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Analysing self-regulatory behaviours in response to daily weighing: a think-aloud study with follow-up interviews
Objective: To examine the extent to which people who are trying to lose weight naturally self-regulate in response to self-weighing and to identify barriers to self-regulation. Design/Main Outcome Measures: Twenty-four participants, who were overweight and trying to lose weight, recorded their thoughts during daily weighing for eight weeks. Semi-structured follow-up interviews assessed participant experiences. Qualitative analysis identified steps of the self-regulation process and barriers to self-regulation. Exploratory regression analysis assessed the relationship between the self-regulation steps and weight loss. Results: On 90% of 498 occasions, participants compared their weight measurement to an expectation or goal, and on 58% they reflected on previous behaviour. Action planning only occurred on 20% of occasions, and specific action planning was rare (6%). Only specific action planning significantly predicted weight loss (−2.1 kg per 1 SD increase in the predictor, 95% CI = −3.9, −0.3). Thematic analysis revealed that barriers to the interpretation of daily weight changes were difficulties in understanding day-to-day fluctuations, losing the overview of trends, forgetting to weigh, and forgetting previous measurements. Conclusion: Specific action planning can lead to weight loss, but is rare in a naturalistic setting. Barriers to self-regulation relate to the interpretation of weight changes.
Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study
Importance: Anticholinergic medicines have short-term cognitive adverse effects, but it is uncertain whether long-term use of these drugs is associated with an increased risk of dementia. Objective: To assess associations between anticholinergic drug treatments and risk of dementia in persons 55 years or older. Design, Setting, and Participants: This nested case-control study took place in general practices in England that contributed to the QResearch primary care database. The study evaluated whether exposure to anticholinergic drugs was associated with dementia risk in 58 769 patients with a diagnosis of dementia and 225 574 controls 55 years or older matched by age, sex, general practice, and calendar time. Information on prescriptions for 56 drugs with strong anticholinergic properties was used to calculate measures of cumulative anticholinergic drug exposure. Data were analyzed from May 2016 to June 2018. Exposures: The primary exposure was the total standardized daily doses (TSDDs) of anticholinergic drugs prescribed in the 1 to 11 years prior to the date of diagnosis of dementia or equivalent date in matched controls (index date). Main Outcomes and Measures: Odds ratios (ORs) for dementia associated with cumulative exposure to anticholinergic drugs, adjusted for confounding variables. Results: Of the entire study population (284 343 case patients and matched controls), 179 365 (63.1%) were women, and the mean (SD) age of the entire population was 82.2 (6.8) years. The adjusted OR for dementia increased from 1.06 (95% CI, 1.03-1.09) in the lowest overall anticholinergic exposure category (total exposure of 1-90 TSDDs) to 1.49 (95% CI, 1.44-1.54) in the highest category (>1095 TSDDs), compared with no anticholinergic drug prescriptions in the 1 to 11 years before the index date. There were significant increases in dementia risk for the anticholinergic antidepressants (adjusted OR [AOR], 1.29; 95% CI, 1.24-1.34), antiparkinson drugs (AOR, 1.52; 95% CI, 1.16-2.00), antipsychotics (AOR, 1.70; 95% CI, 1.53-1.90), bladder antimuscarinic drugs (AOR, 1.65; 95% CI, 1.56-1.75), and antiepileptic drugs (AOR, 1.39; 95% CI, 1.22-1.57) all for more than 1095 TSDDs. Results were similar when exposures were restricted to exposure windows of 3 to 13 years (AOR, 1.46; 95% CI, 1.41-1.52) and 5 to 20 years (AOR, 1.44; 95% CI, 1.32-1.57) before the index date for more than 1095 TSDDs. Associations were stronger in cases diagnosed before the age of 80 years. The population-attributable fraction associated with total anticholinergic drug exposure during the 1 to 11 years before diagnosis was 10.3%. Conclusions and Relevance: Exposure to several types of strong anticholinergic drugs is associated with an increased risk of dementia. These findings highlight the importance of reducing exposure to anticholinergic drugs in middle-aged and older people.
Home care and end-of-life hospital admissions: a retrospective interview study in English primary and secondary care
Background: Enabling death at home remains an important priority in end-of-life care policy. However, hospital continues to be a more prevalent place of death than home in the UK, with admissions at the end-of-life often negatively labelled. Admissions are frequently attributed to an unsuitable home environment, associated with inadequate family care provision and insufficient professional care delivery. Aim: To understand problems in professional and lay care provision that discourage death at home and lead to hospital admissions at the end of life. Design and setting: A qualitative study of admission to a large English hospital of patients close to the end of their life. Method: Retrospective in-depth semi-structured interviews with healthcare professionals (n = 30) and next-of-kin (n = 3) involved in an admission. Interviews addressed why older patients (>65 years) close to the end of life are admitted to hospital. Interviews were transcribed and analysed thematically. Results: Home-based end-of-life care appeared precarious. Hospital admission was considered by healthcare staff when there was insufficient nursing provision, or where family support, which was often extensive but under supported, was challenged. In these circumstances, home was not recognised to be a suitable place of care or death, justifying seeking care provision elsewhere. Conclusion: Challenges in home care provision led to hospital admissions. Home end-of-life care depended on substantial input from family and professional carers, both of which were under-resourced. Where either care was insufficient to meet the needs of patients, home was no longer deemed to be desirable by healthcare staff and hospital care was sought.
A chance to improve end-of-life care
Community nurses (CNs) now have a golden opportunity to work closely with GP colleagues in reviewing and improving end-of-life (EoL) care. The new NHS England (2019a) GP contract has attached substantial financial rewards to implementing a locally led EoL quality-improvement project before the end of March 2020. This reflects the aspirations of the NHS long term plan (NHS England, 2019b) to ‘personalise care to improve end-of-life care’.
Getting anticipatory prescribing right in end-of-life care
There is a growing number of people who need access to high-quality endof life care in the home setting. This requires timely assessments of needs, ensuring good symptom management and recognising the roles undertaken by carers. For some patients, a range of medications may need to be put in place to relieve end-of-life symptoms, using ‘anticipatory prescribing’. District nurses must ensure that they acknowledge the patient’s voiced preferences and be mindful of the safety issues that arise with the supply of controlled drugs in the home. This article highlights the challenges faced by district nurses providing or dealing with anticipatory prescribing during end-of-life care.
Venous thromboembolism in patients with gout and the impact of hospital admission, disease duration and urate-lowering therapy
BACKGROUND: Systemic inflammatory diseases have been associated with increased risk of venous thromboembolism. We aimed to quantify the risk of venous thromboembolism in patients with gout, the most common inflammatory arthritis, and to assess how disease duration, hospital admission and urate-lowering therapy affect this risk. METHODS: We used data from the population-representative, England-based Clinical Practice Research Datalink linked to Hospital Episode Statistics, to identify incident gout cases between 1998 and 2017. We matched cases individually to 1 control without gout on age, gender, general practice and follow-up time. We calculated absolute and relative risks of venous thromboembolism, stratified by age, gender and hospital admission. Among those with gout, we assessed the risk of venous thromboembolism by exposure to urate-lowering therapy. RESULTS: We identified 62 234 patients with incident gout matched to 62 234 controls. Gout was associated with higher risk of venous thromboembolism compared with controls (absolute rate 37.3 [95% confidence interval (CI) 35.5–39.3] v. 27.0 [95% CI 25.5–28.9] per 10 000 person-years, adjusted hazard ratio [HR] 1.25, 95% CI 1.15–1.35). The excess risk in patients with gout, which was sustained up to a decade after diagnosis, was present during the time outside hospital stay (adjusted HR 1.30, 95% CI 1.18–1.42), but not during it (adjusted HR 1.01, 95% CI 0.83–1.24). The risk of venous thromboembolism was similar among patients prescribed versus not prescribed urate-lowering therapy (incidence rate ratio 1.04, 95% CI 0.89–1.23). INTERPRETATION: Gout was associated with higher risk of venous thromboembolism, particularly when the patient was not in hospital and regardless of exposure to urate-lowering therapy. Although the observed excess risk may not be sufficient to warrant preventive intervention, clinical vigilance may be required when caring for these patients.
Using out-of-office blood pressure measurements in established cardiovascular risk scores: a secondary analysis of data from two blood pressure monitoring studies
Background: Blood pressure (BP) measurement is increasingly carried out through home or ambulatory monitoring, yet existing cardiovascular risk scores were developed for use with measurements obtained in clinics. Aim: To describe differences in cardiovascular risk estimates obtained using ambulatory or home BP measurements instead of clinic readings. Design and setting: Secondary analysis of data from adults aged 25–84 years in the UK and the Netherlands without prior history of cardiovascular disease (CVD) in two BP monitoring studies: the Blood Pressure in different Ethnic groups (BP-Eth) study and the Home versus Office blood pressure MEasurements: Reduction of Unnecessary treatment Study (HOMERUS). Method: The primary comparison was Framingham risk calculated using BP measured as in the Framingham study or daytime ambulatory BP measurements. Statistical significance was determined using non-parametric tests. Results: In 442 BP-Eth patients (mean age = 58 years, 50% female [n = 222]) the median absolute difference in 10-year Framingham cardiovascular risk calculated using BP measured as in the Framingham study or daytime ambulatory BP measurements was 1.84% (interquartile range [IQR] 0.65–3.63, P = 0.67). In 165 HOMERUS patients (mean age = 56 years, 46% female) the median absolute difference in 10-year risk for daytime ambulatory BP was 2.76% (IQR 1.19–6.39, P<0.001) and only 8 out of 165 (4.8%) of patients were reclassified. Conclusion: Estimates of cardiovascular risk are similar when calculated using BP measurements obtained as in the risk score derivation study or through ambulatory monitoring. Further research is required to determine if differences in estimated risk would meaningfully influence risk score accuracy.
Anticipatory syringe drivers: a step too far
The recent Gosport War Memorial Hospital inquiry1 has increased UK patient, public and clinician awareness about syringe drivers for continuous subcutaneous delivery of opioids and other medications at the end of life.2 3 The inquiry found that at least 456 patients died where opioids had been prescribed and administered in unjustified doses, commonly via syringe drivers. In safe hands, syringe drivers facilitate appropriate and effective control of pain and other symptoms for patients who are no longer able to swallow or absorb oral medication, commonly when close to the end of life. The Gosport findings highlight the importance of ‘safe hands’. In an overstretched clinical climate in which clinicians are encouraged to plan ahead to optimise patient care, Gosport is a timely warning of the potential dangers of ‘anticipatory syringe drivers’ prescribed in anticipation of future symptoms at the end of life. The anticipatory prescribing and administration of opioids in Gosport hospital was highly anomalous and did not reflect standard palliative care practice. A serious category error was common; most people were in hospital for rehabilitation and were not terminally ill. The inquiry underlined that opioid delivery to the wrong people, at the wrong time, in the wrong doses, hastened many deaths. These unacceptable practices highlight the risks of prescribing anticipatory syringe drivers (along with excessive starting doses or wide dose ranges) to be started by third parties whose clinical assessment skills are unknown to the prescriber. This can result in syringe drivers being started, or doses increased, without skilled assessment and consideration of potentially reversible causes of symptoms and clinical deterioration. Anticipatory prescribing of injectable drugs ahead of need is regarded as best practice for the dying in the UK,4 5 ensuring that relevant drugs are available in the home ‘Just in Case’ they are needed for ‘as required’ or pro re nata (prn) injections in the future. There is a danger that this may be conflated with anticipatory syringe driver prescribing. The two should be regarded as distinct interventions. Commencing a syringe driver marks a more significant change in patient care. Syringe drivers should only be prescribed after symptoms have developed, drugs and doses being decided in the light of response to previous injection doses. Once started, it is rare to discontinue a syringe driver, and family members often perceive death occurs soon afterwards.6 7 Before starting a syringe driver, it is vital to explore patient and family understanding and wishes, to discuss the goals of treatment, including the possible effects of administered drugs and to advise that drugs given in doses appropriate for symptom control will not hasten death.8 9 These conversations require the skills of a compassionate, knowledgeable and experienced doctor or nurse. The authors are aware that on occasions nurses may ask doctors to prescribe an anticipatory syringe driver when it is evident that a patient's condition may deteriorate soon. This can avoid delays in getting drugs prescribed ‘out of hours’ by practitioners unfamiliar with the clinical situation.10 11 Recent local fieldwork by our team found that 2 of 13 general practitioners (GP) interviewed were comfortable with prescribing anticipatory syringe drivers at the end of life. They trusted community nursing colleagues to give these drugs appropriately. Conversely, other GPs thought that syringe drivers should only be prescribed in response to symptoms developing and after a doctor had made a face-to-face assessment to rule out any reversible symptoms. Guidance from the National Institute for Health and Care Excellence (NICE),4 Healthcare Improvement Scotland5 and the British Medical Association12 lacks clarity about anticipatory syringe drivers. NICE guidance simply advises ensuring suitable anticipatory medicines and routes are prescribed as early as possible. Recommendations: In the absence of appropriate guidelines, we recommend syringe drivers should only be prescribed after an experienced doctor or nurse prescriber has reviewed the patient in person in order to consider the causes of deterioration and associated symptoms, evaluate reversibility, establish a dying diagnosis and appraise the effectiveness of previously administered prn drug injections. There is also an urgent need for research to guide safe and effective practice in this area.
Secondary prevention of cardiovascular disease: Time to rethink stratification of disease severity?
Commentary: Cardiovascular disease (CVD) remains a leading cause of mortality globally,1 but with improved management, CVD is less fatal.2 However, this means a large proportion of the people are living with this long-term condition. As of 2015, 1 in 17 of the global population had CVD.3 There is lack of evidence across countries to truly quantify the significant economic consequences of this pressing global health issue.4 Overall, CVD is estimated to cost the European Union (EU) economy €210 billion a year: around 53% (€111 billion) due to healthcare costs, 26% (€54 billion) to productivity losses and 21% (€45 billion) to the informal care of people with CVD.5
Drinking in later life: a systematic review and thematic synthesis of qualitative studies exploring older people’s perceptions and experiences
Background alcohol presents risks to the health of older adults at levels that may have been ‘safer’ earlier in life. Moderate drinking is associated with some health benefits, and can play a positive role in older people’s social lives. To support healthy ageing, we must understand older people’s views with regards to their drinking. This study aims to synthesise qualitative evidence exploring the perceptions and experiences of alcohol use by adults aged 50 years and over. Methods a pre-specified search strategy was applied to Medline, PsychINFO, Scopus, Applied Social Sciences Index and Abstracts and Cumulative Index to Nursing and Allied Health Literature databases from starting dates. Grey literature, relevant journals, references and citations of included articles were searched. Two independent reviewers sifted articles and assessed study quality. Principles of thematic analysis were applied to synthesise the findings from included studies. Results of 2,056 unique articles identified, 25 articles met inclusion criteria. Four themes explained study findings: routines and rituals of older people’s drinking; self-image as a responsible drinker; perceptions of alcohol and the ageing body; and older people’s access to alcohol. Differences between gender, countries and social patterns are highlighted. Conclusions older people perceive themselves as controlled and responsible drinkers. They may not recognise risks associated with alcohol, but appreciate its role in sustaining social and leisure activities important to health and well-being in later life. These are important considerations for intervention development. Drinking is routinised across the life course and may be difficult to change in retirement.
Detection of familial hypercholesterolaemia: external validation of the FAMCAT clinical case-finding algorithm to identify patients in primary care
Background: The vast majority of individuals with familial hypercholesterolaemia in the general population remain unidentified worldwide. Recognising patients most likely to have the condition, to enable targeted specialist assessment and treatment, could prevent major coronary morbidity and mortality. We aimed to evaluate a clinical case-finding algorithm, the familial hypercholesterolaemia case ascertainment tool (FAMCAT), and compare it with currently recommended methods for detection of familial hypercholesterolaemia in primary care. Methods: In this external validation study, FAMCAT regression equations were applied to a retrospective cohort of patients aged 16 years or older with cholesterol assessed, who were randomly selected from 1500 primary care practices across the UK contributing to the QResearch database. In the main analysis, we assessed the ability of FAMCAT to detect familial hypercholesterolaemia (ie, its discrimination) and compared it with that of other established clinical case-finding approaches recommended internationally (Simon Broome, Dutch Lipid Clinic Network, Make Early Diagnosis to Prevent Early Deaths [MEDPED] and cholesterol concentrations higher than the 99th percentile of the general population in the UK). We assessed discrimination by area under the receiver operating curve (AUROC; ranging from 0·5, indicating pure chance, to 1, indicating perfect discrimination). Using a probability threshold of more than 1 in 500 (prevalence of familial hypercholesterolaemia), we also assessed sensitivity, specificity, positive predictive values, and negative predictive values in the main analysis. Findings: A sample of 750 000 patients who registered in 1500 UK primary care practices that contribute anonymised data to the QResearch database between Jan 1, 1999, and Sept 1, 2017, was randomly selected, of which 747 000 patients were assessed. FAMCAT showed a high degree of discrimination (AUROC 0·832, 95% CI 0·820–0·845), which was higher than that of Simon Broome criteria (0·694, 0·681–0·703), Dutch Lipid Clinic Network criteria (0·724, 0·710–0·738), MEDPED criteria (0·624, 0·609–0·638), and screening cholesterol concentrations higher than the 99th percentile (0·581, 0·570–0·591). Using a 1 in 500 probability threshold, FAMCAT achieved a sensitivity of 84% (1028 predicted vs 1219 observed cases) and specificity of 60% (443 949 predicted vs 745 781 observed non-cases), with a corresponding positive predictive value of 0·84% and a negative predictive value of 99·2%. Interpretation: FAMCAT identifies familial hypercholesterolaemia with greater accuracy than currently recommended approaches and could be considered for clinical case finding of patients with the highest likelihood of having hypercholesterolaemia in primary care.
Trends in survival after a diagnosis of heart failure in the United Kingdom 2000-2017: population based cohort study
Objectives: To report reliable estimates of short term and long term survival rates for people with a diagnosis of heart failure and to assess trends over time by year of diagnosis, hospital admission, and socioeconomic group. Design: Population based cohort study. Setting: Primary care, United Kingdom. Participants: Primary care data for 55 959 patients aged 45 and overwith a new diagnosis of heart failure and 278 679 age and sex matched controls in the Clinical Practice Research Datalink from 1 January 2000 to 31 December 2017 and linked to inpatient Hospital Episode Statistics and Office for National Statistics mortality data. Main outcome measures: Survival rates at one, five, and 10 years and cause of death for people with and without heart failure; and temporal trends in survival by year of diagnosis, hospital admission, and socioeconomic group. Results: Overall, one, five, and 10 year survival rates increased by 6.6% (from 74.2% in 2000 to 80.8% in 2016), 7.2% (from 41.0% in 2000 to 48.2% in 2012), and 6.4% (from 19.8% in 2000 to 26.2% in 2007), respectively. There were 30 906 deaths in the heart failure group over the study period. Heart failure was listed on the death certificate in 13 093 (42.4%) of these patients, and in 2237 (7.2%) it was the primary cause of death. Improvement in survival was greater for patients not requiring admission to hospital around the time of diagnosis (median difference 2.4 years; 5.3 v 2.9 years, P<0.001). There was a deprivation gap in median survival of 2.4 years between people who were least deprived and those who were most deprived (11.1 v 8.7 years, P<0.001). Conclusions: Survival after a diagnosis of heart failure has shown only modest improvement in the 21st century and lags behind other serious conditions, such as cancer. New strategies to achieve timely diagnosis and treatment initiation in primary care for all socioeconomic groups should be a priority for future research and policy.
Patients’ understanding of cellulitis and their information needs: a mixed-methods study in primary and secondary care
Background: Cellulitis is a painful infection of the skin and underlying tissues, commonly affecting the lower leg. Approximately one-third of people experience recurrence. Patients’ ability to recover from cellulitis or prevent recurrence is likely to be influenced by their understanding of the condition. Aim: To explore patients’ perceptions of cellulitis, and their information needs. Design and setting: Mixed-methods study comprising semi-structured, face-to-face interviews and a cross-sectional survey, recruiting through primary and secondary care, and advertising. Method: Adults aged ≥18 years with a history of cellulitis were invited to take part in a survey, qualitative interview, or both. Results: In all, 30 interviews were conducted between August 2016 and July 2017. Qualitative data highlighted a low awareness of cellulitis before the first episode, uncertainty about when it had been diagnosed, concern/surprise at the severity of cellulitis, and a perceived insufficient information provision. People were surprised that they had never heard of cellulitis and that they had not received advice or leaflets giving self-care information. Some sought information from the internet and found this confusing. A total of 240 surveys were completed (response rate 17%). These showed that, although many participants had received information on the treatment of cellulitis (60.0%, n = 144), they often reported receiving no information about causes (60.8%, n = 146) or prevention of recurrence (73.3%, n = 176). Conclusion: There is a need to provide information for people with cellulitis, particularly in regard to naming their condition, the management of acute episodes, and how to reduce the risk of recurrences.
Persistent unexplained physical symptoms: a prospective longitudinal cohort study in UK primary care
Background: Unexplained physical symptoms (UPS) are extremely common among primary care attenders, but little is known about their longer-term outcome. Aim: To investigate the persistence of somatic symptoms at 6 months among a cohort with multiple UPS, and identify prognostic factors associated with worsening symptom scores. Design and setting: Prospective longitudinal cohort study involving adults attending UK general practice in North and Central London between January and December 2013. Method: Consecutive adults attending nine general practices were screened to identify those with at least three UPS. Eligible participants completed measures of symptom severity (measured using the Patient Health Questionnaire Somatic Symptom Module [PHQ-15]), physical and mental wellbeing, and past health and social history, and were followed up after 6 months. Multivariable linear regression analysis was conducted to identify prognostic factors associated with the primary outcome: somatic symptom severity. Results: Overall, 245/294 (83%) provided 6-month outcome data. Of these, 135/245 (55%) reported still having UPS, 103/245 (42%) had symptoms still under investigation, and only 26/245 (11%) reported complete symptom resolution. Being female, higher baseline somatic symptom severity, poorer physical functioning, experience of childhood physical abuse, and perception of poor financial wellbeing were significantly associated with higher somatic symptom severity scores at 6 months. Conclusion: This study has shown that at 6 months few participants had complete resolution of unexplained somatic symptoms. GPs should be made aware of the likelihood of UPS persisting, and the factors that make this more likely, to inform decision making and care planning. There is a need to develop prognostic tools that can predict the risk of poor outcomes.
The elicitation and management of multiple health concerns in GP consultations
Objective: To describe the nature of patient concerns and to explore if, when and how they are addressed by GPs in the UK. Methods: Detailed coding and descriptive analysis of 185 video recordings from the EPaC study (Elicitation of Patient Concerns, EPaC) Results: An average of 2.1 concerns were raised per consultation and the most common concerns were musculoskeletal, administrative (e.g. test results and medication related issues), and skin symptoms. GPs who had been trained as part of the EPaC intervention to solicit for additional concerns in the opening phase of the consultation did so 92.6% of the time. In contrast, those in the control arm did so only 7% of the time. However, the particular formulation of the GP soliciting question does not seem to be associated with the likelihood of the patient volunteering an additional concern. Conclusions: GP consultations are complex encounters in which multiple concerns are dealt with across a wide range of disease areas. GPs can be trained to solicit for problems/concerns early in the consultation. Practice implications: Soliciting for additional concerns is not routinely done. But very brief training can substantially help in eliciting concerns early in the consultation, which may help with organising the consultation.
Assessing the severity of Type 2 diabetes using clinical data‐based measures: a systematic review
Aims: To identify and critically appraise measures that use clinical data to grade the severity of Type 2 diabetes. Methods: We searched MEDLINE, Embase and PubMed between inception and June 2018. Studies reporting on clinical data‐based diabetes‐specific severity measures in adults with Type 2 diabetes were included. We excluded studies conducted solely in participants with other types of diabetes. After independent screening, the characteristics of the eligible measures including design and severity domains, the clinical utility of developed measures, and the relationship between severity levels and health‐related outcomes were assessed. Results: We identified 6798 studies, of which 17 studies reporting 18 different severity measures (32 314 participants in 17 countries) were included: a diabetes severity index (eight studies, 44%); severity categories (seven studies, 39%); complication count (two studies, 11%); and a severity checklist (one study, 6%). Nearly 89% of the measures included diabetes‐related complications and/or glycaemic control indicators. Two of the severity measures were validated in a separate study population. More severe diabetes was associated with increased healthcare costs, poorer cognitive function and significantly greater risks of hospitalization and mortality. The identified measures differed greatly in terms of the included domains. One study reported on the use of a severity measure prospectively. Conclusions: Health records are suitable for assessment of diabetes severity; however, the clinical uptake of existing measures is limited. The need to advance this research area is fundamental as higher levels of diabetes severity are associated with greater risks of adverse outcomes. Diabetes severity assessment could help identify people requiring targeted and intensive therapies and provide a major benchmark for efficient healthcare services.
Adverse Events from Emollient Use in Eczema: A Restricted Review of Published Data
Atopic dermatitis/eczema is a chronic inflammatory skin condition, and emollients are the first-line treatment. Despite their widespread use, there is uncertainty about the frequency and type of adverse events associated with different emollients. We conducted a restricted review of published data on adverse events associated with emollient use in eczema. Medline (Ovid) was searched from inception (1946) to June 2018. All types of studies, with the exception of reviews, were included. Eligibility was assessed using a two-stage screening process against inclusion and exclusion criteria. References of all included papers were screened for any additional eligible papers. Data were subsequently extracted from all eligible publications. A limited body of data were found in the published data: 24 papers reported on adverse events with 29 different emollients (3 containing urea, 5 containing ceramide, 4 containing glycerol, 4 were herbal and 13 contained “other” ingredients). Interpretation of the results and comparison of the emollients were difficult due to poor reporting and missing data. Many publications contained no data at all on adverse events, and no study reported serious treatment-related adverse events for any emollient. The proportion of participants in the studies experiencing treatment-related adverse events varied between 2 and 59%. The most common adverse events were skin related and often mild. The range of participants experiencing non-treatment-related adverse events varied between 4 and 43%. From this restricted review, clinicians and patients can be reassured that the emollients studied appear to be generally safe to use. Better studies and reporting of adverse events associated with emollients in common use are needed.
A scholarship to foster future leaders in evidence based medicine
Editorial: The inaugural 2019 Doug Altman Scholarship at EBMLive in Oxford Doug Altman (1948-2018) was The BMJ’s chief statistician for over 20 years. His work on improving the execution and reporting of research made him a world leader in evidence based medicine and a distinguished role model. Doug helped researchers design and report good quality studies to answer important clinical questions. His editorial, “The scandal of poor medical research,” written in 1994 is essential reading for those new to evidence based medicine.1 Its call for “less research, better research, and research done for the right reasons” remains relevant today. His passion for teaching and mentoring makes him a source of inspiration for early career researchers.
Persistent unexplained physical symptoms: a prospective longitudinal cohort study in UK primary care
Background: Unexplained physical symptoms (UPS) are extremely common among primary care attenders, but little is known about their longer-term outcome. Aim: To investigate the persistence of somatic symptoms at 6 months among a cohort with multiple UPS, and identify prognostic factors associated with worsening symptom scores. Design and setting: Prospective longitudinal cohort study involving adults attending UK general practice in North and Central London between January and December 2013. Method: Consecutive adults attending nine general practices were screened to identify those with at least three UPS. Eligible participants completed measures of symptom severity (measured using the Patient Health Questionnaire Somatic Symptom Module [PHQ-15]), physical and mental wellbeing, and past health and social history, and were followed up after 6 months. Multivariable linear regression analysis was conducted to identify prognostic factors associated with the primary outcome: somatic symptom severity. Results: Overall, 245/294 (83%) provided 6-month outcome data. Of these, 135/245 (55%) reported still having UPS, 103/245 (42%) had symptoms still under investigation, and only 26/245 (11%) reported complete symptom resolution. Being female, higher baseline somatic symptom severity, poorer physical functioning, experience of childhood physical abuse, and perception of poor financial wellbeing were significantly associated with higher somatic symptom severity scores at 6 months. Conclusion: This study has shown that at 6 months few participants had complete resolution of unexplained somatic symptoms. GPs should be made aware of the likelihood of UPS persisting, and the factors that make this more likely, to inform decision making and care planning. There is a need to develop prognostic tools that can predict the risk of poor outcomes.
Anticipatory prescribing of injectable medications for adults at the end of life in the community: A systematic literature review and narrative synthesis
Background: The anticipatory prescribing of injectable medications to provide end-of-life symptom relief is an established community practice in a number of countries. The evidence base to support this practice is unclear. Aim: To review the published evidence concerning anticipatory prescribing of injectable medications for adults at the end of life in the community. Design: Systematic review and narrative synthesis. Registered in PROSPERO: CRD42016052108, on 15 December 2016 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=52108). Data sources: Medline, CINAHL, Embase, PsycINFO, Web of Science, Cochrane Library, King’s Fund, Social Care Online, and Health Management Information Consortium databases were searched up to May 2017, alongside reference, citation, and journal hand searches. Included papers presented empirical research on the anticipatory prescribing of injectable medications for symptom control in adults at the end of life. Research quality was appraised using Gough’s ‘Weight of Evidence’ framework. Results: The search yielded 5099 papers, of which 34 were included in the synthesis. Healthcare professionals believe anticipatory prescribing provides reassurance, effective symptom control, and helps to prevent crisis hospital admissions. The attitudes of patients towards anticipatory prescribing remain unknown. It is a low-cost intervention, but there is inadequate evidence to draw conclusions about its impact on symptom control and comfort or crisis hospital admissions. Conclusion: Current anticipatory prescribing practice and policy is based on an inadequate evidence base. The views and experiences of patients and their family carers towards anticipatory prescribing need urgent investigation. Further research is needed to investigate the impact of anticipatory prescribing on patients’ symptoms and comfort, patient safety, and hospital admissions.