient, prescriber, medicine, organizational, and external environment factors. This systematic review also identifies additional factors affecting new medicine use not reported in earlier reviews, which included patient influence and education level, cost of new medicines, formulary and reimbursement restrictions, and guidelines. PROSPERO database (CRD42018108536). / This work presents research funded by the Pharmacy Research UK (grant reference: PRUK-2018-GA-1-KM) and Leeds Teaching Hospitals NHS Trust.

In the ongoing discussion of treatment efficacy, some researchers have argued for the use of evidence from randomized controlled trials while others have argued the case for the use of non-randomized designs (Ingham 2003) in the study of the treatment of stuttering. Few attempts have been made to integrate findings from the research on stuttering intervention {Andrews, et al.1980; Howard, Nye, & Vanryckegbem, 2005; Herder, Howard, Nye & Vanryckeghem 2006; Thomas and Howell, 2001). Since the usual approach to the study of treatment efficacy uses experimental and quasi-experimental sources, a summary of the data available from single subject design {SSD) studies would seem warranted. The purpose of this project was to conduct a systematic review and meta-analysis of the effectiveness of stuttering treatment for children and adults by summarizing studies and determining an overall effect by calculating the percentage of non-overlapping data points (PND). The resulting review provides a summary of the effects of stuttering treatment, the nature of the treatment program characteristics and their associated effectiveness, and a general mapping of the research landscape in stuttering treatment terms of its' strengths and weaknesses and areas of need for future research.

This study serves to collate and evaluate measures of self-directed learning (SDL), with the goal of guiding the measurement and discussion of SDL. Used in a variety of settings, many applications of SDL have been proposed, but a consistent definition has yet to be formulated. Despite the lack of a cohesive definition, several tools exist to measure SDL. Within this study, which implemented the preferred reporting items for systematic reviews and meta-analyses (PRISMA) and Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) protocols, 157 articles were analyzed for content and themes were identified. An important finding of this study was a definite lack of cohesion in application and understanding of SDL as a framework. While some regard it as a stand-alone learning intervention, others address it as a personality trait. Close examination of the instruments used to measure SDL led to the conclusion that it is both inappropriate and ineffective to continue using, as they broadly lack construct validity and generalizability. Limitations of this study are single subject research, number studies available within databases used, and lack of raw data from studies covered. Future research surrounding the conceptual framework and instrumentation is indicated to further develop the field's understanding of SDL's value and implications.

Yes / Background: medication-related problems occur frequently when older patients are discharged from hospital. Interventions to support medication use have been developed; however, their effectiveness in older populations are unknown. This review evaluates interventions that support successful transitions of care through enhanced medication continuity. Methods: a database search for randomised controlled trials was conducted. Selection criteria included mean participant age of 65 years and older, intervention delivered during hospital stay or following recent discharge and including activities that support medication continuity. Primary outcome of interest was hospital readmission. Secondary outcomes related to the safe use of medication and quality of life. Outcomes were pooled by random-effects meta-analysis where possible. Results: twenty-four studies (total participants=17,664) describing activities delivered at multiple time points were included. Interventions that bridged the transition for up to 90 days were more likely to support successful transitions. The meta-analysis, stratified by intervention component, demonstrated that self-management activities (RR 0.81 [0.74, 0.89]), telephone followup (RR 0.84 [0.73, 0.97]) and medication reconciliation (RR 0.88 [0.81, 0.96]) were statistically associated with reduced hospital readmissions. Conclusion: our results suggest that interventions that best support older patients’ medication continuity are those that bridge transitions; these also have the greatest impact on reducing hospital readmission. Interventions that included self management, telephone follow-up and medication reconciliation activities were most likely to be effective; however, further research needs to identify how to meaningfully engage with patients and caregivers to best support post-discharge medication continuity. Limitations included high subjectivity of intervention coding, study heterogeneity and resource restrictions. / National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant PB-PG-0317-20010).

Burnout is a psychological syndrome characterized by feelings of exhaustion, cynicism, and inefficacy, and is particularly prevalent in surgical specialties. Despite the widespread recognition that burnout is the result of exposure to chronic job stressors, research on burnout among physicians has primarily focused on individual correlates and solutions to this issue. We also have a limited understanding of what kinds of interventions have become available to physicians following the pandemic and what the most effective options are for those in independent practice. Thus, this thesis serves to fill a gap in the literature on physician burnout by using a validated organizational framework to identify the organizational drivers of burnout among surgeons and McMaster and update the literature on the state of burnout interventions in medicine. The first chapter explores the state of the literature on physician burnout, with a specific focus on surgical specialties and the theoretical gaps that exist in this field. Chapters two through four describe the design and findings of a mixed methods study exploring surgeons’ experiences with burnout and the workplace stressors associated with its symptoms. Chapter five consists of a systematic review and meta-analysis evaluating the effectiveness of interventions for physician burnout and provides a methodological critique of the available studies in this field. Finally, chapter six integrates the finding from the quantitative and qualitative strand of the mixed methods study while considering the findings in reference to available interventions. The findings presented in this thesis provide tangible recommendations to McMaster’s Department of Surgery on how to improve burnout symptoms with specific reference to the role of payment structures, tensions among leadership positions, patient care burden, moral injury, workplace incivility, and gender inequity. It also highlights opportunities for future intervention development focusing on health system stressors and organizational structures. / Dissertation / Doctor of Philosophy (PhD) / Burnout is a condition that results from issues in the workplace and is extremely common among physicians. Although we generally know where burnout comes from, what causes burnout tends to take different forms in different medical specialties and workplaces. Given the negative effects that burnout has on both physicians and the quality of patient care they are able to provide, it is important that we identify the specific stressors leading to burnout within different medical settings and identify effective interventions for the problems they face. Using a range of evaluation methods, including surveys, interviews, and reviews of the current research on this subject, this thesis looked to identify issues leading to burnout among surgeons at McMaster University, and provide specific recommendations on how to address them.

This dissertation explores how urban leaders and stakeholders can leverage urban innovation to address complex challenges and the uncertainties come with them at the local level, specifically for marginalized communities. Through a series of three standalone articles, including a pilot study on tactical urbanism and two systematic reviews on urban innovation governance and just city implications, the research employs an abductive approach to reconceptualize urban innovation as a platform for collective action and self-governance. The pilot study examines tactical urbanism as a promising trend for addressing uncertainties at the hyper-local level during the COVID-19 pandemic, using a qualitative analysis of academic and grey literature, as well as case studies of tactical urbanism interventions. Building upon these findings, the first systematic review delves into the concept of "urban innovation governance," proposing a participatory, community-based governance conceptualization. This review employs a mixed method meta-synthesis research strategy and an umbrella review methodology to assess the available evidence on urban innovation governance from a multidisciplinary perspective. Through triangulating my theoretical lens, the second review explores urban innovation as a platform for active and inclusive citizenship, utilizing a scoping review methodology to synthesize the practical implications of just city research, and identifying strategies for promoting equitable and inclusive urban transformations. By synthesizing insights from these studies, this dissertation challenges technocratic and top-down perspectives, arguing that community-driven urban innovation is key to locally attuned, inclusive action. The findings contribute to debates on public governance, community development, and innovation, offering evidence-based principles to guide localized innovation governance regimes tailored to unique urban contexts. This research highlights the transformative potential of urban innovation when approached through a self-governing, community-level lens.

Yes / Purpose: We systematically reviewed the literature to investigate when refraction is stable following routine cataract surgery implanting monofocal intraocular lenses. Current advice recommends obtaining new spectacles 4–6 weeks following surgery. Due to advancements in surgical techniques, we hypothesised that refractive stability would be achieved earlier, which could have major short-term improvements in quality of life for patients. Methods: Medline, CINAHL, AMED, Embase, Web of Science and the Cochrane Library were searched with key words chosen to find articles, which assessed refraction following uncomplicated cataract surgery. Citation chains and the reference lists of all included papers were searched. Unpublished literature was identified using OpenGrey (www.opengrey.eu). The review considered studies that measured refraction at regular intervals following surgery until stability was achieved. Results: The search identified 6,680 papers. Two reviewers independently screened the abstracts and nine papers were found to fit the criteria, of which five were included in the meta-analysis. The quality of the papers was evaluated using the Methodological Index for Non-Randomised Studies (MINORS) instrument. Meta-analysis of 301 patients’ data of spherical, cylindrical and spherical equivalent correction were performed using Review Manager 5 (RevMan 5.3) (https://revman.cochrane.org/). Refraction at 1-week versus the gold standard of 4-weeks showed no significant difference for sphere data (effect size and 95% confidence interval of; ES = 0.00, 95% CI: −0.17, 0.17; p = 1.00), cylindrical data (ES = +0.06; 95% CI: −0.05, 0.17; p = 0.31), and spherical equivalent (ES = −0.01; 95% CI: −0.12, 0.10; p = 0.90). Heterogeneity was non-significant (I2

Assessment of risk of bias in the included randomized controlled trials (RCTs) has become an essential step in systematic reviews, which informs the decision of whether to rate down certainty of evidence due to risk of bias applying the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Many instruments exist for rating risk of bias in RCTs; however, even those most commonly used that developed by the Cochrane group, suffer from limitations. In particular, the revised Cochrane instrument, while reflecting methodological advances, sacrificed simplicity and practicability. The objective of this thesis is to use rigorous methodology to develop a simple-structured RCT risk of bias instrument that is easy for systematic review authors to use. The thesis begins with a chapter introducing the background and the structure of the thesis. The thesis subsequently describes a systematic survey of existing RCT risk of bias instruments for their included items, through which we collected potential candidate items for the new instrument. We then present a summary of empirical evidence investigating how the possible risk of bias issues influence the estimates of intervention effects in RCTs, which assisted with the item selection for the new instrument. Then, this thesis describes the detailed process for instrument development and providing the new instrument. This thesis ends with a chapter summarizing key findings, discussing strengths and limitations, and exploring directions for future research. / Thesis / Doctor of Philosophy (PhD)

Background: The coronavirus disease 2019 (COVID-19) presents diagnostic evaluation and patient management challenges, including uncertainty regarding the role of imaging tests. This series of reviews from the suite of Cochrane ‘living systematic reviews’ aims to evaluate the accuracy of chest imaging (computed tomography (CT), X-ray and ultrasound) for diagnosis and management of individuals with suspected COVID-19. Methods: The Bern COVID-19 Living Database, Cochrane COVID-19 Register, and CDC Library were searched through 30 September 2020 (for review version 3) and 17 February 2021 (for review version 4). Diagnostic accuracy studies involving participants with suspected COVID-19 were included. Screening, data extraction, and risk of bias assessments (using the QUADAS-2 tool) were completed independently, in duplicate. Pooled accuracy estimates and 95% confidence intervals (CIs) were determined using a bivariate random effects model. Results: In the third version of the review, chest CT (41 studies, 16133 participants, 8110 (50%) cases) had a pooled sensitivity of 87.9% (95%CI 84.6-90.6) and specificity of 80.0% (74.9-84.3). Chest X-ray (9 studies, 3694 participants, 2111 (57%) cases) had a pooled sensitivity of 80.6% (69.1-88.6) and specificity of 71.5% (59.8-80.8). Ultrasound of the lungs (5 studies, 446 participants, 211 (47%) cases) had a pooled sensitivity of 86.4% (72.7-93.9) and specificity of 54.6% (35.3-72.6). Indirect comparisons showed that chest CT gave higher specificity (P=0.0052) and similar sensitivity (P=0.77) compared to ultrasound. There were no differences (P≥0.05) in accuracy between CT and X‐ray, or X‐ray and ultrasound. In the fourth version of the review, chest CT (69 studies, 28285 participants, 14342 (51%) cases) had a pooled sensitivity of 86.9% (83.6-89.6) and specificity of 78.3% (73.7-82.3). Chest X‐ray (17 studies, 8530 participants, 5303 (62%) cases) had a pooled of sensitivity=73.1% (64.1-80.5) and specificity of 73.3% (61.9-82.2). Ultrasound of the lungs (15 studies, 2410 participants, 1158 (48%) cases) had a pooled sensitivity of 88.9% (84.9-92.0) and specificity of 72.2% (58.8-82.5). Indirect comparisons showed that chest CT and ultrasound had similar sensitivities (P=0.42), and each gave higher sensitivities than X-ray (P=0.0003 and P=0.001, respectively). All modalities had similar specificities (P≥0.05). Conclusion: The most recent evidence indicates that both chest CT and ultrasound of the lungs are sensitive and moderately specific for diagnosing individuals with suspected COVID-19, while chest X-ray is moderately sensitive and moderately specific. Chest CT and ultrasound may be useful for ruling out COVID‐19, but not for distinguishing COVID-19 from other illnesses. Research assessing the prognostic value of imaging for predicting morbidity and mortality in individuals with COVID-19 is underway and will also be published in the suite of Cochrane ‘living' systematic reviews.