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Royal college of general practitioners research and surveillance centre (RCGP RSC) sentinel network: A cohort profile
Purpose: The Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) is one of the longest established primary care sentinel networks. In 2015, it established a new data and analysis hub at the University of Surrey. This paper evaluates the representativeness of the RCGP RSC network against the English population. Participants and method: The cohort includes 1 042 063 patients registered in 107 participating general practitioner (GP) practices. We compared the RCGP RSC data with English national data in the following areas: demographics; geographical distribution; chronic disease prevalence, management and completeness of data recording; and prescribing and vaccine uptake. We also assessed practices within the network participating in a national swabbing programme. Findings to date: We found a small overrepresentation of people in the 25-44 age band, under-representation of white ethnicity, and of less deprived people. Geographical focus is in London, with less practices in the southwest and east of England. We found differences in the prevalence of diabetes (national: 6.4%, RCPG RSC: 5.8%), learning disabilities (national: 0.44%, RCPG RSC: 0.40%), obesity (national: 9.2%, RCPG RSC: 8.0%), pulmonary disease (national: 1.8%, RCPG RSC: 1.6%), and cardiovascular diseases (national: 1.1%, RCPG RSC: 1.2%). Data completeness in risk factors for diabetic population is high (77-99%). We found differences in prescribing rates and costs for infections (national: 5.58%, RCPG RSC: 7.12%), and for nutrition and blood conditions (national: 6.26%, RCPG RSC: 4.50%). Differences in vaccine uptake were seen in patients aged 2 years (national: 38.5%, RCPG RSC: 32.8%). Owing to large numbers, most differences were significant ( p<0.00015). Future plans: The RCGP RSC is a representative network, having only small differences with the national population, which have now been quantified and can be assessed for clinical relevance for specific studies. This network is a rich source for research into routine practice.
Disparities in glycaemic control, monitoring, and treatment of type 2 diabetes in England: A retrospective cohort analysis
BACKGROUND: Disparities in type 2 diabetes (T2D) care provision and clinical outcomes have been reported in the last 2 decades in the UK. Since then, a number of initiatives have attempted to address this imbalance. The aim was to evaluate contemporary data as to whether disparities exist in glycaemic control, monitoring, and prescribing in people with T2D. METHODS AND FINDINGS: A T2D cohort was identified from the Royal College of General Practitioners Research and Surveillance Centre dataset: a nationally representative sample of 164 primary care practices (general practices) across England. Diabetes healthcare provision and glucose-lowering medication use between 1 January 2012 and 31 December 2016 were studied. Healthcare provision included annual HbA1c, renal function (estimated glomerular filtration rate [eGFR]), blood pressure (BP), retinopathy, and neuropathy testing. Variables potentially associated with disparity outcomes were assessed using mixed effects logistic and linear regression, adjusted for age, sex, ethnicity, and socioeconomic status (SES) using the Index of Multiple Deprivation (IMD), and nested using random effects within general practices. Ethnicity was defined using the Office for National Statistics ethnicity categories: White, Mixed, Asian, Black, and Other (including Arab people and other groups not classified elsewhere). From the primary care adult population (n = 1,238,909), we identified a cohort of 84,452 (5.29%) adults with T2D. The mean age of people with T2D in the included cohort at 31 December 2016 was 68.7 ± 12.6 years; 21,656 (43.9%) were female. The mean body mass index was 30.7 ± SD 6.4 kg/m2. The most deprived groups (IMD quintiles 1 and 2) showed poorer HbA1c than the least deprived (IMD quintile 5). People of Black ethnicity had worse HbA1c than those of White ethnicity. Asian individuals were less likely than White individuals to be prescribed insulin (odds ratio [OR] 0.86, 95% CI 0.79-0.95; p < 0.01), sodium-glucose cotransporter-2 (SGLT2) inhibitors (OR 0.68, 95% CI 0.58-0.79; p < 0.001), and glucagon-like peptide-1 (GLP-1) agonists (OR 0.37, 95% CI 0.31-0.44; p < 0.001). Black individuals were less likely than White individuals to be prescribed SGLT2 inhibitors (OR 0.50, 95% CI 0.39-0.65; p < 0.001) and GLP-1 agonists (OR 0.45, 95% CI 0.35-0.57; p < 0.001). Individuals in IMD quintile 5 were more likely than those in the other IMD quintiles to have annual testing for HbA1c, BP, eGFR, retinopathy, and neuropathy. Black individuals were less likely than White individuals to have annual testing for HbA1c (OR 0.89, 95% CI 0.79-0.99; p = 0.04) and retinopathy (OR 0.82, 95% CI 0.70-0.96; p = 0.011). Asian individuals were more likely than White individuals to have monitoring for HbA1c (OR 1.10, 95% CI 1.01-1.20; p = 0.023) and eGFR (OR 1.09, 95% CI 1.00-1.19; p = 0.048), but less likely for retinopathy (OR 0.88, 95% CI 0.79-0.97; p = 0.01) and neuropathy (OR 0.88, 95% CI 0.80-0.97; p = 0.01). The study is limited by the nature of being observational and defined using retrospectively collected data. Disparities in diabetes care may show regional variation, which was not part of this evaluation. CONCLUSIONS: Our findings suggest that disparity in glycaemic control, diabetes-related monitoring, and prescription of newer therapies remains a challenge in diabetes care. Both SES and ethnicity were important determinants of inequality. Disparities in glycaemic control and other areas of care may lead to higher rates of complications and adverse outcomes for some groups.
End of season influenza vaccine effectiveness in primary care in adults and children in the United Kingdom in 2018/19
© 2019 2018/19 was the first season of introduction of a newly licensed adjuvanted influenza vaccine (aTIV) for adults aged 65 years and over and the sixth season in the roll-out of a childhood influenza vaccination programme with a quadrivalent live attenuated influenza vaccine (LAIV). The season saw mainly A(H1N1)pdm09 and latterly A(H3N2) circulation. End-of-season adjusted vaccine effectiveness (aVE) estimates against laboratory confirmed influenza infection in primary care were calculated using the test negative case control method adjusting for key confounders. End-of-season aVE was 44.3% (95% CI: 26.8, 57.7) against all laboratory-confirmed influenza; 45.7% (95% CI: 26.0, 60.1) against influenza A(H1N1)pdm09 and 35.1% (95% CI: −3.7,59.3) against A(H3N2). Overall aVE was 49.9% (95%CI: −13.7, 77.9) for all those ≥ 65 years of age and 62.0% (95% CI: 3.4, 85.0) for those who received aTIV. Overall aVE for 2–17 year olds receiving LAIV was 48.6% (95% CI: −4.4, 74.7). The paper provides evidence of overall significant influenza VE in 2018/19, most notably against influenza A(H1N1)pdm09, however, as seen in 2017/18, there was reduced, non-significant VE against A(H3N2). aTIV provided significant protection for those 65 years of age and over.
Foreign objects in college bodies: young women's feelings about long-acting reversible contraception (LARC).
Long-acting reversible contraceptives (LARC) are now recommended for use among nulliparous young women to prevent unintended pregnancy. While research has explored LARC knowledge, attitudes, and use among young women in the United States, college women's feelings about LARC have received limited attention. This article reports findings from a focus group study conducted with a convenience sample of 45 women, ages 18-25 years, enrolled in a large public university in the southeastern USA in April 2017. Focus groups combined LARC users and non-users and elicited a range of positive and negative affective responses to LARC. Some participants had an aversion to LARC because they perceived them to be unnatural, while others felt a sense of security because of their long-term effectiveness. Feelings about the location and mode of insertion for the intrauterine device (IUD) versus the implant played a significant role in the decision to use a specific LARC method: some found being able to feel the implant in their arm reassuring, while others found it disturbing and preferred the IUD. College-going LARC users also appear to be effective advocates for LARC use among their peers.
Patients' experiences with South Carolina's immediate postpartum Long-acting reversible contraception Medicaid policy
© 2019 Elsevier Inc. Objectives: We sought to examine women's experiences with immediate postpartum LARC counseling and use in the context of South Carolina's Medicaid policy. Study design: In 2016–18, we conducted semi-structured individual interviews with 25 women, ages 18–35, who gave birth within 2 years of the interview in South Carolina while insured by Medicaid and received contraceptive counseling about immediate postpartum LARC during their pregnancies. We analyzed the interviews using a combination of deductive and inductive coding approaches. Results: Participants were counseled on immediate postpartum LARC during prenatal care (n=23) and/or while in the hospital for childbirth (n=16). Some expressed dissatisfaction with providers' approaches to contraceptive counseling because they either did not receive enough information to make a fully informed decision or felt they were being pressured to use LARC. Among those who received in-hospital contraceptive counseling, some objected to the timing because they were in labor and/or already had a non-LARC postpartum contraceptive plan. Three out of the 10 participants who elected to receive immediate postpartum LARC later desired removal but encountered barriers. Conclusions: Our findings suggest providers' timing, style, and content of contraceptive counseling about immediate postpartum LARC may not be sufficiently patient-centered. Additionally, lack of access to unfettered LARC removal limits patients' reproductive autonomy. Implications: If providers use a patient-centered approach to immediate postpartum LARC counseling, consistently engage in comprehensive contraceptive counseling during prenatal care, avoid pressuring patients to choose LARC, and collaborate with hospital staff to increase care coordination, they can improve Medicaid recipients' contraceptive care experiences and facilitate informed contraceptive decision-making.
Contraceptive knowledge, attitudes, and use among adolescent mothers in the Cook Islands
© 2018 Elsevier B.V. Background: While the adverse health outcomes and broader economic and social factors associated with adolescent motherhood are well documented globally, limited research on unplanned pregnancy and birth among young women in Pacific Island nations exists. The study addresses this gap in the literature by examining the social and contextual factors that inform contraceptive knowledge, attitudes, and use among young women in the Cook Islands. Methods: Individual, in-depth interviews were conducted with ten women who became mothers before age twenty. Adolescents’ contraceptive knowledge, attitudes, and behaviours were examined while taking into account the context in which they experienced an unplanned birth. Findings: Five participants were not using a contraceptive method when they became pregnant, believing they would not become pregnant. The remaining participants were using oral contraception but doing so inconsistently. Four participants had a sexual debut prior to age 15. The findings suggest a need to expand comprehensive approaches to sexual and reproductive health education, increase access to long-acting reversible contraceptive methods, and decrease the stigma associated with accessing family planning services in order to more effectively prevent unplanned pregnancy among adolescents in the Cook Islands. Interpretation: The findings provide insight into the factors contributing to high rates of adolescent pregnancy and birth in the Pacific region and suggest how public health advocates and health care providers might reduce reproductive health disparities in the Cook Islands and similar Pacific Island nations.
Naltrexone-bupropion (Mysimba®) in management of obesity: a systematic review and meta-analysis of unpublished clinical study reports.
AIMS: To compare the benefits and harms of naltrexone-bupropion using evidence from clinical study reports (CSRs). METHODS: We searched FDA and EMA websites, PubMed, and Clinicaltrials.gov (May 2016) to identify pivotal trials; we then sent a freedom of information request to the EMA (July 2016). We included pivotal, phase III placebo-controlled trials. We assessed the risks of bias using the Cochrane criteria, and the quality of the evidence using GRADE. We used a random-effects model for meta-analyses. RESULTS: Over a 27-month period (July 2016 to August 2018), we received 31 batches of CSR documents containing over 65 000 pages of data from four pivotal trials (n=4536). Significantly more participants who took naltrexone-bupropion achieved ≥5% reduction in body weight: RR=2.1 (1.35 to 3.28, P=0.001, GRADE=low, NNTB =5 (3 to 17); this represents a 2.53 kg (1.85 to 3.21) reduction in baseline body weight compared with placebo. Naltrexone-bupropion had significantly beneficial effects on other cardiovascular risk factors; however, the true effect sizes for these are uncertain because of incomplete outcome data. Naltrexone-bupropion significantly increased the risk of adverse events: RR=1.11 (1.05 to 1.18, P=0.0004, GRADE=low, NNTH =12 (7 to 27); serious adverse events: RR=1.70 (1.38 to 2.1), P<0.00001, GRADE=moderate, NNTH =21 (13 to 38); and discontinuation because of adverse events: RR=1.92 (1.65 to 2.24), P<0.00001, GRADE=moderate, NNTD =9 (8 to 13). CONCLUSIONS: Naltrexone-bupropion significantly reduces body weight by a small amount but significantly increases the risk of adverse events. A rigorous process of post-marketing surveillance is required.
Acceptability and feasibility of weight management programmes for adults with severe obesity: a qualitative systematic review.
OBJECTIVES: To improve our understanding of the acceptability of behavioural weight management programmes (WMPs) for adults with severe obesity. DESIGN: A systematic review of qualitative evidence. DATA SOURCES: Medline, Embase, PsycINFO, CINAHL, SCI, SSCI and CAB abstracts were searched from 1964 to May 2017. ELIGIBILITY CRITERIA: Papers that contained qualitative data from adults with body mass index (BMI) ≥35 kg/m2 (and/or the views of providers involved in their care) and considered issues about weight management. DATA EXTRACTION AND SYNTHESIS: Two reviewers read and systematically extracted data from the included papers which were compared, and contrasted according to emerging issues and themes. Papers were appraised for methodological rigour and theoretical relevance using Toye's proposed criteria for quality in relation to meta-ethnography. RESULTS: 33 papers met our inclusion criteria from seven countries published 2007-2017. Findings were presented from a total of 644 participants and 153 programme providers. Participants described being attracted to programmes that were perceived to be novel or exciting, as well as being endorsed by their healthcare provider. The sense of belonging to a group who shared similar issues, and who had similar physiques and personalities, was particularly important and seemed to foster a strong group identity and related accountability. Group-based activities were enjoyed by many and participants preferred WMPs with more intensive support. However, some described struggling with physical activities (due to a range of physical comorbidities) and not everyone enjoyed group interaction with others (sometimes due to various mental health comorbidities). Although the mean BMI reported across the papers ranged from 36.8 to 44.7 kg/m2, no quotes from participants in any of the included papers were linked to specific detail regarding BMI status. CONCLUSIONS: Although group-based interventions were favoured, people with severe obesity might be especially vulnerable to physical and mental comorbidities which could inhibit engagement with certain intervention components.
The Molecular Profile of Synovial Fluid Changes upon Joint Distraction and is Associated with Clinical Response in Knee Osteoarthritis.
OBJECTIVE: Surgical knee joint distraction (KJD) leads to clinical improvement in knee osteoarthritis (OA) and also apparent cartilage regeneration by magnetic resonance imaging. We investigated if alteration of the joint's mechanical environment during the 6 week period of KJD was associated with a molecular response in synovial fluid, and if any change was associated with clinical response. METHOD: 20 individuals undergoing KJD for symptomatic radiographic knee OA had SF sampled at baseline, midpoint and endpoint of distraction (6 weeks). SF supernatants were measured by immunoassay for 10 predefined mechanosensitive molecules identified in our previous pre-clinical studies. The composite Knee injury and OA Outcome Score-4 (KOOS4) was collected at baseline, 3, 6 and 12 months. RESULTS: 13/20 (65%) were male with mean age 54±5yrs. All had Kellgren-Lawrence grade≥2 knee OA. 6/10 analytes showed statistically significant change in SF over the 6 weeks distraction (activin A;TGFβ-1;MCP-1;IL-6;FGF-2;LTBP2), P<0.05. Of these, all but activin A increased. Those achieving the minimum clinically important difference of 10 points for KOOS4 over 6 months showed greater increases in FGF-2 and TGFβ-1 than non-responders. An increase in IL-8 during the 6 weeks of KJD was associated with significantly greater improvement in KOOS4 over 12 months. CONCLUSION: Detectable, significant molecular changes are observed in SF following KJD, that are remarkably consistent between individuals. Preliminary findings appear to suggest that increases in some molecules are associated with clinically meaningful responses. Joint distraction may provide a potential opportunity in the future to define regenerative biomarker(s) and identify pathways that drive intrinsic cartilage repair.
Establishing a causal link between social relationships and health using the Bradford Hill Guidelines
© 2019 The Authors An abundance of evidence suggests that the size and quality of our social relationships improves humans' physical and mental health while increasing lifespan. However most of this evidence comes from observational rather than experimental (randomised trial) evidence, leaving open the possibility that the connection between social relationships and health could be associational rather than causal. However there are examples, including the link between smoking and lung cancer, where a cause was established without experimental evidence. This was sometimes achieved by looking at the totality of evidence, using the ‘Bradford Hill Guidelines’, which considers factors including the strength of association, reversibility, and evidence of a plausible mechanism. In this paper we apply the Bradford Hill Guidelines to the link between social relationships and health. We conclude that having strong and supportive social relationships causes better health and longer life. Beyond establishing that social relationships are a causal factor for health, the method we used here can be applied to other areas where randomised trials are unethical or not feasible.