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Type 2 diabetes remission trajectories and variation in risk of diabetes complications: A population-based cohort study
Abstract Biochemical remission of type 2 diabetes is achievable through dietary changes, physical activity and subsequent weight loss. We aim to identify distinct diabetes remission trajectories in a large population-based cohort over seven-years follow-up and to examine associations between remission trajectories and diabetes complications. Group-based trajectory modelling examined longitudinal patterns of HbA1c level (adjusting for remission status) over time. Multivariable Cox models quantified the association between each remission trajectory and microvascular complications, macrovascular complications, cardiovascular (CVD) events and all-cause mortality. Four groups were assigned. Group 1 (8,112 [13.5%]; achieving HbA1c <48 mmol/mol (6.5%) followed by increasing HbA1c levels); Group 2 (6,369 [10.6%]; decreasing HbA1c levels >48 mmol/mol (6.5%)); Group 3 (36,557 [60.6%]; stable high HbA1c levels); Group 4 (9,249 [15.3%]; stable low HbA1c levels (<48mmol/mol or <6.5%)). Compared to Group 3, Groups 1 and 4 had lower risk of microvascular complications (aHRs (95% CI): 0.65 (0.61–0.70), p-value <0.001;0.59 (0.55–0.64) p-value<0.001, respectively)), macrovascular complications (aHRs (95% CI): 0.83 (0.75–0.92), p-value<0.001; 0.66 (0.61–0.71), p-value<0.001) and CVD events (aHRs (95% CI): 0.74(0.67–0.83), p-value<0.001; 0.67(0.61–0.73), p-vlaue<0.001). Risk of CVD outcomes were similar for Groups 2 and 3. Compared to Group 3, Group 1 (aHR: 0.82(95% CI: 0.76–0.89)) had lower risk of mortality, but Group 4 had higher risk of mortality (aHR: 1.11(95% CI: 1.03–1.19)). Risk of CVD outcomes vary by pattern of remission over time, with lowest risk for those in remission longer. People who achieve remission, even for shorter periods of time, continue to benefit from this lower exposure to hyperglycaemia, which may, in turn, lower the risk of CVD outcomes including mortality.
Even short periods of diabetes remission are linked to lower risk of heart attack and stroke
Why was the study needed? More than 3.8 million people in the UK have type 2 diabetes. The condition places them at increased risk of cardiovascular events and complications of the large and small blood vessels. Lifestyle changes including weight loss and exercise can reduce blood sugar levels and lead to remission from diabetes (defined as HbA1c less than 6.5%/48 mmol/mol without medication). However, over time, some people regain weight and relapse into type 2 diabetes. Researchers assessed whether diabetes remission, even for a short period, reduces people’s long term risk of cardiovascular disease. What did the study do? The analysis was based on the medical records of 60 287 people with type 2 diabetes from 150 GP practices in southern England. Participants’ average age was 65 and more than half (57%) were male. Over an average of seven years, 19% achieved remission for at least six months (HbA1c less than 6.5% / 48 mmol/mol) without the help of medication or weight loss surgery. The researchers grouped people according to the broad pattern of their blood sugar control. They considered groups that: Achieved remission and did not relapse (15%) Achieved remission and then relapsed (14%) Decreased their blood sugar levels but did not achieve remission (11%) Had consistently high blood sugar levels and did not achieve remission (61%). What did it find? Over the study period, 7% of people had a cardiovascular event, 8% had a large blood vessel complication, 26% had a small blood vessel complication, and 12% died. The researchers explored whether these events were more likely in some groups than others. They adjusted results for sex, age, ethnicity, and other factors. Compared with people who had consistently high blood sugar levels, people who achieved remission, even if they later relapsed, were: Less likely to have a cardiovascular event (76% less likely without relapse; 71% with relapse) Less likely to have a large blood vessel complication (85% less likely without relapse; 70% with relapse) Less likely to have a small blood vessel complication (63% less likely without relapse; 56% with relapse). People who decreased their blood sugar levels but did not achieve remission were less likely to have small blood vessel complications than those who had consistently high blood sugar levels, but similarly likely to have a cardiovascular event. In a pooled analysis, people who achieved remission at any point had a lower risk of death compared with people who did not achieve remission and had consistently high blood sugar levels. However, a separate individual analysis found that people who achieved remission and did not relapse were more likely to die than people who had consistently high blood sugar levels. The researchers say that many in this group (who achieved remission and did not relapse) had large reductions in their weight, which could have been due to other conditions such as cancer. Why is this important? The study shows that remission is linked with a lower risk of cardiovascular complications. This should reassure people with type 2 diabetes and clinicians that achieving remission is possible and has long term health benefits. Data on blood sugar levels were missing for almost half the participants. The researchers caution that they showed a link between remission and a reduced risk of cardiovascular disease; other factors such as weight and age also influence risk. To read the full NIHR Alert, go to: https://evidence.nihr.ac.uk/alert/even-short-periods-of-diabetes-remission-are-linked-to-lower-risk-of-heart-attack-and-stroke/
Developing a quality framework for community pharmacy: a systematic review of international literature
Abstract Objective To identify the defining features of the quality of community pharmacy (CP) services and synthesise these into an evidence-based quality framework. Design Systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data sources International research evidence (2005 onwards) identified from six electronic databases (Embase, PubMed, Scopus, CINAHL, Web of Science and PsycINFO) was reviewed systematically from October 2022 to January 2023. Search terms related to ‘community pharmacy’ and ‘quality’. Eligibility criteria for selecting studies Titles and abstracts were screened against inclusion or exclusion criteria, followed by full-text screening by at least two authors. Qualitative, quantitative and mixed-method studies relevant to quality in CP were included. Data extraction and synthesis A narrative synthesis was undertaken. Following narrative synthesis, a patient and public involvement event was held to further refine the quality framework. Results Following the title and abstract screening of 11 493 papers, a total of 81 studies (qualitative and quantitative) were included. Of the 81 included studies, 43 investigated quality dimensions and/or factors influencing CP service quality; 21 studies assessed patient satisfaction with and/or preferences for CP, and 17 studies reported the development and assessment of quality indicators, standards and guidelines for CPs, which can help define quality. The quality framework emerging from the global literature consisted of six dimensions: person-centred care, access, environment, safety, competence and integration within local healthcare systems. Quality was defined as having timely and physical access to personalised care in a suitable environment that is safe and effective, with staff competent in the dispensing process and pharmacy professionals possessing clinical knowledge and diagnostic skills to assess and advise patients relative to pharmacists’ increasingly clinical roles. Conclusion The emerging framework could be used to measure and improve the quality of CP services. Further research and feasibility testing are needed to validate the framework according to the local healthcare context.
What are important areas where better technology would support women’s health? Findings from a priority setting partnership
Background Women’s health has historically lacked investment in research and development. Technologies that enhance women’s health (‘FemTech’) could contribute to improving this. However, there has been little work to understand which priority unmet needs should be a focus for women’s health technology development. The voices of clinicians and those who experience and utilise these technologies (including those used at home or encountered in clinical settings) are needed to ensure that device development aligns with need, without risking exacerbating or creating health inequities. Method We undertook a priority setting partnership project exploring unmet needs in women’s health and well-being where physical technologies or innovations could help. This comprised gathering feedback from: patients and clinicians using both qualitative surveys and discussions; collating and publishing these responses and asking for feedback; evidence checking unmet needs identified, and holding a partnership priority setting event to agree a top 10 and top 20 list of priorities. Results We generated a ‘longlist’ of 54 suggestions for areas where better kit, devices or equipment could support women’s health. For three, we found evidence of existing technologies which mitigated against that need. We took the remaining 51 suggestions to a partnership priority setting meeting which brought together clinicians and service users. Through discussion as this group, we generated a list of the top 10 areas identified as priorities for technological development and improvement. These included better devices to manage examination, diagnosis and treatment of pelvic pain (including endometriosis), prolapse care, continence (treatment and prevention, related to pregnancy and beyond), menstruation, vaginal pain and vaginismus, point of care tests for common infections, and nipple care when breastfeeding. Conclusion The top priorities suggest far-reaching areas of unmet need across women’s life course and across multiple domains of health and well-being, and opportunities where innovation in the devices that people use themselves or encounter in health settings could potentially enhance health and healthcare experiences.
Editorial: Developing research potential in the primary and community-nursing workforce: the impact of a community of practice
Nurses are an under-represented discipline in health and care research career pathways, even more so in primary and community settings (Avery et al., Reference Avery, Westwood and Richardson2022). Primary care and community nurses are an extremely diverse workforce, working in distinct specialities supporting patients and their families across the lifespan (NHS, 2023). They have the experiential knowledge required to understand the needs of patients, families and communities, working in partnership with them, to recognise what works and what does not. This unique nature of their roles requires them to build long-term relationships with their patients, liaising across services; they are in an ideal position to develop, support and conduct research, informed by their insights and clinical expertise (DHSC, 2013). However, there are few nurses within these settings who are actively involved in health and care research and even fewer embarking on their own clinical academic careers (Bradbury et al., Reference Bradbury, Shortland, Jones, Hewett and Storey2021).
Beyond Information Provision: Analysis of the Roles of Structure and Agency in COVID-19 Vaccine Confidence in Ethnic Minority Communities
Abstract People from Black and Asian backgrounds are more likely to die from COVID-19 but less likely to be vaccinated, threatening to exacerbate health inequalities already experienced by ethnic minority groups. The literature suggests that mistrust rooted in structural inequality (including socioeconomic position and experience of racism) may be a key barrier to COVID-19 vaccine uptake. Understanding and addressing structural inequality is likely to lead to longer-term impacts than information alone. The aim of this study is to draw on health and sociological theories of structure and agency to inform our understanding of how structural factors influence vaccine confidence. We conducted qualitative interviews and focus groups with 22 people from London and the surrounding areas from December 2021 to March 2022. Fourteen participants were members of the public from ethnic minority backgrounds, and seven were professionals working with the public to address concerns and encourage vaccine uptake. Our findings suggest that people from ethnic minority backgrounds make decisions regarding COVID-19 vaccination based on a combination of how they experience external social structures (including lack of credibility and clarity from political authority, neglect by health services, and structural racism) and internal processes (weighing up COVID-19 vaccine harms and benefits and concerns about vaccine development and deployment). We may be able to support knowledge accumulation through the provision of reliable and accessible information, particularly through primary and community care, but we recommend a number of changes to research, policy and practice that address structural inequalities. These include working with communities to improve ethnicity data collection, increasing funding allocation to health conditions where ethnic minority communities experience poorer outcomes, greater transparency and public engagement in the vaccine development process, and culturally adapted research recruitment processes.
Achieving patient weighing in UK primary care. A conversation analytic study
Abstract Addressing issues of weight with people with type 2 diabetes is increasingly becoming part of the workload of primary care. This includes taking weight measurements during consultations. Evidence suggests that weighing is experienced as difficult for health professionals and patients. This study explores how weighing is accomplished and identifies strategies and practices that can be used in primary care settings. Data are drawn from two large UK based archives of over 600 audio and video recorded primary care consultations. Conversation analysis was used to systematically inspect the consultation data. We identified the linguistic practices employed by GPs and resulting interactions around the measurement of weight in primary care. Seven consultations form this corpus. We identify the sequential interactional pattern through which GPs and patients engage to achieve weighing and identify delicacy features in GPs talk which are used to build alignment with patients to achieve weighing. The analysis also highlighted the ways in which GPs justify their need to weigh patients, including marking the measurement as clinically necessary and preferring a need for an objective measure of weight. The analyses highlight that patient responses to requests to weigh are varied and that weighing patients can necessitate considerable interactional effort. Achieving weighing of patients in primary care consultations requires considerable interactional work between GPs and patients and it is important for the delicacy of these requests to be appreciated. There is a need for greater attention to how to achieve weighing, given the increasing attention weight has in relation to health.
What are important areas where better technology would support women’s health? Findings from a priority setting partnership
Abstract Background Women’s health has historically lacked investment in research and development. Technologies that enhance women’s health (‘FemTech’) could contribute to improving this. However, there has been little work to understand which priority unmet needs should be a focus for women’s health technology development. The voices of clinicians and those who experience and utilise these technologies (including those used at home or encountered in clinical settings) are needed to ensure that device development aligns with need, without risking exacerbating or creating health inequities. Method We undertook a priority setting partnership project exploring unmet needs in women’s health and well-being where physical technologies or innovations could help. This comprised gathering feedback from: patients and clinicians using both qualitative surveys and discussions; collating and publishing these responses and asking for feedback; evidence checking unmet needs identified, and holding a partnership priority setting event to agree a top 10 and top 20 list of priorities. Results We generated a ‘longlist’ of 54 suggestions for areas where better kit, devices or equipment could support women’s health. For three, we found evidence of existing technologies which mitigated against that need. We took the remaining 51 suggestions to a partnership priority setting meeting which brought together clinicians and service users. Through discussion as this group, we generated a list of the top 10 areas identified as priorities for technological development and improvement. These included better devices to manage examination, diagnosis and treatment of pelvic pain (including endometriosis), prolapse care, continence (treatment and prevention, related to pregnancy and beyond), menstruation, vaginal pain and vaginismus, point of care tests for common infections, and nipple care when breastfeeding. Conclusion The top priorities suggest far-reaching areas of unmet need across women’s life course and across multiple domains of health and well-being, and opportunities where innovation in the devices that people use themselves or encounter in health settings could potentially enhance health and healthcare experiences.
Providing care to marginalised communities: a qualitative study of community pharmacy teams
Background: Health inequalities in the UK are widening, particularly since the COVID- 19 pandemic. Community pharmacies are the most visited healthcare provider in England and are ideally placed to provide and facilitate access to care for those most disadvantaged. Aim: To explore the experiences and needs of community pharmacy teams in providing care for marginalised groups and how this has changed since the COVID-19 pandemic. Design and Setting: A qualitative study in community pharmacy and across primary care. Method: Semi structured interviews were undertaken with members of community pharmacy teams, PCN pharmacists, GPs and nurses in the North of England. Results: Thirty one individuals participated in an interview (26 pharmacy staff, 3 GPs and 2 nurses). Most participants acknowledged that their pharmacy had become busier since COVID-19 due to increased footfall compounded by patient difficulties in navigating remote digital systems. Few participants had received any formal training on working with marginalised communities; however, organisational barriers (lack of access to translation facilities), combined with inter-organisational barriers (lack of integrated care), made it more difficult to provide care for some marginalised groups. However, the continuity of care provided by many pharmacies was viewed as an important factor in enabling marginalised groups to access and receive care. Conclusion: There are opportunities to better utilise the skills of community pharmacy teams. Resources such as access to translation services and interventions to enable better communication between community pharmacy teams and other primary care services such as general practice are essential.
Relationship Between Clinician Language and the Success of Behavioral Weight Loss Interventions A Mixed-Methods Cohort Study
Background: International guidelines recommend that primary care clinicians recognize obesity and offer treatment opportunistically, but there is little evidence on how clinicians can discuss weight and offer treatment in ways that are well received and effective. Objective: To examine relationships between language used in the clinical visit and patient weight loss. Design: Mixed-methods cohort study. Setting: 38 primary care clinics in England participating in the Brief Intervention for Weight Loss trial. Participants: 246 patients with obesity seen by 87 general practitioners randomly sampled from the intervention group of the randomized clinical trial. Measurements: Conversation analysis of recorded discussions between 246 patients with obesity and 87 clinicians regarding referral to a 12-week behavioral weight management program offered as part of the randomized clinical trial. Clinicians’ interactional approaches were identified and their association with patient weight loss at 12 months (primary outcome) was examined. Secondary outcomes included patients’ agreement to attend weight management, attendance, loss of 5% body weight, actions taken to lose weight, and postvisit satisfaction. Results: Three interactional approaches were identified on the basis of clinicians’ linguistic and paralinguistic practices: creating a sense of referrals as “good news” related to the opportunity of the referral (n = 62); “bad news,” focusing on the harms of obesity (n = 82); or neutral (n = 102). Outcome data were missing from 57 participants, so weighted analyses were done to adjust for missingness. Relative to neutral news, good news was associated with increased agreement to attend the program (adjusted risk difference, 0.25 [95% CI, 0.15 to 0.35]), increased attendance (adjusted risk difference, 0.45 [CI, 0.34 to 0.56]), and weight change (adjusted difference, −3.60 [CI, −6.58 to −0.62]). There was no evidence of differences in mean weight change comparing bad and neutral news, and no evidence of differences in patient satisfaction across all 3 approaches. Limitations: Data were audio only, so body language and nonverbal cues could not be assessed. There is potential for selection bias and residual confounding. Conclusion: When raising the topic of excess weight in clinical visits, presenting weight loss treatment as a positive opportunity is associated with greater uptake of treatment and greater weight loss.
The financial costs of anticipatory prescribing: A retrospective observational study of prescribed, administered and wasted medications using community clinical records
Background: The prescribing of injectable end-of-life anticipatory medications ahead of possible need is recommended best practice. The financial costs of these medications have been little studied. Aim: To identify the costs of anticipatory medications prescribed, used and not used for patients approaching the end-of-life at home and in residential care. Design: Retrospective observational study using general practitioner and community nursing clinical records. Setting/participants: Data were collected from eleven general practitioner practices using the records of the 30 most recent deaths per practice. Patients were aged 18+ and died between 2017 and 2019 from any cause except trauma, sudden death or suicide. Results: Anticipatory medications were prescribed to 167/329 patients, of which 164 were included in the analysis. Costs (GBP) were analysed both at patient-level and drug-level. Median anticipatory prescription cost was £43.17 (IQR: £38.98–£60.47, range £8.76–£229.82). Median administered (used) drug cost was £2.16 (IQR: £0.00–£12.09, range £0.00–£83.14). Median unused (wasted) drug cost was £41.47 (IQR: £29.15–£54.33, range £0.00–£195.36). Prescription, administered and unused costs were significantly higher for the 59 patients prescribed an anticipatory syringe driver. There were wide variations in the unused costs of individual drugs; Haloperidol and Cyclizine contributed 49% of total unused costs. Conclusion: The costs of prescribed and unused anticipatory medications were higher than previously reported but remain modest. Usage of prescriptions was lower than previously documented. There may be scope to reduce the quantity of vials that are routinely prescribed without adversely affecting care; further research is needed to investigate this possibility.
Seasonal trends in antidepressant prescribing, depression, anxiety and self-harm in adolescents and young adults: an open cohort study using English primary care data
Abstract Background There is an increasing demand for mental health services for young people, which may vary across the year. Objective To determine whether there are seasonal patterns in primary care antidepressant prescribing and mental health issues in adolescents and young adults. Methods This cohort study used anonymised electronic health records from general practices in England contributing to QResearch. It included 5 081 263 males and females aged 14–18 (adolescents), 19–23 and 24–28 years between 2006 and 2019. The incidence rates per 1000 person-years and the incidence rate ratios (IRRs) were calculated for the first records of a selective serotonin reuptake inhibitor (SSRI) prescription, depression, anxiety and self-harm. The IRRs were adjusted for year, region, deprivation, ethnic group and number of working days. Findings There was an increase in SSRI prescribing, depression and anxiety incidence in male and female adolescents in the autumn months (September–November) that was not seen in older age groups. The IRRs for SSRI prescribing for adolescents peaked in November (females: 1.75, 95% CI 1.67 to 1.83, p<0.001; males: 1.72, 95% CI 1.61 to 1.84, p<0.001, vs in January) and for depression (females: 1.29, 95% CI 1.25 to 1.33, p<0.001; males: 1.29, 95% CI 1.23 to 1.35, p<0.001). Anxiety peaked in November for females aged 14–18 years (1.17, 95% CI 1.13 to 1.22, p<0.001) and in September for males (1.19, 95% CI 1.12 to 1.27, p<0.001). Conclusions There were higher rates of antidepressant prescribing and consultations for depression and anxiety at the start of the school year among adolescents. Clinical implications Support around mental health issues from general practitioners and others should be focused during autumn.
Improving access to general practice for and with people with severe and multiple disadvantage
Background: People with severe and multiple disadvantage (SMD- combinations of homelessness, substance misuse, violence, abuse and poor mental health) have high health needs and poor access to primary care. Aim: To explore perceptions and experiences of improving access to general practice for people with SMD in healthcare staff and people with lived experience. Design and Setting: Bridging Gaps is a collaboration between healthcare staff, researchers, women with lived experience of SMD and a charity that supports them in a UK city. We co-produced a project to improve access to general practice for people with SMD, that was further developed with 3 inner city general practices. Method: We facilitated nine service improvement meetings at three general practices and formally observed six of these. We interviewed nine practice staff and four participants with lived experience. Three participants with lived experience and one staff member who supports them participated in a focus group. Data was analysed inductively and deductively using thematic analysis. Results: Enabling motivated general practice staff with time and funding opportunities, galvanised by lived experience involvement, resulted in service changes. These included: prioritising patients on an inclusion patient list with more flexible access, continuity from a care coordinator and micro-team, and an information sharing tool. The process and outcomes improved connections within and between general practices, support organisations and people with SMD. Conclusion: These co-designed strategies could be locally adapted and evaluated in other areas. Investing in this focused way of working may improve healthcare accessibility, health equity and staff wellbeing.
The Longitudinal Impact of Social Media Use on UK Adolescents' Mental Health: Longitudinal Observational Study
Background: Cross-sectional studies have found a relationship between social media use and depression and anxiety in young people. However, few longitudinal studies using representative data and mediation analysis have been conducted to understand the causal pathways of this relationship. Objective: This study aims to examine the longitudinal relationship between social media use and young people’s mental health and the role of self-esteem and social connectedness as potential mediators. Methods: The sample included 3228 participants who were 10- to 15-year-olds from Understanding Society (2009-2019), a UK longitudinal household survey. The number of hours spent on social media was measured on a 5-point scale from “none” to “7 or more hours” at the ages of 12-13 years. Self-esteem and social connectedness (number of friends and happiness with friendships) were measured at the ages of 13-14 years. Mental health problems measured by the Strengths and Difficulties Questionnaire were assessed at the ages of 14-15 years. Covariates included demographic and household variables. Unadjusted and adjusted multilevel linear regression models were used to estimate the association between social media use and mental health. We used path analysis with structural equation modeling to investigate the mediation pathways. Results: In adjusted analysis, there was a nonsignificant linear trend showing that more time spent on social media was related to poorer mental health 2 years later (n=2603, β=.21, 95% CI −0.43 to 0.84; P=.52). In an unadjusted path analysis, 68% of the effect of social media use on mental health was mediated by self-esteem (indirect effect, n=2569, β=.70, 95% CI 0.15-1.30; P=.02). This effect was attenuated in the adjusted analysis, and it was found that self-esteem was no longer a significant mediator (indirect effect, n=2316, β=.24, 95% CI −0.12 to 0.66; P=.22). We did not find evidence that the association between social media and mental health was mediated by social connectedness. Similar results were found in imputed data. Conclusions: There was little evidence to suggest that more time spent on social media was associated with later mental health problems in UK adolescents. This study shows the importance of longitudinal studies to examine this relationship and suggests that prevention strategies and interventions to improve mental health associated with social media use could consider the role of factors like self-esteem.
Physical rehabilitation for people with advanced dementia who fracture their hip – expert consensus process
Purpose: Hip fracture is common in older people – with prevalence even higher for people with dementia. Research often excludes people with dementia – especially those in the more advanced stages. Therefore, the most appropriate interventions remain unknown. The main aim of this study was to gain consensus about the core considerations needed to deliver a physical intervention for people with advanced dementia who fracture their hip. Materials and Methods: An expert consensus process was undertaken, using Nominal Group Technique, to explore the key considerations when delivering rehabilitation. Data collection was undertaken in January 2023 and involved an online group discussion followed by voting and off-line rating. Qualitative content analysis and quantitative analysis of consensus scoring was undertaken. An international group of seven highly specialised physiotherapists took part. Results: 59 statements were agreed following the process. Content analysis was used to categorise these statements according to the International Classification of Functioning, Disability and Health. Although consensus levels were high, there was disagreement in several areas. Conclusion: The statements provide an overarching understanding of the multidisciplinary expertise that is needed to effectively deliver rehabilitation interventions to this population. People with dementia require highly skilled and trained professionals, providing holistic and person-centred approaches to deliver rehabilitation interventions.
Family carers' administration of injectable medications at the end of life: a service evaluation of a novel intervention
Abstract Timely and safe administration of injectable medications for patients at home is vital in optimally managing distressing symptoms in the final days of life. This article discusses a service evaluation of family carers' (including close friends) administrating subcutaneous end-of-life medications. The procedure was not intended to become normal care, rather the exception when appropriate and needed, with 24/7 skilled support from community nursing and palliative care services. A service evaluation of the procedure was undertaken in rural and urban areas in the South East of England. The procedure ran over 6 months and used detailed processes with recruitment criteria to mitigate risk of harm. In total, 11 patients participated with their family carers, including five carers with experience in healthcare roles. Of the 11 family carers, 10 were able to administer injections safely with structured training and support in place. Patients received timely symptom relief and their family carers were able to support loved ones by administering injectable medications rapidly without waiting for a nurse to arrive. This was particularly welcomed in more rural areas where waiting times were greater due to the large geographical area covered and limited staff availability during out-of-hours periods. The findings informed a carefully monitored wider rollout and ongoing evaluation in adult community nursing services in the NHS Trust.
Feasibility of a placebo-controlled trial of antibiotics for possible urinary tract infection in care homes: a qualitative interview study
Abstract Background Diagnosis of suspected urinary tract infection (UTI) in care and nursing home residents is commonly based on vague non-localising symptoms (for example, confusion), potentially leading to inappropriate antibiotic prescription. The safety of withholding antibiotics in such cases could be addressed by a randomised controlled trial (RCT); however, this would require close monitoring of residents, and support from care home staff, clinicians, residents, and families. Aim To explore the views of residential care and nursing home staff (herein referred to as care home staff) and primary care clinicians on the feasibility and design of a potential RCT of antibiotics for suspected UTI in care home residents, with no localising urinary symptoms. Design & setting A qualitative interview study with primary care clinicians and care home staff in the UK. Method Semi-structured interviews with 16 care home staff and 11 primary care clinicians were thematically analysed. Results Participants were broadly supportive of the proposed RCT. The safety of residents was a priority and there was strong support for using the RESTORE2 (Recognise Early Soft Signs, Take Observations, Respond, Escalate) assessment tool to monitor residents; however, there were concerns about associated training requirements, especially for night and temporary staff. Effective communication (with residents, families, and staff) was deemed essential, and carers were confident that residents and families would be supportive of the RCT if the rationale was clearly explained and safety systems were robust. There were mixed views on a placebo-controlled design. The perceived additional burden was seen as a potential barrier, and the use of temporary staff and the out-of-hours period were highlighted as potential risk areas. Conclusion The support for this potential trial was encouraging. Future development will need to prioritise resident safety (especially in the out-of-hours period), effective communication, and minimising additional burden on staff to optimise recruitment.
Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: a systematic review and individual participant data meta-analysis
Summary Background Many international clinical guidelines recommend therapeutic exercise as a core treatment for knee and hip osteoarthritis. We aimed to identify individual patient-level moderators of the effect of therapeutic exercise for reducing pain and improving physical function in people with knee osteoarthritis, hip osteoarthritis, or both. Methods We did a systematic review and individual participant data (IPD) meta-analysis of randomised controlled trials comparing therapeutic exercise with non-exercise controls in people with knee osteoathritis, hip osteoarthritis, or both. We searched ten databases from March 1, 2012, to Feb 25, 2019, for randomised controlled trials comparing the effects of exercise with non-exercise or other exercise controls on pain and physical function outcomes among people with knee osteoarthritis, hip osteoarthritis, or both. IPD were requested from leads of all eligible randomised controlled trials. 12 potential moderators of interest were explored to ascertain whether they were associated with short-term (12 weeks), medium-term (6 months), and long-term (12 months) effects of exercise on self-reported pain and physical function, in comparison with non-exercise controls. Overall intervention effects were also summarised. This study is prospectively registered on PROSPERO (CRD42017054049). Findings Of 91 eligible randomised controlled trials that compared exercise with non-exercise controls, IPD from 31 randomised controlled trials (n=4241 participants) were included in the meta-analysis. Randomised controlled trials included participants with knee osteoarthritis (18 [58%] of 31 trials), hip osteoarthritis (six [19%]), or both (seven [23%]) and tested heterogeneous exercise interventions versus heterogeneous non-exercise controls, with variable risk of bias. Summary meta-analysis results showed that, on average, compared with non-exercise controls, therapeutic exercise reduced pain on a standardised 0–100 scale (with 100 corresponding to worst pain), with a difference of –6·36 points (95% CI –8·45 to –4·27, borrowing of strength [BoS] 10·3%, between-study variance [τ2] 21·6) in the short term, –3·77 points (–5·97 to –1·57, BoS 30·0%, τ2 14·4) in the medium term, and –3·43 points (–5·18 to –1·69, BoS 31·7%, τ2 4·5) in the long term. Therapeutic exercise also improved physical function on a standardised 0–100 scale (with 100 corresponding to worst physical function), with a difference of –4·46 points in the short term (95% CI –5·95 to –2·98, BoS 10·5%, τ2 10·1), –2·71 points in the medium term (–4·63 to –0·78, BoS 33·6%, τ2 11·9), and –3·39 points in the long term (–4·97 to –1·81, BoS 34·1%, τ2 6·4). Baseline pain and physical function moderated the effect of exercise on pain and physical function outcomes. Those with higher self-reported pain and physical function scores at baseline (ie, poorer physical function) generally benefited more than those with lower self-reported pain and physical function scores at baseline, with the evidence most certain in the short term (12 weeks). Interpretation There was evidence of a small, positive overall effect of therapeutic exercise on pain and physical function compared with non-exercise controls. However, this effect is of questionable clinical importance, particularly in the medium and long term. As individuals with higher pain severity and poorer physical function at baseline benefited more than those with lower pain severity and better physical function at baseline, targeting individuals with higher levels of osteoarthritis-related pain and disability for therapeutic exercise might be of merit.
Non-pharmaceutical interventions and risk of COVID-19 infection: survey of U.K. public from November 2020 – May 2021
Abstract Introduction Non-pharmaceutical interventions (NPIs), such as handwashing, social distancing and face mask wearing, have been widely promoted to reduce the spread of COVID-19. This study aimed to explore the relationship between self-reported use of NPIs and COVID-19 infection. Methods We conducted an online questionnaire study recruiting members of the UK public from November 2020 to May 2021. The association between self-reported COVID-19 illness and reported use of NPIs was explored using logistic regression and controlling for participant characteristics, month of questionnaire completion, and vaccine status. Participants who had been exposed to COVID-19 in their household in the previous 2 weeks were excluded. Results Twenty-seven thousand seven hundred fifty-eight participants were included and 2,814 (10.1%) reported having a COVID-19 infection. The odds of COVID-19 infection were reduced with use of a face covering in unadjusted (OR 0.17 (95% CI: 0.15 to 0.20) and adjusted (aOR 0.19, 95% CI 0.16 to 0.23) analyses. Social distancing (OR 0.27, 95% CI: 0.22 to 0.31; aOR 0.35, 95% CI 0.28 to 0.43) and handwashing when arriving home (OR 0.57, 95% CI 0.46 to 0.73; aOR 0.63, 95% CI: 0.48 to 0.83) also reduced the odds of COVID-19. Being in crowded places of 10–100 people (OR 1.89, 95% CI: 1.70 to 2.11; aOR 1.62, 95% CI: 1.42 to 1.85) and > 100 people (OR 2.33, 95% CI: 2.11 to 2.58; aOR 1.73, 95% CI: 1.53 to 1.97) were both associated with increased odds of COVID-19 infection. Handwashing before eating, avoiding touching the face, and cleaning things with virus on were all associated with increased odds of COVID-19 infections. Conclusions This large observational study found evidence for strong protective effects for individuals from use of face coverings, social distancing (including avoiding crowded places) and handwashing on arriving home on developing COVID-19 infection. We also found evidence for an increased risk associated with other behaviours, possibly from recall bias.
The relationship between reported daily nicotine dose from NRT and daily cigarette consumption in pregnant women who smoke in an observational cohort study
Abstract Introduction For nonpregnant people unable to quit smoking, the NHS recommends nicotine replacement therapy (NRT) for smoking reduction. This is not recommended during pregnancy due to concerns about higher nicotine intake than smoking alone. We investigated the relationship between daily nicotine dose from NRT and cigarette consumption reported by pregnant women receiving smoking cessation support. Methods We conducted secondary analysis of data from currently smoking pregnant women, recruited from antenatal clinics (Nottingham University Hospitals, UK) or online between June 2019–September 2020. Participants set a quit date, received a prototype NRT adherence intervention, and reported cigarettes per day (CPD) and daily NRT dose (mg) via smartphone app for 28 days. Results 388 women were screened, 32 (8%) were eligible and joined the study. 24 (75%) submitted 510 app reports in total. 17 (71%) reported smoking and using NRT concurrently on at least one day, with concurrent use reported on 109 (21%) of app reports. The relationship between daily NRT dose and CPD followed an exponential decay curve of approximately 7%. In multilevel repeated measures modelling using 4 linear splines (knots 17, 40, and 85 mg/NRT), significant fixed effects of daily NRT dose on CPD were observed for splines 1, 3, and 4. The strongest association was spline 1 (0–17 mg/NRT), where each 10 mg NRT increase was associated with a 0.6 CPD reduction (24% on average). Conclusions Among women in a cessation study, many smoked and used NRT concurrently; within these women, daily nicotine dose and heaviness of smoking were inversely related. Implications Findings have implications for the design of future interventions intended to reduce harm associated with smoking in pregnancy. They suggest using NRT alongside smoking in pregnancy could help some women reduce the number of cigarettes they smoke per day.