retrospective cohort study level of evidence

In the third set of analyses, to examine whether differential distribution of patients across surgeons played a role in the inequities found, we compared the original results (linear probability model of 30 day mortality for all eight surgical procedures as a function of race and sex, also controlling for age, Medicaid dual eligibility, disability, 27 chronic conditions, hospital service area fixed effects, weekend surgery, month fixed effects, year fixed effects, and procedure fixed effects) when including hospital service area fixed effects with the results when replacing hospital service area fixed effects with surgeon fixed effects. NSAIDs and smoking were also associated with more dental implant failures. A complete assessment of the quality of individual studies requires critical appraisal of all aspects of study design. This article describes the most common types of designs conducted by researchers. Level I: Evidence from a systematic review of all relevant randomized controlled trials. Evidence from other countries that have examined racial inequities in surgical access and outcomes is limited to studies on individual surgical procedures with relatively small sample size. This study has several limitations. The views expressed here are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs, the US government, or other affiliated institutions. (For definitions of terms used see our glossary) Produced by Bob Phillips, Chris Ball, Dave Sackett, Doug Badenoch, Sharon Straus, Brian Haynes, We use cookies to help provide and enhance our service and tailor content and ads. HHS Vulnerability Disclosure, Help Apreciated the information provided above. As, in cohort studies we are looking at incidence (new) cases, so if an outcome have occurred before the exposure, I can leave them out of the analysis. Thanks a lot. However, given that processed food, a contributory factor in obesity, and tobacco are more readily available in racially minoritized communities than regions with predominantly White residents,5253 these variables can be seen as factors in the causal pathway linking race and sex with surgical mortality and thus should not be adjusted for in analyses. Compared with Black men, White men and White women were less likely to be Medicaid dual eligible and less likely to enter Medicare because of disability, whereas Black women were more likely to be Medicaid dual eligible. Participants 1 868 036 Black and White Medicare beneficiaries aged 65-99 years undergoing one of eight common surgeries: repair of abdominal aortic aneurysm, appendectomy, cholecystectomy, Conducting successful research requires choosing the appropriate study design. quasi-experimental). This is one of their important strengths. WebCohort studies can be classified as prospective or retrospective studies, and they have several advantages and disadvantages. Although we support the importance of patient and public involvement, this was a secondary data analysis of existing claims data where the identifiers were not available for patients or members of the public for analysis, and as such it was not practical to involve them as members of this research study. Another retrospective cohort study at an academic medical center evaluated pregnancy outcomes and OHSS using a sliding scale hCG protocol in 10427 fresh in vitro fertilizationintracytoplasmic sperm injections. 97 0 obj WebA population-based retrospective cohort study of end-of-life emergency department visits by people with dementia: multilevel modelling of individual- and service-level factors using linked data A recent systematic review of international literature identified moderate-to For instance, to estimate fracture risk among unselected community men with prostate cancer and systematically assess associations with androgen deprivation therapy and other risk factors for fracture, investigators used data from the Rochester Epidemiology Project database (a unique medical records-linkage system that encompasses the care delivered to residents of Rochester and Olmsted County, Minnesota) to identify all men with prostate cancer first diagnosed in 199099, allowing for a decade of more of subsequent follow-up [25]. Critically-appraised individual articles and synopses include: 1. The .gov means its official. In the hierarchy used to classify evidence-based research in medicine, level 2 evidence includes prospective cohort studies. There are five levels of evidence in the hierarchy of evidence being 1 (or in some cases A) for strong and high-quality evidence and 5 (or E) for evidence with effectiveness not established, as you can see in the pyramidal scheme below: Level 1: (higher quality of evidence) High-quality randomized trial or prospective study; testing of previously developed diagnostic criteria on consecutive patients; sensible costs and alternatives; values obtained from many studies with multiway sensitivity analyses; systematic review of Level I RCTs and Level I studies. Mortality rates after elective surgical procedures by number of postoperative days and by race and sex, among Medicare beneficiaries, 2016-18. Placebo (control) is given to one of the groups whereas the other is treated with medication. It all depends on your research question. For elective procedures, surgeons have more opportunity to both optimize patients (eg, improve management of chronic diseases such as diabetes and hypertension) before surgery and choose (or avoid) patients. age, sex) to ensure these do not confound the study results. Retrospective cohort studies are NOT the same as case-control studies. Comments or Suggestions? LEVEL 1 Randomized Control Trials In Randomized Control Trials (RCTs) study subjects are randomly assigned to intervention or control groups. YT was supported by the National Institute on Aging (R01 AG068633) for other work not related to this study. These findings highlight the need to understand better the unique challenges Black men who require surgery face in the US. Mortality rates were then studied longitudinally to examine how any inequities evolved over time. Really good work man. Both medications were comparable in terms of clinical pregnancy and OHSS rates as compared to placebo [14c]. Web Level II-1: Evidence obtained from well-designed controlled trials without randomization. Keywords: Grades are assigned on the basis of the quality and consistency of available evidence. official website and that any information you provide is encrypted The majority of glioma tumors do increase in size during pregnancy, though this does not necessarily cause new symptoms or clinical decline (Peeters et al., 2018). WebEvidence Levels: Level I: Cohort studies can be retrospective, looking back over time at data that has already been collected, or can be prospective, following a group forward into the future and collecting data along the way. <> Nevertheless, as case-controls are retrospective, they are more prone to bias. In addition to race and sex, patient covariates included age (defined categorically in five year age groups), dual eligibility for Medicaid (as an indicator for socioeconomic status because only individuals with low income are eligible for Medicaid coverage in the US), disability as the original reason for Medicare eligibility, and 27 chronic conditions (see table 1) found in the Medicare Master Beneficiary Summary File. Impact of the Momentum pilot project on male involvement in maternal health and newborn care in Kinshasa, Democratic Republic of the Congo: a quasi-experimental study. Graphic representation of a retrospective cohort study type. 2023-03-04T08:10:16-08:00 A retrospective cohort study was conducted to assess the RR of various drinking water sources, to measure the microcystin concentration in different water sources, and to analyze the relationship between the incidence of CRC and the toxin concentration. Strategies to reduce the renal toxicity of polymyxin B are urgently needed [104c]. All P values were from two sided tests and results were considered statistically significant at P<0.05. WebA retrospective cohort study was conducted to examine the risk of mortality, cancer, and other adverse health outcomes, at the United States' largest chromate chemicals manufacturing facility in Castle Hayne, North Carolina. Of course, it is recommended to use level A and/or 1 evidence for more accurate results but that doesnt mean that all other study designs are unhelpful or useless. <> The study then follows these participants for a defined period to assess the proportion that develop the outcome/disease of interest. No difference was found between river and pond or between well and tap water. This difference was noticeable within seven days of surgery and persisted for at least 60 days. While cohort studies are considered a lower Az=(&g*r, A SIMPLE, HOME-THERAPY ALGORYTHM TO PREVENT HOSPITALIZATION OF COVID-19 PATIENTS: A RETROSPECTIVE OBSERVATIONAL MATCHED-COHORT STUDY. Retrospective cohort study is a type of study whereby investigators design the study, recruit subjects, and collect background information of the subject after the outcome of interest has been developed while the prospective cohort <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/Type/Page>> Prospective cohort studies are more common. Main outcome measure The main outcome measure was 30 day mortality, defined as death during hospital admission or within 30 days of the surgical procedure. endobj They clearly define two groups at the start: one with the outcome/disease and one without the outcome/disease. See Figure 2 for a pictorial representation of a cohort study design. Thank you for the easy to understand blog in cohort studies. Overall, 99% of death days have been validated in the Medicare data,19 and we excluded patients whose death days had not been validated (therefore our data were not censored). Error bars represent 95% confidence intervals. Predictors of Documented Goals-of-Care Discussion for Hospitalized Patients With Chronic Illness. HWK$7@ U;=56BWfw{ K_"$.^O|nmq7G5s.nOnuZX~ Case-control studies are retrospective. The outcome measure in cohort studies is usually a risk ratio / relative risk (RR). Ten statistics commandments that almost never should be broken. | Library Webmaster. The Top 5 Qualities of Every Good Researcher. Advantages and disadvantages of cohort studies. Prospective Study is a study in which the research question was developed, (and the statistical analysis for determining power) were developed before data Use the simulator below to check the price for your manuscript, using the total number of words in the document. Since a retrospective cohort study depends on past information about the exposure history of the cohort members, this type of cohort study is also called a historical cohort study. For example, Black patients living in neighborhoods with predominantly Black residents tend to live close to hospitals that lack resources to provide high quality healthcare.3233 As a result, Black patients may lack access to specialists (including surgeons) with advanced clinical training and to important clinical resources, such as advanced diagnostic imaging studies and tests.34 This could lead to delays in care resulting in more advanced disease that requires longer or more difficult operations and might explain our finding of an increased mortality with elective procedures.3536 Poorer preoperative optimization of comorbidities such as diabetes and hypertension among racially minoritized patients may also lead to inequities in surgical outcomes. Studies outside of surgical care and outcomes have found a complex interplay between race and sex, with Black men exhibiting a shorter life expectancy.8 Although informative, evidence is limited as to how surgical outcomes differ by race and sex. We identified acuity of surgery based on the admission type code variable, with elective defined by a code of elective and non-elective defined by a code of urgent or emergency.7142021222324 The surgeon performing the procedure was identified from the operating physician field of the inpatient claim.14. Zimbabwe. When examining how inequities in mortality by race and sex for elective surgical procedures evolved over time, in adjusted analyses the difference in mortality after an elective procedure between Black men and White men was apparent within seven days of surgery (0.30% (95% confidence interval 0.28% to 0.32%) for White men and 0.53% (0.43% to 0.64%) for Black men; difference of 0.23 percentage points (95% confidence interval 0.12 to 0.34)) and persisted for at least 60 days after surgery (1.23% (1.20% to 1.27%) for White men and 1.68% (1.49% to 1.86%) for Black men; difference of 0.44 percentage points (0.25 to 0.63)) (fig 2 and supplementary table C). We conducted a retrospective cohort study of people with type-2 diabetes (T2DM) diagnosed 24 months before enrolment who were being followed up at Medical/Endocrine clinics of five hospitals selected by stratified random sampling in Anuradhapura, a rural district of Sri Lanka from June 2018 to May 2019 and retrospectively They also assessed if nephrotoxicity occurred based on the RIFLE criteria. Overall, teicoplanin was renally tolerated in this patient population [40c]. This translates to 31.3% of the difference between Black men and White men in elective surgical mortality attributable to differences in distribution of these patients across surgeons, but leaving two thirds of the difference attributable to other factors. The Relationship Between Microcystin in Different Drinking Water and CRC, Daniel A. Grabell, Adelaide A. Hebert, in Treatment of Skin Disease (Fifth Edition), 2018. The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication. But how many grades are there? Controlled studies carry a higher level of evidence than those in which control groups are not used. -`oP'i:kZ\s[|+k5@E%GYq[JuswB|>XP2|UUaRS=0jGF6["+?Y\s?ukkqun/pv^|z][^"[Psp'8fb,gaZjjC&u+]1auZ:M!DL\A-ET=b3uMa0jJ/-f`g kju l1eF.p{~p@ y{\c#tz ed[V"HaI=\((C9!c$EorOR>[M-46\neOQCCLY-Op^Np&ggRG_y? Results were similar when elective and non-elective surgical procedures were examined together (see supplementary table E), with 35.2% of the difference in overall surgical mortality between Black men and White men attributable to differences in distribution of these patients across surgeons. Additionally, the DKD phenotype was categorized into three distinct groups based on the eGFR levels (normal vs. reduced) and PU (negative vs a retrospective cohort study. Level V. Evidence from systematic reviews of descriptive and qualitative studies This was an expedited study, so there subjects were enrolled in a specific cohort based on date(s) of the drug infused. my aim is to check the rates of different health outcomes between the exposed)dementia) and unexposed(non-dementia) individuals. The incidence rate of CRC and RR for different drinking water sources were different compared to well water, the RR for CRC was 2.12 (tap), 17.31 (river), and 33.37 (pond), respectively (p<0.01) (Table 19.7).100, Table 19.7. KCN was supported by the National Center for Advancing Translational Sciences (UL1 TR000124), National Institute on Aging (P30 AG021684), and National Institute on Minority Health and Health Disparities (P50 MD017366) for other work not related to this study. Thank you so much. Reporting and Casecontrol This retrospective, observational study identifies an outcome of interest and compares a sample of people with that outcome ( case) and a sample of people without that outcome ( control ). The incidence of adverse events was extremely lowonly one patient. High quality prospective cohort study with adequate power or systematic review of these studies. WebRetrospective cohort studies are also weakened by the fact that the data fields available are not designed with the study in mindinstead, the researcher simply has to make use of whatever data are available, which may hinder the quality of the study. This information is simple and well presented to the point. Additionally, they are good for rare exposures, e.g. $029, P2'hny'l2RM endstream This 0.45 percentage point difference implies that mortality after elective procedures was 50% higher in Black men compared with White men. 2. See Figure 1 for a pictorial representation of a case-control study design. This blog summarizes the concepts of cluster randomization, and the logistical and statistical considerations while designing a cluster randomized controlled trial. Overall, 40479 (2.2%) were Black men, 761076 (40.7%) were White men, 998166 (53.4%) were White women, and 68315 (3.7%) were Black women (table 1). In the medical and health care area, for example, it is very important that professionals not only have access to information but also have instruments to determine which evidence is stronger and more trustworthy, building up the confidence to diagnose and treat their patients. Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one centre or research group. Because this evidence hasnt been appraised by experts, it might be questionable, but not necessarily false or wrong. Results are based on claims data, and more specific details about patient risk during the surgical procedure were not included. <> 2023-03-04T08:10:16-08:00 For example, it is not the same to use a systematic review or an expert opinion as a basis for an argument. This was one of the few studies that determined the lowest threshold dose of hCG to maintain high pregnancy rates while decreasing risk of OHSS [15c]. Whilst cohort studies are useful, they can be expensive and time-consuming, especially if a long follow-up period is chosen or the disease itself is rare or has a long latency. Objective To assess inequities in mortality by race and sex for eight common surgical procedures (elective and non-elective) across specialties in the United States. ScienceDirect is a registered trademark of Elsevier B.V. ScienceDirect is a registered trademark of Elsevier B.V. NYU Winthrop Hospital, Mineola, United States, University of Pennsylvania, Philadelphia, United States, A Worldwide Yearly Survey of New Data in Adverse Drug Reactions, Encyclopedia of Toxicology (Third Edition), Marcus and Feldman's Osteoporosis (Fifth Edition), Recent Advances in Cancer Research and Therapy, Treatment of Skin Disease (Fifth Edition). Methods A retrospective cohort design was employed. Other factors may interact with structural racism to worsen surgical outcomes. The Recommended schedule cohort included 90 patients treated at home by their family doctors according to the published Find more about Levels of evidence in research on Pinterest: Cookies are used by this site. Our use of inpatient data precludes the inclusion of surgical procedures performed at other sites, including ambulatory surgery centers. This kind of research is key to learning about a treatments effectiveness. The study found no evidence of renal impairment in 92.4% of teicoplanin treatments. endobj Fracture risk was increased even among men not on androgen deprivation therapy but was elevated a further 1.7-fold among androgen deprivation therapytreated compared with untreated men with prostate cancer. BMC Womens Health. 2022. One of the main examples is recall bias. Carleton RN, Krtzig GP, Sauer-Zavala S, Neary JP, Lix LM, Fletcher AJ, Afifi TO, Brunet A, Martin R, Hamelin KS, Teckchandani TA, Jamshidi L, Maguire KQ, Gerhard D, McCarron M, Hoeber O, Jones NA, Stewart SH, Keane TM, Sareen J, Dobson K, Asmundson GJG. White men, White women, and Black women were more likely to be admitted for elective surgery compared with Black men. Emily C. Tucker MBBS, MPH&TM, FRACP, Tilenka R.J. Thynne MBBS, FRACP, in Side Effects of Drugs Annual, 2019. The use of surgeon fixed effects effectively compares differences in 30 day mortality rate for patients of different subgroups of race and sex seen by the same surgeon. Prospective cohort studies (which track participants forward in time) are more reliable than retrospective cohort studies. No patients or members of the public were involved in setting the research question or the outcome measures, nor were they involved in developing plans for the design or implementation of the study or asked to advise on interpretation or writing up of results. An inherent issue with selecting cases is that a certain proportion of those with the disease would not have a formal diagnosis, may not present for medical care, may be misdiagnosed or may have died before getting a diagnosis. endobj 2003. Oral administration caused liver and lung tumors in mice and liver and uterine tumors in rats. The Medicare Beneficiary Summary File was used for date of death, which is verified using death certificates. Methods. endobj Meta-Analysis: Uses quantitative methods to synthesize a combination of results from independent studies. Most failures occurred between 10 and 20 months after implant. As individual patient level matched data for comparative study (effectiveness) Real World Data (RWD) WebThe CEBM Levels of Evidence 1 document sets out one approach to systematising this process for different question types. Level IV - Evidence from well-designed case-control and cohort studies. endobj The fact that the analysis is retrospective, allows rare diseases or diseases with long latency periods to be investigated. Mean treatment period was 3.4 months, and photos were evaluated by investigators to correspond to a 0 to 100 visual analog scale. Lambert, in Encyclopedia of Toxicology (Third Edition), 2014. This article reviews the essential characteristics of cohort studies and includes recommendations on the design, statistical analysis, and reporting of cohort studies in respiratory and critical care medicine. The regression model examining both non-elective and elective procedures also controlled for surgical acuity. The study population comprised 1868036 older patients (mean age 75.4 (standard deviation 6.9); 1066481 (57.1%) women) who underwent one of eight examined surgical procedures. A retrospective cohort study in humans reported that occupational exposure to hydrazine did not increase the risk of cancer. really thanks for wonderful information because i doing my bachelor degree research by survival model. 2008;158(5-6):174-9. doi: 10.1007/s10354-008-0516-0. Unauthorized use of these marks is strictly prohibited. Whether you are writing for the top of the pyramid or for its base, with Language Editing Plus Service you can achieve excellency in written text, impacting your readers exactly the way you aspire. Quite informative thank you so much for the info please continue posting. They clearly define two groups at the start: one with the outcome/disease and one without the outcome/disease. The levels of evidence provide a guide and the reader needs to be cautious when interpreting these Similarly, Black individuals are more likely to live in areas with greater exposure to hazards such as air pollution, which might increase the prevalence and severity of chronic diseases.3738 These differences in neighborhood and home environments and in resources could make it more challenging for Black patients to recover at home and to attend postoperative clinical visits.39 Our finding that surgical mortality is higher among Black men compared with other subgroups of race and sex is consistent with the finding that Black men have substantially shorter life expectancy at birth compared with other subgroups.40 Even for comparisons within races, Black men show a higher burden of homicide and HIV than Black women.40 In addition, it is possible that Black men in particular may face especially high cumulative amounts of stress and allostatic load in the US, potentially contributing to accelerated declines in physical health status41424344 and leading to a higher mortality after surgical procedures. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/Type/Page>> The US Environmental Protection Agency (EPA) considers hydrazine a probable human carcinogen and has developed oral slope and inhalation unit risk factors. A SIMPLE, HOME-THERAPY ALGORYTHM TO PREVENT HOSPITALIZATION OF COVID-19 PATIENTS: A RETROSPECTIVE OBSERVATIONAL MATCHED-COHORT STUDY Hispanic men and Hispanic women showed a lower overall mortality (2.49% (95% confidence interval 2.29% to 2.69%) for Hispanic men and 2.38% (2.22% to 2.55%) for Hispanic women versus 3.06% (2.86% to 3.25%) for Black men) and a lower mortality after elective surgical procedures (0.92% (0.76% to 1.09%) for Hispanic men and 0.87% (0.75% to 0.98%) for Hispanic women versus 1.30% (1.14% to 1.47%) for Black men) (see supplementary table F). We thank Ruixin Li, Mengtong Pan, and Rong Guo for programming assistance. contact with a chemical radiation blast. The mean age at initiation of therapy was 8 months, with 85% of patients dosed at 0.5% strength and the remainder being treated with 0.1%. Mendel Suchmacher, Mauro Geller, in Practical Biostatistics, 2012. Only 6.4% of treatments were classified to be in the Risk category and 1.2% in the Injury category. Table 1. Accessibility When drafting a systematic review, authors are expected to deliver a critical assessment and evaluation of all this literature rather than a simple list. Level IV. Save my name, email, and website in this browser for the next time I comment. Levels 3, 4 and 5 include evidence coming from unfiltered information. Case-control studies should include two groups that are identical EXCEPT for their outcome / disease status. BMC Psychol. The Royal Canadian Mounted Police (RCMP) Study: protocol for a prospective investigation of mental health risk and resilience factors. We analyzed four subgroups of race and sex: Black men, White men, White women, and Black women. Findings in all our sensitivity analyses remained qualitatively unchanged (see supplementary tables G-O). Finally, to test whether differential coding of procedure acuity influenced our results, we repeated our analyses excluding the procedure acuity (elective versus non-elective) from the adjustment variables. Acrobat Distiller 10.1.16 (Windows) %PDF-1.5 % Adjusted probabilities were calculated using marginal standardization from linear probability models of 30 day mortality for eight common surgical procedures (repair of abdominal aortic aneurysm, appendectomy, cholecystectomy, colectomy, coronary artery bypass surgery, hip replacement, knee replacement, and lung resection) as a function of category of race and sex (White men, White women, and Black women compared with Black men), also controlling for age, Medicaid dual eligibility, disability, 27 chronic conditions, surgical procedure, hospital service area, weekend surgery, month, and year. It really helped me to understand the topic. YT is the guarantor. Focusing once more on the healthcare and medical field, see how different study designs fit into particular questions, that are not necessarily located at the tip of the pyramid: Every kind of evidence is useful for the progress of science. Thanks n stay connected, Saul you absolute melt! A retrospective cohort study in Norway found that pregnancy did not have an effect on survivorship in women diagnosed with low-grade gliomas (WHO grade I) (Rnning et al., 2016). Methods. Hierarchy of evidence: a framework for ranking evidence - Published by Elsevier Inc. All rights reserved. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Case-control studies are retrospective. Key Concepts Assessing treatment claims, Observational Studies: Cohort and Case-Control Studies, Efficiency of case-control studies with multiple controls per case: Continuous or dichotomous data. The GALA II and SAGE II studies, Race/ethnicity and asthma management among adults presenting to the emergency department, Systemic And Structural Racism: Definitions, Examples, Health Damages, And Approaches To Dismantling, Visible and Invisible Trends in Black Mens Health: Pitfalls and Promises for Addressing Racial, Ethnic, and Gender Inequities in Health, Disentangling race and social context in understanding disparities in chronic conditions among men, When Resilience Becomes Risk: A Latent Class Analysis of Psychosocial Resources and Allostatic Load Among African American Men, Allostatic Load, Income, and Race Among Black and White Men in the United States, Allostatic Load and Its Impact on Health: A Systematic Review, Physicians perceptions of patients social and behavioral characteristics and race disparities in treatment recommendations for men with coronary artery disease, Assessment of Racial Disparities in Primary Care Physician Specialty Referrals, Disparities in cardiac arrest and failure to rescue after major elective noncardiac operations, Defining racial and ethnic disparities in pain management, Enhanced Recovery After Surgery (ERAS) Eliminates Racial Disparities in Postoperative Length of Stay After Colorectal Surgery, Outcome of Femoral-popliteal Bypass Procedures in Different Ethnic Groups in England: A Retrospective Analysis of Hospital Episode Statistics, Ethnic-specific mortality of infants undergoing congenital heart surgery in England and Wales, Neighborhood disparities in access to healthy foods and their effects on environmental justice, The Philippine tobacco industry: the strongest tobacco lobby in Asia, Inequities in surgical outcomes by race and sex in the United States: retrospective cohort study, http://creativecommons.org/licenses/by-nc/4.0/, https://www.ncbi.nlm.nih.gov/books/NBK220358/, https://resdac.org/articles/death-information-research-identifiable-medicare-data, https://www2.ccwdata.org/web/guest/condition-categories-chronic, https://seer.cancer.gov/seerstat/variables/countyattribs/hsa.html, Birmingham and Solihull Mental Health NHS Foundation Trust: Consultant Psychiatrist General Adult - Orsborn House CMHT, NHS Tayside: Salaried GP with Special Interest in Drug Use, Harm and Reduction, Birmingham and Solihull Mental Health NHS Foundation Trust: Consultant Psychiatrist General Adult - Northcroft CMHT, Brent Area Medical Centre: Salaried GP - Brent Area Medical Centre, Womens, childrens & adolescents health.

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