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  • Patient use of blood pressure self-screening facilities in general practice waiting rooms: A qualitative study in the UK

    3 July 2018

    © British Journal of General Practice 2017. Background Blood pressure (BP) self-screening, whereby members of the public have access to BP monitoring equipment outside of healthcare consultations, may increase the detection and treatment of hypertension. Currently in the UK such opportunities are largely confined to GP waiting rooms. Aim To investigate the reasons why people do or do not use BP self-screening facilities. Design and setting A cross-sectional, qualitative study in Oxfordshire, UK. Method Semi-structured interviews with members of the general public recruited using posters in GP surgeries and community locations were recorded, transcribed, and coded thematically. Results Of the 30 interviewees, 20% were hypertensive and almost half had self-screened. Those with no history of elevated readings had limited concern over their BP: self-screening filled the time waiting for their appointment or was done to help their doctor. Patients with hypertension self-screened to avoid the feelings they associated with 'white coat syndrome' and to introduce more control into the measurement process. Barriers to self-screening included a lack of awareness, uncertainty about technique, and worries over measuring BP in a public place. An unanticipated finding was that several interviewees preferred monitoring their BP in the waiting room than at home. Conclusion BP self-screening appeared acceptable to service users. Further promotion and education could increase awareness among non-users of the need for BP screening, the existence of self-screening facilities, and its ease of use. Waiting room monitors could provide an alternative for patients with hypertension who are unwilling or unable to monitor at home.

  • Effectiveness of curcuminoids in the treatment of knee osteoarthritis: a systematic review and meta-analysis of randomized clinical trials

    3 July 2018

    © 2017 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd Aim: To critically appraise and evaluate the evidence for effectiveness of curcuminoids in the treatment of osteoarthritis (OA) in adults. Methods: We conducted electronic searches in Medline, Embase, AMED, Cinahl and the Cochrane library. We included randomized controlled trials (RCTs) that investigated the effectiveness of orally-administered curcuminoids in OA in adults, and assessed risk of bias using the Cochrane risk of bias criteria. We used a random-effect model for meta-analysis. Results: We included seven studies with a total of 797 participants with primarily knee OA. All studies were conducted in Asia. The overall risk of bias was moderate. Compared with placebo, curcuminoids significantly reduced knee pain (visual analogue scale): (standardized mean difference: −3.45; 95% CI: −5.52 to −1.38; I2 = 95% P = 0.001), and improved quality of life (Lequesne pain-function index): (mean difference: −2.69; 95% CI: −3.48 to −1.90; I2 = 0% P < 0.00001). There were significantly fewer effects on pain relief, knee stiffness and physical function with curcuminoids compared with ibuprofen. Significant improvements in Western Ontario and McMaster Universities Arthritis Index total scores, with significant reductions in the use of rescue medication were also observed with curcuminoids. No serious adverse events were reported. Conclusions: Curcuminoids may have some beneficial effects on knee pain and quality of life in patients with knee OA. However, they are less effective at relieving pain compared with ibuprofen. Curcuminoids appear safe on the short-term, and may reduce the need for rescue medication. Published RCTs vary in reporting quality, are characterized by small sample sizes, and have all been conducted in Asia. Further clinical trials are therefore warranted.

  • A real-world approach to Evidence-Based Medicine in general practice: A competency framework derived from a systematic review and Delphi process

    3 July 2018

    © 2017 The Author(s). Background: Evidence-Based Medicine (EBM) skills have been included in general practice curricula and competency frameworks. However, GPs experience numerous barriers to developing and maintaining EBM skills, and some GPs feel the EBM movement misunderstands, and threatens their traditional role. We therefore need a new approach that acknowledges the constraints encountered in real-world general practice. The aim of this study was to synthesise from empirical research a real-world EBM competency framework for general practice, which could be applied in training, in the individual pursuit of continuing professional development, and in routine care. We sought to integrate evidence from the literature with evidence derived from the opinions of experts in the fields of general practice and EBM. Methods: We synthesised two sets of themes describing the meaning of EBM in general practice. One set of themes was derived from a mixed-methods systematic review of the literature; the other set was derived from the further development of those themes using a Delphi process among a panel of EBM and general practice experts. From these two sets of themes we constructed a real-world EBM competency framework for general practice. Results: A simple competency framework was constructed, that acknowledges the constraints of real-world general practice: (1) mindfulness - in one's approach towards EBM itself, and to the influences on decision-making; (2) pragmatism - in one's approach to finding and evaluating evidence; and (3) knowledge of the patient - as the most useful resource in effective communication of evidence. We present a clinical scenario to illustrate how a GP might demonstrate these competencies in their routine daily work. Conclusion: We have proposed a real-world EBM competency framework for general practice, derived from empirical research, which acknowledges the constraints encountered in modern general practice. Further validation of these competencies is required, both as an educational resource and as a strategy for actual practice.

  • Care, Control, and the Electroconvulsive Therapy Ritual: Making Sense of Polarized Patient Narratives

    3 July 2018

    © SAGE Publications. Despite evidence of short-term effectiveness of ECT (electroconvulsive therapy), both positive and negative patient reports are common. However, research examining these polarized accounts has not adequately elucidated why such divergences occur. We thus sought to examine opposing patient narratives to better understand underlying meanings. Eighteen interviews were conducted with U.K.-based people who had experienced the treatment. Our analysis revealed that the quality of relations with staff, ECT artifacts (e.g., the ECT suite), and perceived outcomes all play a role in divergent accounts. Positive reflections on ECT emerged alongside narratives of trust in staff, comfort with ECT, and perception of sufficient personal control. Conversely, where negative evaluations of ECT predominated, there was anger associated with a lack of control, a belief that ECT made little sense, and was linked to past abuses and/or the unacceptability of side effects. We discuss the implications of our findings for professionals.

  • The influence of maternally derived antibody and infant age at vaccination on infant vaccine responses: An individual participant meta-analysis

    3 July 2018

    © 2017 American Medical Association. All rights reserved. IMPORTANCE The design of infant immunization schedules requires an understanding of the factors that determine the immune response to each vaccine antigen. DATA SOURCES Deidentified individual participant data from GlaxoSmithKline clinical trials were obtained through Clinical Study Data Request. The data were requested on January 2, 2015, and final data were received on April 11, 2016. STUDY SELECTION Immunogenicity trials of licensed or unlicensed vaccines administered to infants were included if antibody concentrations in infants were measured prior to the first dose of vaccine. DATA EXTRACTION AND SYNTHESIS The databasewas examined; studies that appeared to have appropriate data were reviewed. MAIN OUTCOMES AND MEASURES Antigen-specific antibody concentration measured 1 month after priming vaccine doses, before booster vaccination, and 1 month after booster vaccine doses. RESULTS A total of 7630 infants from 32 studies in 17 countries were included. Mean (SD) age at baseline was 9.0 (2.3) weeks; 3906 (51.2%) were boys. Preexisting maternal antibody inhibited infant antibody responses to priming doses for 20 of 21 antigens. The largest effects were observed for inactivated polio vaccine, where 2-fold higher maternal antibody concentrations resulted in 20%to 28%lower postvaccination antibody concentration (geometric mean ratios [GMRs], type 1: 0.80; 95%CI, 0.78-0.83; type 2: 0.72; 95%CI, 0.69-0.74; type 3: 0.78; 95%CI, 0.75-0.82). For acellular pertussis antigens, 2-fold higher maternal antibody was associated with 11%lower postvaccination antibody for pertussis toxoid (GMR, 0.89; 95%CI, 0.87-0.90) and filamentous hemagglutinin (GMR, 0.89; 95%CI, 0.88-0.90) and 22%lower pertactin antibody (GMR, 0.78; 95%CI, 0.77-0.80). For tetanus and diphtheria, these estimates were 13%(GMR, 0.87; 95%CI, 0.86-0.88) and 24%(GMR, 0.76; 95%CI, 0.74-0.77), respectively. The influence of maternal antibody was still evident in reduced responses to booster doses of acellular pertussis, inactivated polio, and diphtheria vaccines at 12 to 24 months of age. Children who were older when first immunized had higher antibody responses to priming doses for 18 of 21 antigens, after adjusting for the effect of maternal antibody concentrations. The largest effect was seen for polyribosylribitol phosphate antibody, where responses were 71%higher per month (GMR, 1.71; 95%CI, 1.52-1.92). CONCLUSIONS AND RELEVANCE Maternal antibody concentrations and infant age at first vaccination both influence infant vaccine responses. These effects are seen for almost all vaccines contained in global immunization programs and influence immune response for some vaccines even at the age of 24 months. These data highlight the potential for maternal immunization strategies to influence established infant programs.

  • Corrigendum to “Persistence of bactericidal antibodies following booster vaccination with 4CMenB at 12, 18 or 24 months and immunogenicity of a fifth dose administered at 4 years of age-a phase 3 extension to a randomised controlled trial” (Vaccine (2017) 35(2) (395–402) (S0264410X16310404) (10.1016/j.vaccine.2016.11.009))

    3 July 2018

    © 2017 The Author(s) The authors regret that since the publication of this paper, they have discovered an error in the Conclusion of the Abstract. The corrected Conclusion is listed below. The authors would also like to correct the name of Dr. Miguel Tortajada-Girbés in The European Men B vaccine study group section. Conclusion: Waning of protective antibodies occurred 24–36 months after toddler booster regardless of age at boost. This was least marked against target strains 5/99 and M10713. A robust memory response occurred after a booster dose given at 4 years of age. The authors would like to apologise for any inconvenience caused.

  • How can point-of-care HbA1c testing be integrated into UK primary care consultations? – A feasibility study

    3 July 2018

    © 2017 The Authors Aims Point-of-care (POC) HbA1c testing gives a rapid result, allowing testing and treatment decisions to take place in a single appointment. Trials of POC testing have not been shown to improve HbA1c, possibly because of how testing was implemented. This study aimed to identify key components of POC HbA1c testing and determine strategies to optimise implementation in UK primary care. Methods This cohort feasibility study recruited thirty patients with type 2 diabetes and HbA1c > 7.5% (58 mmol/mol) into three primary care clinics. Patients’ clinical care included two POC HbA1c tests over six months. Data were collected on appointment duration, clinical decisions, technical performance and patient behaviour. Results Fifty-three POC HbA1c consultations took place during the study; clinical decisions were made in 30 consultations. Five POC consultations with a family doctor lasted on average 11 min and 48 consultations with nurses took on average 24 min. Five POC study visits did not take place in one clinic. POC results were uploaded to hospital records from two clinics. In total, sixty-three POC tests were performed, and there were 11 cartridge failures. No changes in HbA1c or patient behaviour were observed. Conclusions HbA1c measurement with POC devices can be effectively implemented in primary care. This work has identified when these technologies might work best, as well as potential challenges. The findings can be used to inform the design of a pragmatic trial to implement POC HbA1c testing.

  • Using the Medical Research Council framework for development and evaluation of complex interventions in a low resource setting to develop a theory-based treatment support intervention delivered via SMS text message to improve blood pressure control

    3 July 2018

    © 2018 The Author(s). Background: Several frameworks now exist to guide intervention development but there remains only limited evidence of their application to health interventions based around use of mobile phones or devices, particularly in a low-resource setting. We aimed to describe our experience of using the Medical Research Council (MRC) Framework on complex interventions to develop and evaluate an adherence support intervention for high blood pressure delivered by SMS text message. We further aimed to describe the developed intervention in line with reporting guidelines for a structured and systematic description. Methods: We used a non-sequential and flexible approach guided by the 2008 MRC Framework for the development and evaluation of complex interventions. Results: We reviewed published literature and established a multi-disciplinary expert group to guide the development process. We selected health psychology theory and behaviour change techniques that have been shown to be important in adherence and persistence with chronic medications. Semi-structured interviews and focus groups with various stakeholders identified ways in which treatment adherence could be supported and also identified key features of well-regarded messages: polite tone, credible information, contextualised, and endorsed by identifiable member of primary care facility staff. Direct and indirect user testing enabled us to refine the intervention including refining use of language and testing of interactive components. Conclusions: Our experience shows that using a formal intervention development process is feasible in a low-resource multi-lingual setting. The process enabled us to pre-test assumptions about the intervention and the evaluation process, allowing the improvement of both. Describing how a multi-component intervention was developed including standardised descriptions of content aimed to support behaviour change will enable comparison with other similar interventions and support development of new interventions. Even in low-resource settings, funders and policy-makers should provide researchers with time and resources for intervention development work and encourage evaluation of the entire design and testing process. Trial registration: The trial of the intervention is registered with South African National Clinical Trials Register number (SANCTR DOH-27-1212-386; 28/12/2012); Pan Africa Trial Register (PACTR201411000724141; 14/12/2013); ClinicalTrials.gov (NCT02019823; 24/12/2013).