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BackgroundAdults at high risk of fragility fracture should be offered pharmacological treatment when not contraindicated, however under-treatment is common.ObjectiveThis study aimed to investigate factors associated with bone-health medication initiation in older patients attending primary care.DesignRetrospective cohort study.Setting44 general practices in Ireland from 2011-2017.SubjectsAdults aged ≥65 years who were naïve to bone-health medication for 12 months.MethodsOverall fracture-risk (based on QFracture) and individual fracture-risk factors were described for patients initiated and not initiated onto medication and compared using generalised linear model regression with Poisson distribution.ResultsOf 36,799 patients (51 % female, mean age 75.4 (SD=8.4)) included, 8% (n=2,992) were observed to initiate on bone-health medication during the study. One fifth of all patients (n=8,193) had osteoporosis or had high fracture-risk but only 21% of them (n=1,687) initiated on medication. Female sex, older age, state-funded health cover and osteoporosis were associated with initiation. Independently of osteoporosis and co-variates, high 5-year QFracture risk for hip (IRR=1.33 (95% CI=1.17-1.50), pConclusionsBone-health medication initiation is targeted at patients at higher fracture-risk but much potential under-treatment remains, particularly in those >80 years and with co-morbidities. This may reflect clinical uncertainty in older multimorbid patients, and further research should explore decision-making in preventive bone medication prescribing.Key pointsDuring this study, 23% of women and 11% of men defined as high-risk of fracture were newly initiated on bone-health medication.Rates of potential under-treatment were highest in patients over 80 years old.Fracture history, corticosteroid use, and rheumatoid arthritis were independently associated with medication initiation.Patients with diabetes, and liver, kidney, or cardiovascular disease were less likely to be initiated on medication.Clinical guidelines should provide advice on risk-benefit decisions in osteoporosis treatment where co-morbidities are present.

Objective To investigate the association between potentially serious alcohol–medication interactions (POSAMINO criteria), hypothesised to increase the risk of falls in older adults, and falls in community-dwelling older adults at two and 4 years follow-up. Design A prospective cohort study. Setting The Irish Longitudinal Study on Ageing. Subjects A total of 1,457 community-dwelling older adults aged ≥65 years, with a complete alcohol and regular medication data to allow for the application of the POSAMINO criteria. Outcomes Self-reported falls at 2 and 4 years follow-up, any falls (yes/no), injurious falls (yes/no) and number of falls (count variable). Results The number of participants who reported falling since their baseline interview at 2 and 4 years were 357 (24%) and 608 (41.8%), respectively; 145 (10%) reported an injurious fall at 2 years and 268 (18%) at 4 years. Median (IQR) number of falls was 1 (1–2) at 2 years and 2 (1–3) at 4 years. Exposure to CNS POSAMINO criteria, hypothesised to increase the risk of falls due primarily to increased sedation, was associated with a significantly increased risk for falling (adjusted relative risk (RR) 1.50, 95% confidence interval (CI) 1.21–1.88) and for injurious falls (adjusted RR 1.62, 95% CI: 1.03–2.55) at 4 years. These equate to an absolute risk of 19% for falling (95% CI: 5–33%) and 8% for injurious falls (95% CI, 4–20%) at 4 years. Conclusions Assessment and management strategies to prevent falls in community-dwelling older adults should consider patients’ alcohol consumption alongside their assessment of patient medications, particularly among those receiving CNS agents.

Background Hospitalisation for specific conditions considered to be `ambulatory-care sensitive' (ACS) could signify problems with primary or outpatient care access. The aims of this study are to quantify and explore potential causes for geographical variation across emergency hospital admissions for relevant ACS conditions in older adults in Ireland. Methods The number of emergency hospital admissions among adults aged 65+ with a diagnosis of an ACS condition between 2012-2016 were extracted from Ireland’s Hospital Inpatient Enquiry system according to condition, sex, age-group, residence area and year. Conditions included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes complications, angina (excluding therapeutic procedures), pyelonephritis and urinary tract infections (UTI), dehydration and pneumonia. Age-sex standardised discharge rates (SDRs) were calculated for 21 areas. Systematic components of variance (SCV) quantified variation. Regression analyses were conducted between SDRs and year, unemployment rate, % urban population, General Practitioner (GP) supply, and % short emergency hospital stays. Results In total, 147,722 emergency hospital admissions (50 per 1,000 eligible population; 49% male) were included. COPD was the most common condition (31%), followed by pneumonia (22%), pyelonephritis/UTI (21%) and CHF (16%). CHF showed low geographic variation (SCV=2-3). COPD, diabetes, pyelonephritis/UTI and pneumonia showed high variation (SCV=4-12). Angina and dehydration showed very high variation (SCV=12-50). In multivariable analysis, higher unemployment was associated with higher SDRs for COPD. Lower GP supply was associated with higher SDRs for CHF, diabetes and pneumonia. Rurality was associated with SDRs for angina. Conclusion The rate of emergency admissions for ACS conditions studied is in line with research in the United States, although COPD and angina account for a higher proportion of admissions in our study. There is significant geographical variation in ACS admission rates among older adults in Ireland. Further research should explore local factors influencing emergency admission, particularly in socio-economically disadvantaged areas and those with lower GP supply.

BACKGROUND: The CRB-65 score is recommended as a decision support tool to help identify patients with community-acquired pneumonia (CAP) who can safely be treated as outpatients. OBJECTIVE: To perform an updated meta-analysis of the accuracy, discrimination, and calibration of the CRB-65 score using a novel approach to calculation of stratum-specific likelihood ratios. DESIGN: Meta-analysis of accuracy, discrimination, and calibration. METHODS: We searched PubMed, Google, previous systematic reviews, and reference lists of included studies. Data was abstracted and quality assessed in parallel by two investigators. The quality assessment used an adaptation of the TRIPOD and PROBAST criteria. Measures of discrimination, calibration, and stratum-specific likelihood ratios are reported. KEY RESULTS: Twenty-nine studies met our inclusion criteria and provided usable data. Most studies were set in Europe, none in North America, and 12 were judged to be at low risk of bias. The pooled estimate of area under the receiver operating characteristic curve was 0.74 (95% CI 0.71–0.77) for all studies. Calibration was good although there was significant heterogeneity; the pooled estimate of the ratio of observed to expected mortality for all studies was 1.04 (95% CI 0.91–1.19). The corresponding values for studies at low risk of bias where patients could be treated as outpatients or inpatients were 0.76 (0.70–0.81) and 0.88 (0.69–1.13). Summary estimates of stratum-specific likelihood ratios for all studies were 0.19 for the low-risk group, 1.1 for the moderate-risk group, and 4.5 for the high-risk group, and 0.13, 1.3, and 5.6 for studies at low risk of bias where patients could be treated as outpatients or inpatients. CONCLUSIONS: The CRB-65 is useful for identifying low-risk patients for outpatient therapy. Given a 4% overall mortality risk, patients classified as low risk by the CRB-65 had an outpatient mortality risk of no more than 0.5%. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-04869-z) contains supplementary material, which is available to authorized users.

This study aims to estimate (i) the prevalence of potentially serious alcohol-medication interactions in a nationally representative sample of older adults using the Potentially Serious Alcohol-Medication Interactions in Older adults (POSAMINO) criteria, and (ii) whether POSAMINO prevalence changes over time. A prospective cohort study of adults aged ≥ 65 years, using data from the first three waves of The Irish Longitudinal Study on Ageing (TILDA). All 38 POSAMINO criteria were applied at each wave using respondents’ information on regular medications and alcohol consumption. Multilevel logistic regression and negative binomial models were used to investigate whether the prevalence of POSAMINO varied over time. The overall prevalence of POSAMINO was 18% at baseline, with 8% at risk of one potentially serious alcohol-medication interaction, and 10% at risk of two or more. The most common POSAMINO involved cardiovascular (CVS) agents (15% baseline; 11% wave 2; 14% wave 3), followed by central nervous system (CNS) agents (4% baseline; 4% wave 2; 5% wave 3). Prevalence of any POSAMINO (AOR 0.94, 95% CI 0.81, 1.08) or number of POSAMINO criteria (AIRR 0.97, 95% CI 0.91, 1.04) did not change over time. Any POSAMINO and number of POSAMINO were associated with younger age, male sex and number of medications and chronic conditions. Potentially serious alcohol-medication interactions occurred in 18% of older adults in this study. Alcohol screening and brief interventions should be considered for high-risk groups at the point of prescribing, particularly among younger older adults, men and as patients receive more medications or develop additional illnesses.

ObjectiveAmbulatory care sensitive (ACS) conditions are those for which intensified primary care management could potentially prevent emergency admissions. This study aimed to quantify geographical variation in emergency admissions with ACS conditions in older adults and explore factors influencing variation.DesignRepeated cross-sectional study.Setting34 public hospitals in the Ireland.ParticipantsAdults aged ≥65 years hospitalised for seven ACS conditions between 2012 and 2016 (chronic obstructive pulmonary disease, congestive heart failure (CHF), diabetes, angina, pyelonephritis/urinary tract infections (UTIs), dehydration and pneumonia).Primary outcome measureAge and sex standardised emergency admission rates (SARs) per 1000 older adults.AnalysisAge and sex SARs were calculated for 21 geographical areas. Extremal quotients and systematic components of variance (SCV) quantified variation. Spatial regression analyses was conducted for SARs with unemployment, urban population proportion, hospital turnover, supply of general practitioners (GPs), and supply of hospital-based specialists as explanatory variables.ResultsOver time, an increase in UTI/pyelonephritis SARs was seen while SARs for angina and CHF decreased. Geographic variation was moderate overall and high for dehydration and angina (SCV=11.7–50.0). For all conditions combined, multivariable analysis showed lower urban population (adjusted coefficient: −2.2 (−3.4 to −0.9, pConclusionsFuture research should evaluate methods of preventing admissions for ACS conditions among older adults, including how resources are allocated at a local level.

Summary Gaps in pharmacological treatment for osteoporosis can reduce effectiveness. Among older adults, we found about half of new users of oral bisphosphonate and denosumab persisted with their treatment at 2 years, with few switching to alternative therapy. Persistence is suboptimal and warrants evaluation of interventions to improve this. Purpose Gaps in pharmacological treatment for osteoporosis can reduce effectiveness. This study aimed to estimate persistence rates for oral bisphosphonates and denosumab in older primary care patients and identify factors associated with discontinuation. Methods Older patients newly prescribed oral bisphosphonates or denosumab during 2012–2017 were identified from 44 general practices (GP) in Ireland. Persistence without a coverage gap of >90 days was calculated for both medications from therapy initiation. Factors associated with time to discontinuation were explored using Cox regression analysis. Exposures included age group, osteoporosis diagnosis, fracture history, calcium/vitamin D prescription, number of other medications, health cover, dosing frequency (bisphosphonates) and previous bone-health medication (denosumab). Results Of 41,901 patients, n=1569 were newly initiated on oral bisphosphonates and n=1615 on denosumab. Two-year persistence was 49.4% for oral bisphosphonates and 53.8% for denosumab and pp Conclusion Persistence for osteoporosis medications is suboptimal. Of concern, few patients are switched to other bone-health treatments when denosumab is stopped which could increase fracture risk. Free access to GP services and medications may have resulted in better medication persistence in this cohort. Future research should explore prescribing choices in primary care osteoporosis management and evaluate cost-effectiveness of interventions for improving persistence.

Objective To systematically review clinical prediction rules (CPRs) that have undergone validation testing for predicting response to physiotherapy-related interventions for musculoskeletal conditions. Study design and setting PubMed, EMBASE, CINAHL and Cochrane Library were systematically searched to September 2020. Search terms included musculoskeletal (MSK) conditions, physiotherapy interventions and clinical prediction rules. Controlled studies that validated a prescriptive CPR for physiotherapy treatment response in musculoskeletal conditions were included. Two independent reviewers assessed eligibility. Original derivation studies of each CPR were identified. Risk of bias was assessed with the PROBAST tool (derivation studies) and the Cochrane Effective Practice and Organisation of Care group criteria (validation studies). Results Nine studies aimed to validate seven prescriptive CPRs for treatment response for MSK conditions including back pain, neck pain, shoulder pain and carpal tunnel syndrome. Treatments included manipulation, traction and exercise. Seven studies failed to demonstrate an association between CPR prediction and outcome. Methodological quality of derivation studies was poor and for validation studies was good overall. Conclusion Results do not support the use of any CPRs identified to aid physiotherapy treatment selection for common musculoskeletal conditions, due to methodological shortcomings in the derivation studies and lack of association between CPR and outcome in validation studies.

ObjectiveTo determine the prevalence and predictors of oral to intravenous antibiotic switch among adult emergency department (ED) patients with acute bacterial skin and skin structure infections (ABSSSIs).DesignMulticentre, pilot cohort study.SettingThree urban EDs in Dublin, Ireland.ParticipantsConsecutive ED patients aged >16 years old with ABSSSIs between March 2015 and September 2016.InterventionOral flucloxacillin 500 mg–1 g four times a day (alternative in penicillin allergy).Primary and secondary outcome measuresThe primary outcome was to determine the prevalence and predictors of oral to intravenous antibiotic switch. Secondary outcomes were to determine the prevalence and predictors of receiving an extended course of oral antibiotic treatment and measurement of interobserver reliability for clinical predictors at enrolment.ResultsOverall, 159 patients were enrolled of which eight were lost to follow-up and five were excluded. The majority of patients were male (65.1%) and ConclusionThe prevalence of oral to intravenous antibiotic switch in this pilot study is 8.9% (95% CI 4.8% to 14.7%). We identify the predictors of oral to intravenous switch worthy of future investigation.Trial registration numberNCT02230813.

BackgroundAspirin use for cardiovascular indications is widespread despite evidence not supporting use in patients without cardiovascular disease (CVD). This study characterises aspirin prescribing among people aged ≥50 years in Ireland for primary and secondary prevention, and factors associated with prescription.MethodsThis cross-sectional study includes participants from wave 3 (2014-2015) of The Irish Longitudinal Study on Ageing. We identified participants reporting use of prescribed aspirin, other antiplatelets/anticoagulants, and doctor-diagnosed CVD (MI, angina, stroke, TIA) and other cardiovascular conditions. We examined factors associated with aspirin use for primary and secondary prevention in multivariate regression. For a subset, we also examined 10-year cardiovascular risk (using the Framingham general risk score) as a predictor of aspirin use.ResultsAmong 6,618 participants, the mean age was 66.9 years (SD 9.4) and 55.6% (3,679) were female. Prescribed aspirin was reported by 1,432 participants (21.6%), and 77.6% of aspirin users had no previous CVD. Among participants with previous CVD, 17% were not prescribed aspirin/another antithrombotic. This equates to 201,000 older adults nationally using aspirin for primary prevention, and 16,000 with previous CVD not prescribed an antithrombotic. Among those without CVD, older age, male sex, free health care, and more GP visits were associated with aspirin prescribing. Cardiovascular risk was significantly associated with aspirin use (adjusted relative risk 1.15, 95%CI 1.08-1.23, per 1% increase in cardiovascular risk).ConclusionAlmost four-fifths of people aged ≥50 years on aspirin have no previous CVD, equivalent to 201,000 adults nationally, however prescribing appears rational in targeting higher cardiovascular risk patients.

Objective: The objective of this study was to determine whether trajectories of older adults’ alcohol consumption are influenced by the following life course transitions, relationship status, employment status, and self-rated health. Method: Volume and frequency of drinking were harmonized across first three waves of The Irish Longitudinal Study on Ageing (TILDA; N = 4,295). Multilevel regression models were used to model frequency, average weekly consumption, and heavy episodic drinking. Results: Men and women drank more frequently over time, with frequency decreasing with age for women. Average weekly consumption decreased over time and with increasing age. Transitions in self-rated health, particularly those reflecting poorer health, were associated with lower frequency and weekly consumption. Heavy episodic drinking decreased with age. Men who were retired across all waves were more likely to engage in heavy episodic drinking at baseline. Discussion: Despite the decline in average weekly consumption and heavy episodic drinking, the observed quantities consumed and the increase in frequency of consumption suggest that older Irish adults remain vulnerable to alcohol-related harms.

Older people with several chronic conditions require multiple drugs from different classes to be adequately treated. This study aims to: (i) measure medication adherence across multiple conditions and therapeutic drug groups in older community-dwelling patients, and (ii) examine the effect of multimorbidity on adherence. This is a retrospective cohort study of medication adherence in 855 community-dwelling patients aged ≥ 70 years from 15 practices in Ireland using the Health Service Executive Primary Care Reimbursement Service (HSE-PCRS) pharmacy claims database. Multimorbidity was measured using the RxRisk-V and by the number of different drug classes. The RxRisk-V algorithm classifies prescription drug fills into 45 chronic disease classes for older populations based on the WHO Anatomical Therapeutic Chemical classification system. Adherence to medications was assessed by: (i) calculating the average medication possession ratio (MPR) per patient and (ii) an MPR

Aspirin use for cardiovascular indications is widespread despite evidence not supporting use in patients without cardiovascular disease (CVD). This study characterises aspirin prescribing among people aged ≥50 years in Ireland for primary and secondary prevention, and factors associated with prescription. This cross-sectional study includes participants from wave 3 (2014-2015) of The Irish Longitudinal Study on Ageing. We identified participants reporting use of prescribed aspirin, other antiplatelets/anticoagulants, and doctor-diagnosed CVD (MI, angina, stroke, TIA) and other cardiovascular conditions. We examined factors associated with aspirin use for primary and secondary prevention in multivariate regression. For a subset, we also examined 10-year cardiovascular risk (using the Framingham general risk score) as a predictor of aspirin use. Among 6618 participants, the mean age was 66.9 years (SD 9.4) and 55.6% (3679) were female. Prescribed aspirin was reported by 1432 participants (21.6%), and 77.6% of aspirin users had no previous CVD. Among participants with previous CVD, 16.5% were not prescribed aspirin/another antithrombotic. This equates to 201,000 older adults nationally using aspirin for primary prevention, and 16,000 with previous CVD not prescribed an antithrombotic. Among those without CVD, older age, male sex, free health care, and more GP visits were associated with aspirin prescribing. Cardiovascular risk was significantly associated with aspirin use (adjusted relative risk 1.15, 95%CI 1.08-1.23, per 1% increase in cardiovascular risk). Almost four-fifths of people aged ≥50 years on aspirin have no previous CVD, equivalent to 201,000 adults nationally, however prescribing appears to target higher cardiovascular risk patients.

Background. Hypercholesterolaemia is an important modifiable risk factor for cardiovascular disease (CVD) which requires monitoring and management at a population level. Aims. This study aims to describe the distribution of serum cholesterol in a community living population of older adults in Ireland and to examine the awareness, treatment and control of hypercholesterolaemia according to CVD risk status. Method. This is a cross-sectional study in a nationally representative sample of adults aged 50–79 years (n = 5287). Hypercholesterolaemia was defined as lowdensity lipoprotein cholesterol (LDL-C) in excess of the recommended CVD risk category target and/or on lipidlowering medication. Results. This study reports a mean total cholesterol (TC) of 5.1 mmol/L (95% CI 5.0–5.1 mmol/L) and a mean LDL-C of 2.9 mmol/L (95% CI 2.8–2.9 mmol/L) in those aged 50–79 years. In a subgroup aged 50–64 years, 73% (95% CI 71.5–74.5%) were hypercholesterolaemic. LDL-C was controlled to the guideline target in 57% of those with CVD and 49% of those with diabetes. Lack of awareness of hypercholesterolaemia was high across the remainder of the population. Conclusion. Despite a substantial reduction in population mean TC from a high of 6.0 mmol/L in the 1980s to 5.1 mmol/L, this study reports a failure to control hypercholesterolaemia to recommended risk-stratified targets in the Irish adult population. Recommendations for policy include continued monitoring of those at highest risk and CVD risk assessment in those perceived to be at low risk in order to inform shared decision making in relation to lifestyle modification and medication management.

Aims To examine the risk of mortality associated with interruptions to the continuity of methadone maintenance treatment (MMT), including transfers between services, in opioid‐dependent individuals attending specialist addiction services. Design Retrospective cohort study using addiction services and primary care dispensing records, the National Methadone Register and National Drug‐Related Death Index (NDRDI). Setting Geographically defined population in Dublin, Ireland. Participants A total of 2899 people prescribed and dispensed methadone in specialist addiction services between January 2010 and December 2015. There were five exposure groups: weeks 1–4 following transfer between treatment providers; weeks 1–4 out of treatment; weeks 5–52 out of treatment; weeks 1–4 of treatment initiation; and weeks 5+ of continuous treatment (reference category). Measurements Primary outcome: drug‐related poisoning (DRP) deaths. Secondary outcome: all‐cause mortality (ACM). Mortality rates calculated by dividing number of deaths (DRP; ACM) in exposure groups by person‐years exposure. Unadjusted and adjusted Poisson regression (covariates age, sex, incarceration, methadone dose and comorbidities) estimated differences in mortality rates. Findings There were 154 ACM deaths, 55 (35.7%) identified as DRP deaths. No deaths were observed in the first month following transfer between treatment providers. The risk of DRP mortality was highest in weeks 1–4 out of treatment [adjusted relative risk (aRR = 4.04, 95% confidence interval (CI) = 1.43–11.43, P = 0.009] and weeks 1–4 of treatment initiation (ARR = 3.4, 95% CI = 1.2–9.64, P = 0.02). Similarly, risk of ACM was highest in weeks 1–4 out of treatment (ARR = 11.78, 95% CI = 7.73–17.94, P

ObjectiveTo examine the extent of geographical variation across musculoskeletal surgical procedures and associated factors in Ireland.DesignRepeated cross-sectional study.Setting36 public hospitals in Ireland.ParticipantsAdult admissions for hip fracture, hip and knee replacement, knee arthroscopy and lumbar spine interventions over 5 years (2012–2016).Primary outcome measureStandardised discharge rate (SDR).AnalysisAge and sex SDRs were calculated for 21 geographical areas. Extremal quotients, coefficients of variation and systematic components of variance were calculated. Linear regression analyses were conducted exploring the relationship between SDRs and year, unemployment, % urban population, number of referral hospitals, % on waiting lists>6 months and % with private health insurance for each procedure.ResultsAcross 36 public hospitals, n=102 756 admissions were included. Hip fracture repair showed very low variation. Elective hip and knee procedures showed high variation in particular years, while variation for lumbar interventions was very high. Knee arthroscopy rates decreased over time. Higher unemployment was associated with knee and hip replacement rates and urban areas had lower hip replacement rates. Spinal procedure rates were associated with a lower number of referral hospitals in a region and spinal injection rates were associated with shorter waiting lists. A higher proportion of patients having private health insurance was associated with higher rates of hip and knee replacement and lumbar spinal procedures.ConclusionsVariation and factors associated with SDRs for publicly funded hip and knee procedures are consistent with similar international research in this field. Further research should explore reasons for high rates of spinal injections and the impact of private practice on musculoskeletal procedure variation.

This project was funded by the National Institute for Health Research Health Technology Assessment Programme (project number 10/57/08). Dr M. Monteiro-Soares is supported by Project ‘NORTE-01-0145-FEDER-000016’ (NanoSTIMA), financed by the North Portugal Regional Operational Programme NORTE 2020, under the PORTUGAL 2020 Partnership Agreement, and the European Regional Development Fund (ERDF). Aims: Diabetes guidelines recommend screening for the risk of foot ulceration but vary substantially in the underlying evidence base. Our purpose was to derive and validate a prognostic model of independent risk factors for foot ulceration in diabetes using all available individual patient data from cohort studies conducted worldwide. Methods: We conducted a systematic review and meta‐analysis of individual patient data from 10 cohort studies of risk factors in the prediction of foot ulceration in diabetes. Predictors were selected for plausibility, availability and low heterogeneity. Logistic regression produced adjusted odds ratios (ORs) for foot ulceration by ulceration history, monofilament insensitivity, any absent pedal pulse, age, sex and diabetes duration. Results: The 10 studies contained data from 16 385 participants. A history of foot ulceration produced the largest OR [6.59 (95% CI 2.49 to 17.45)], insensitivity to a 10 g monofilament [3.18 (95% CI 2.65 to 3.82)] and any absent pedal pulse [1.97 (95% CI 1.62 to 2.39)] were consistently, independently predictive. Combining three predictors produced sensitivities between 90.0% (95% CI 69.9% to 97.2%) and 95.3% (95% CI 84.5% to 98.7%); the corresponding specificities were between 12.1% (95% CI 8.2% to 17.3%) and 63.9% (95% CI 61.1% to 66.6%). Conclusions: This prognostic model of only three risk factors, a history of foot ulceration, an inability to feel a 10 g monofilament and the absence of any pedal pulse, compares favourably with more complex approaches to foot risk assessment recommended in clinical diabetes guidelines. Postprint

Introduction: Pharmacovigilance may detect safety issues after marketing of medications, and this can result in regulatory action such as direct healthcare professional communications (DHPC). DHPC can be effective in changing prescribing behaviour, however the extent to which prescribers vary in their response to DHPC is unknown. This study aims to explore changes in prescribing and prescribing variation among general practitioner (GP) practices following a DHPC on the safety of mirabegron, a medication to treat overactive bladder (OAB). Methods: This is an interrupted time series study of English GP practices from 2014&ndash, 2017. National Health Service (NHS) Digital provided monthly statistics on aggregate practice-level prescribing and practice characteristics (practice staff and registered patient profiles, Quality and Outcomes Framework indicators, and deprivation of the practice area). The primary outcome was monthly mirabegron prescriptions as a percentage of all OAB drug prescriptions and we assessed the change following a DHPC issued by the European Medicines Agency in September 2015. The DHPC stated mirabegron use was contraindicated with severe uncontrolled hypertension and cautioned with hypertension. Variation between practices in mirabegron prescribing before and after the DHPC was assessed using the systematic component of variation (SCV). Multilevel segmented regression with random effects quantified the change in level and trend of prescribing after the DHPC. Practice characteristics were assessed for their association with a reduction in prescribing following the DHPC. Results: This study included 7408 practices. During September 2015, 88.9% of practices prescribed mirabegron and mirabegron comprised a mean of 8.2% (SD 6.8) of OAB prescriptions. Variation between practices was classified as very high and the median SCV did not change significantly (p = 0.11) in the six months after the September 2015 DHPC (12.4) compared to before (11.6). Before the DHPC, the share of mirabegron over all OAB drug prescriptions increased by 0.294 (95% confidence interval (CI), 0.287, 0.301) percentage points per month. There was no significant change in the month immediately after the DHPC (&minus, 0.023, 95% CI &minus, 0.105 to 0.058), however there was a significant reduction in trend (&minus, 0.036, 95% CI &minus, 0.049 to &minus, 0.023). Higher numbers of registered patients, patients aged &ge, 65 years, and practice area deprivation were associated with having a significant decrease in level and slope of mirabegron prescribing post-DHPC. Conclusion: Variation in mirabegron prescribing was high over the study period and did not change substantively following the DHPC. There was no immediate prescribing change post-DHPC, although the monthly growth did slow. Knowledge of the degree of variation in and determinants of response to safety communications may allow those that do not change prescribing habits to be provided with additional support.

Objectives Decision analysis study that incorporates patient preferences and probability estimates to investigate the impact of women’s preferences for referral or an alternative strategy of watchful waiting if faced with symptoms that could be due to breast cancer. Setting Community-based study. Participants Asymptomatic women aged 30–60 years. Interventions Participants were presented with 11 health scenarios that represent the possible consequences of symptomatic breast problems. Participants were asked the risk of death that they were willing to take in order to avoid the health scenario using the standard gamble utility method. This process was repeated for all 11 health scenarios. Formal decision analysis for the preferred individual decision was then estimated for each participant. Primary outcome measure The preferred diagnostic strategy was either watchful waiting or referral to a breast clinic. Sensitivity analysis was used to examine how each varied according to changes in the probabilities of the health scenarios. Results A total of 35 participants completed the interviews, with a median age 41 years (IQR 35–47 years). The majority of the study sample was employed (n=32, 91.4%), with a third-level (university) education (n=32, 91.4%) and with knowledge of someone with breast cancer (n=30, 85.7%). When individual preferences were accounted for, 25 (71.4%) patients preferred watchful waiting to referral for triple assessment as their preferred initial diagnostic strategy. Sensitivity analysis shows that referral for triple assessment becomes the dominant strategy at the upper probability estimate (18%) of breast cancer in the community. Conclusions Watchful waiting is an acceptable strategy for most women who present to their general practitioner (GP) with breast symptoms. These findings suggest that current referral guidelines should take more explicit account of women’s preferences in relation to their GPs initial management strategy.

Purpose This study aims to compare the prevalence of potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs) using several screening tools in an Irish community-dwelling older cohort, to assess if the prevalence changes over time and to determine factors associated with any change. Methods This is a prospective cohort study of participants aged ≥65 years in The Irish Longitudinal Study on Ageing (TILDA) with linked pharmacy claims data (n = 2051). PIM and PPO prevalence was measured in the year preceding participants’ TILDA baseline interviews and in the year preceding their follow-up interviews using the Screening Tool for Older Persons’ Prescriptions (STOPP), Beers criteria (2012), Assessing Care of Vulnerable Elders (ACOVE) indicators and the Screening Tool to Alert doctors to Right Treatment (START). Generalised estimating equations were used to determine factors associated with change in prevalence over time. Results Depending on the screening tool used, between 19.8 % (ACOVE indicators) and 52.7 % (STOPP) of participants received a PIM at baseline, and PPO prevalence ranged from 38.2 % (START) to 44.8 % (ACOVE indicators), while 36.7 % of participants had both a PIM and PPO. Common criteria were aspirin for primary prevention (19.6 %) and omission of calcium/vitamin D in osteoporosis (14.7 %). Prevalence of PIMs and PPOs increased at follow-up (PIMs range 22–56.1 %, PPOs range 40.5–49.3 %), and this was associated with patient age, female sex, and numbers of medicines and chronic conditions. Conclusions Sub-optimal prescribing is common in older patients. Ongoing prescribing review to optimise care is important, particularly as patients get older, receive more medicines or develop more illnesses. Electronic supplementary material The online version of this article (doi:10.1007/s00228-015-1815-1) contains supplementary material, which is available to authorized users.

Background Several new medications for type 2 diabetes (T2DM) have been introduced, including dipeptidyl peptidase-4 (DPP-4) inhibitors and glucagon-like peptide-1 receptor (GLP-1) agonists. Variation in the prescribing of these agents has implications for quality, safety and costs. We aimed to investigate geographical variation in the prescribing of anti-diabetic medications in Ireland. Methods Cross-sectional analyses were undertaken on the two main national pharmacy claims databases in Ireland in 2013 and 2014. Direct standardized rates of individual anti-diabetic medication prescribing per 100 000 population were calculated by geographical area. Variation in prescribing was assessed using the systematic component of variation (SCV) and classified as very high (>10), high (5.4-10), moderate (3-5.4) or low (

peer-reviewed Background The publication of clinical prediction rules (CPRs) studies has risen significantly. It is unclear if this reflects increasing usage of these tools in clinical practice or how this may vary across clinical areas. Aim To review clinical guidelines in selected areas and survey GPs in order to explore CPR usefulness in the opinion of experts and use at the point of care. Design and setting A review of clinical guidelines and survey of UK GPs. Method Clinical guidelines in eight clinical domains with published CPRs were reviewed for recommendations to use CPRs including primary prevention of cardiovascular disease, transient ischaemic attack (TIA) and stroke, diabetes mellitus, fracture risk assessment in osteoporosis, lower limb fractures, breast cancer, depression, and acute infections in childhood. An online survey of 401 UK GPs was also conducted. Results Guideline review: Of 7637 records screened by title and/or abstract, 243 clinical guidelines met inclusion criteria. CPRs were most commonly recommended in guidelines regarding primary prevention of cardiovascular disease (67%) and depression (67%). There was little consensus across various clinical guidelines as to which CPR to use preferentially. Survey: Of 401 responders to the GP survey, most were aware of and applied named CPRs in the clinical areas of cardiovascular disease and depression. The commonest reasons for using CPRs were to guide management and conform to local policy requirements. Conclusion GPs use CPRs to guide management but also to comply with local policy requirements. Future research could focus on which clinical areas clinicians would most benefit from CPRs and promoting the use of robust, externally validated CPRs.

Objectives The Leiden clinical prediction rule (CPR) was developed in 2007 to predict disease progression in patients with recent-onset undifferentiated arthritis (UA). This systematic review and meta-analysis investigates the predictive ability of the rule at identifying patients who are at a high risk of developing rheumatoid arthritis (RA). Methods A systematic review of the literature search was conducted from 2007 to May 2013 to identify studies that validated the rule. This study adhered to the PRISMA guidelines. The methodological quality of studies was assessed using the QUADAS-2 tool. Pooled sensitivity and specificity values for each of the cut points were generated using a bivariate random-effects model. Heterogeneity was assessed using the variance of logit-transformed sensitivity and specificity. Bayes' theorem was used to calculate post-test probability of progression from UA to RA. Results The search identified four relevant studies, resulting in six data sets ( n = 1084). A cut point of ≥9 was identified as the optimal cut point for determining progression to RA. It is associated with a greater pooled specificity (0.99, 95% CI 0.95–1.00) than sensitivity (0.31, 95% CI 0.24–0.37). Using Bayes' theorem, a score of ≥9 points increased the pre-test probability from 40.04% to 93.63%. A less stringent cut-off of ≥8 also identified a significant proportion of patients at risk of RA who have a high likelihood of progressing to RA (LR + 9.5, 95% CI 6.21–14.54). Conclusion A cut point of ≥9 offers an optimal estimate for identifying patients with UA who are at a high risk of developing RA and warrant intervention. However, a number of methodological limitations identified across studies suggest that the results should be interpreted cautiously and that further validation of the Leiden CPR is necessary.

Purpose We sought to estimate the prevalence of potentially inappropriate prescriptions (PIP) and potential prescribing omissions (PPOs) using a subset of the STOPP/START criteria in a population based sample of Irish adults aged ≥65 years using data from The Irish LongituDinal Study on Ageing (TILDA). Methods A subset of 26 PIP indicators and 10 PPO indicators from the STOPP/START criteria were applied to the TILDA dataset. PIP/PPO prevalence according to individual STOPP/START criteria and the overall prevalence of PIP/PPO were estimated. The relationship between PIP and PPOs and polypharmacy, age, gender and multimorbidity was examined using logistic regression. Results The overall prevalence of PIP in the study population (n = 3,454) was 14.6 %. The most common examples of PIP identified were NSAID with moderate-severe hypertension (200 participants; 5.8 %) and aspirin with no history of coronary, cerebral, or peripheral vascular symptoms or occlusive event (112 participants; 3.2 %). The overall prevalence of PPOs was 30 % (n = 1,035). The most frequent PPO was antihypertensive therapy where systolic blood pressure consistently >160 mmHg (n = 341, 9.9 %), There was a significant association between PIP and PPO and polypharmacy when adjusting for age, sex and multimorbidity (adjusted OR 2.62, 95 % CI 2.05–3.33 for PIP and adjusted OR 1.46, 95 % CI 1.23–1.75 for prescribing omissions). Conclusion Our findings indicate prescribing omissions are twice as prevalent as PIP in the elderly using a subset of the STOPP/START criteria as an explicit process measure of potentially inappropriate prescribing and prescribing omissions. Polypharmacy was independently associated with both PPO and PIP. Application of such screening tools to prescribing decisions may reduce unnecessary medication, related adverse events, healthcare utilisation and cost. Electronic supplementary material The online version of this article (doi:10.1007/s00228-014-1651-8) contains supplementary material, which is available to authorized users.

This study aimed to i) describe methadone dosing before, during and after pregnancy, ii) to compare the incidence of neonatal abstinence syndrome (NAS) between those with dose decreases and those with steady or increasing doses and iii) to describe prescribed medication use among opioid dependent pregnant women.

Objectives Multimorbidity, defined as the presence of 2 or more chronic medical conditions in an individual, is associated with poorer health outcomes. Several multimorbidity measures exist, and the challenge is to decide which to use preferentially in predicting health outcomes. The study objective was to compare the performance of 5 count-based multimorbidity measures in predicting emergency hospital admission and functional decline in older community-dwelling adults attending primary care. Setting 15 general practices (GPs) in Ireland. Participants n=862, ≥70 years, community-dwellers followed-up for 2 years (2010–2012). Exposure at baseline: Five multimorbidity measures (disease counts, selected conditions counts, Charlson comorbidity index, RxRisk-V, medication counts) calculated using GP medical record and linked national pharmacy claims data. Primary outcomes (1) Emergency admission and ambulatory care sensitive (ACS) admission (GP medical record) and (2) functional decline (postal questionnaire). Statistical analysis Descriptive statistics and measure discrimination (c-statistic, 95% CIs), adjusted for confounders. Results Median age was 77 years and 53% were women. Prevalent rates ranged from 37% to 91% depending on which measure was used to define multimorbidity. All measures demonstrated poor discrimination for the outcome of emergency admission (c-statistic range: 0.62, 0.65), ACS admission (c-statistic range: 0.63, 0.68) and functional decline (c-statistic range: 0.55, 0.61). Medication-based measures were equivalent to diagnosis-based measures. Conclusions The choice of measure may have a significant impact on prevalent rates. Five multimorbidity measures demonstrated poor discrimination in predicting emergency admission and functional decline, with medication-based measures equivalent to diagnosis-based measures. Consideration of multimorbidity in isolation is insufficient for predicting these outcomes in community settings.

Background Potentially inappropriate prescribing (PIP) is common in older people in primary care, as evidenced by a significant body of quantitative research. However, relatively few qualitative studies have investigated the phenomenon of PIP and its underlying processes from the perspective of general practitioners (GPs). The aim of this paper is to explore qualitatively, GP perspectives regarding prescribing and PIP in older primary care patients. Method Semi-structured qualitative interviews were conducted with GPs participating in a randomised controlled trial (RCT) of an intervention to decrease PIP in older patients (≥70 years) in Ireland. Interviews were conducted with GP participants (both intervention and control) from the OPTI-SCRIPT cluster RCT as part of the trial process evaluation between January and July 2013. Interviews were conducted by one interviewer and audio recorded. Interviews were transcribed verbatim and a thematic analysis was conducted. Results Seventeen semi-structured interviews were conducted (13 male; 4 female). Three main, inter-related themes emerged (complex prescribing environment, paternalistic doctor-patient relationship, and relevance of PIP concept). Patient complexity (e.g. polypharmacy, multimorbidity), as well as prescriber complexity (e.g. multiple prescribers, poor communication, restricted autonomy) were all identified as factors contributing to a complex prescribing environment where PIP could occur, as was a paternalistic-doctor patient relationship. The concept of PIP was perceived to be of variable usefulness to GPs and the criteria to measure it may be at odds with the complex processes of prescribing for this patient population. Conclusions Several inter-related factors contributing to the occurrence of PIP were identified, some of which may be amenable to intervention. Improvement strategies focused on improved management of polypharmacy and multimorbidity, and communication across primary and secondary care could result in substantial improvements in PIP. Trial registration Current controlled trials ISRCTN41694007

Evidence for current interventions is limited. Emma Wallace and colleagues discuss the alternatives

This review provided an overview of the current evidence in relation to the use of e-prescribing and other forms of technology, such as CDSS, to reduce inappropriate prescribing in older people. The evidence indicates that various types of e-prescribing and CDSS interventions have the potential to reduce inappropriate prescribing and polypharmacy in older people, but the magnitude of their effect varies according to study design and setting. There was significant heterogeneity in the studies reported in terms of study designs, intervention design, patient settings, and outcome measures with patient outcomes seldom reported. Widespread diffusion of these interventions has not occurred in any of the health care settings examined. Overall, health care providers report being satisfied with e-prescribing systems and see the systems as having a positive impact on the safety of their prescribing practices, yet the problem of overriding or ignoring alerts persists. The problem of large numbers of inaccurate and insignificant alerts and this issue, along with the other barriers that have been identified, warrant further investigation.

(Headache 2011;51:1140-1148) Objective.— The purpose of this systematic review with meta-analysis is to determine the diagnostic accuracy of the identification of migraine (ID Migraine) as a decision rule for identifying patients with migraine. Background.— The ID Migraine screening tool is designed to identify patients with migraine in primary care settings. Several studies have validated the ID Migraine across various clinical settings, including primary care, neurology departments, headache clinics, dental clinics, ear, nose, and throat (ENT) and ophthalmology. Methods.— A systematic literature search was conducted to identify all studies validating the ID Migraine, with the International Headache Criteria as the reference standard. The methodological quality of selected studies was assessed using the Quality of Diagnostic Accuracy Studies tool. All selected studies were combined using a bivariate random effects model. A sensitivity analysis was also conducted, pooling only those studies using representative patient groups (primary care, neurology departments, and headache clinics) to determine the potential influence of spectrum bias on the results. Results.— Thirteen studies incorporating 5866 patients are included. The weighted prior probability of migraine across the 13 studies is 59%. The ID Migraine is shown to be useful for ruling out rather than ruling in migraine, with a greater pooled sensitivity estimate (0.84, 95% confidence interval 0.75-0.90) than specificity (0.76, 95% confidence interval 0.69-0.83). A negative ID Migraine score reduces the probability of migraine from 59% to 23%. The sensitivity analysis reveals similar results. Conclusions.— This systematic review quantifies the diagnostic accuracy of the ID Migraine as a brief, practical, and easy to use diagnostic tool for Migraine. Application of the ID Migraine as a diagnostic tool is likely to improve appropriate diagnosis and management of migraine sufferers.

Background: Annual foot checks are recommended in patients with diabetes mellitus (DM) to identify those at risk of foot ulceration. Systematic reviews have found few studies evaluating the predictive value of tests in community-based diabetic populations. Aim: To quantify the predictive value of clinical risk factors in relation to foot ulceration in a community population. Methods: A cohort of 1192 people with diabetes receiving care in community settings was recruited and a screening procedure, covering symptoms, signs and diagnostic tests was conducted at baseline. At an average 1-year follow-up patients who developed a foot ulcer were identified by an independent blind assessor. Multivariable analysis was performed to identify clinical predictors of foot ulceration. Findings: The incidence of foot ulceration was 1.93% [95% confidence interval (CI) 1.27–2.89). Three time-independent clinical predictors with five factors were selected: previous amputation [odds ratio (OR) 14.7, 95% CI 3.1–69.5), use of insulin before 3 months with inability to distinguish between cool and cold temperatures (OR 2.97, 95% CI 1.9–4.5) and failure to obtain at least one blood pressure reading for the calculation of ankle-brachial index with the failure to feel touch with a 10-g monofilament (OR 1.7, 95% CI 1.3–2.2). Interpretation: Recommendations for annual diabetic foot check in low-risk, community-based patients should be reviewed as absolute events of ulceration are low. The accuracy of foot risk assessment tools to predict ulceration requires evaluation in randomized controlled trials with concurrent economic evaluations.

Objective. The purpose of this systematic review with meta-analysis is to determine the predictive value of the ABCD2 at 7 and 90 days across three strata of risk. Background. The risk of stroke after transient ischaemic attack (TIA) is significant. The ABCD2 clinical prediction rule is designed to predict early risk of stroke after TIA. A number of independent validation studies have been conducted since the rule was derived. Methods. A systematic literature search was conducted to identify studies that validated the ABCD2. The derived rule was used as a predictive model and applied to subsequent validation studies. Comparisons were made between observed and predicted number of strokes stratified by risk group: low (0–3 points), moderate (4–5 points) and high (6–7 points). Pooled results are presented as risk ratios (RRs) with 95% confidence intervals (CIs), in terms of over-prediction (RR > 1) or under-prediction (RR Results. We include 16 validation studies. Fourteen studies report 7-day stroke risk (n = 6282, 388 strokes). The ABCD2 rule correctly predicts occurrence of stroke at 7 days across all three risk strata: low [RR 0.86, 95% CI (0.47–1.58), I2 = 16%], moderate [RR 0.99, 95% CI (0.67–1.47), I2 = 68%] and high [RR 0.84, 95% CI (0.6–1.19), I2 = 46%]. Eleven studies report 90-day stroke risk (n = 6304). There is a non-significant trend towards over-prediction of stroke in all risk categories at 90 days. There are 426 strokes observed in contrast to a predicted 626 strokes. As the trichotomized ABCD2 score increases, the risk of stroke increases (P 0.05). Conclusion. The ABCD2 is a useful CPR, particularly in relation to 7-day risk of stroke.

Being able to sort the majority of patients who have self-limiting and benign medical conditions from those who need more urgent investigation or referral because they may have a potentially serious underlying disorder remains a key challenge for GPs. This can be a difficult task, given the wide range of medical problems in general practice and the time constraints under which GPs often have to work. Searching for alarm symptoms, signs or diagnostic tests—or ‘red flags’—can help with ‘ruling in’ and ‘ruling out’ serious diagnoses, such as cancer, myocardial infarction or stroke. This article discusses the usefulness—and limitations—of red flags in clinical practice.

SummaryThe CHADS2 predicts annual risk of ischaemic stroke in non-valvular atrial fibrillation. This systematic review and meta-analysis aims to determine the predictive value of CHADS2. The literature was systematically searched from 2001 to October 2010. Data was pooled and analysed using discrimination and calibration statistical measures, using a random effects model. Eight data sets (n=2815) were included. The diagnostic accuracy suggested a cut-point of ≥1 has higher sensitivity (92%) than specificity (12%) and a cut-point of ≥4 has higher specificity (96%) than sensitivity (33%). Lower summary estimates were observed for cut-points ≥2 (sensitivity 79%, specificity 42%) and ≥3 (specificity 77%, sensitivity 50%). There was insufficient data to analyse cut-points ≥5 or ≥6. Moderate pooled c statistic values were identified for the classic (0.63, 95% CI 0.52–0.75) and revised (0.60, 95% CI 0.43–0.72) view of stratification of the CHADS2 . Calibration analysis in-dicated no significant difference between the predicted and observed strokes across the three risk strata for the classic or revised view. All results were associated with high heterogeneity, and conclusions should be made cautiously. In conclusion, the pooled c statistic and calibration analysis suggests minimal clinical utility of both the classic and revised view of the CHADS2 in predicting ischaemic stroke across all risk strata. Due to high heterogeneity across studies and low event rates across all risk strata, the results should be interpreted cautiously. Further validation of CHADS2 should perhaps be undertaken, given the methodological differences between many of the available validation studies and the original CHADS2 derivation study.

Objective To determine whether hospital admission is associated with potentially inappropriate prescribing among older primary care patients (aged ≥65 years) and whether such prescribing was more likely after hospital admission than before. Design Longitudinal study of retrospectively extracted data from general practice records. Setting 44 general practices in Ireland in 2012-15. Participants Adults aged 65 years or over attending participating practices. Exposure Admission to hospital (any hospital admission versus none, and post-admission versus pre-admission). Main outcome measures Prevalence of potentially inappropriate prescribing assessed using 45 criteria from the Screening Tool for Older Persons’ Prescription (STOPP) version 2, analysed both as rate of distinct potentially inappropriate prescribing criteria met (stratified Cox regression) and binary presence of potentially inappropriate prescribing (logistic regression) and adjusted for patients’ characteristics. A sensitivity analysis used matching with propensity scores based on patients’ characteristics and diagnoses. Results Overall 38 229 patients were included, and during 2012 the mean age was 76.8 (SD 8.2) years and 43% (13 212) were male. Each year, 10.4-15.0% (3015/29 077 in 2015 to 4537/30 231 in 2014) of patients had at least one hospital admission. The overall prevalence of potentially inappropriate prescribing ranged from 45.3% (13 940/30 789) of patients in 2012 to 51.0% (14 823/29 077) in 2015. Independently of age, sex, number of prescription items, comorbidity, and health cover, hospital admission was associated with a higher rate of distinct potentially inappropriate prescribing criteria met; the adjusted hazard ratio for hospital admission was 1.24 (95% confidence interval 1.20 to 1.28). Among participants who were admitted to hospital, the likelihood of potentially inappropriate prescribing after admission was higher than before admission, independent of patients’ characteristics; the adjusted odds ratio for after hospital admission was 1.72 (1.63 to 1.84). Analysis of propensity score matched pairs showed a slight reduction in the hazard ratio for hospital admission to 1.22 (1.18 to 1.25). Conclusion Hospital admission was independently associated with potentially inappropriate prescribing. It is important to determine how hospital admission may affect appropriateness of prescribing for older people and how potential adverse consequences of admission can be minimised.

Background Women with one previous caesarean section must decide which mode of delivery they would prefer in their next pregnancy. This involves a choice between attempted vaginal birth and elective caesarean section. Objective To explore women’s mode of delivery preferences and the values placed on the outcomes of decision making. Greater insight into these issues could benefit both clinical care and future research. Design Observational study using longitudinal data collected within a randomized controlled trial. Setting and Participants Seven hundred and forty-two women with one previous caesarean section recruited at four antenatal clinics in South West England and Scotland. Main outcome measures Mode of delivery preference recorded at 19 and 37 weeks’ gestation and visual analogue scale ratings of health and delivery outcomes. Results Comparison of mid and late pregnancy preferences and actual mode of delivery shows that 57% of women hold the same mode of delivery preferences at both times and 65% of women actually have the birth they prefer. The visual analogue scale ratings show variation in the way women value the outcomes of the decision. Discussion and Conclusions Understanding the way women’s mode of delivery preferences change, how these relate to actual mode of delivery and how women value the outcomes of their decision will be beneficial to health professionals who wish to support women both during pregnancy and after birth. In addition, the visual analogue scale ratings provide evidence that may improve the development of population-level and economic models of decision making.

Purpose To examine the extent, nature and determinants of medication use in early pregnancy. Methods We reviewed early pregnancy medication use, as reported to a midwife at the booking interview, in women delivering between 2000 and 2007 in a large maternity hospital in Dublin, Ireland (n = 61 252). Results Excluding folic acid, at least one medication was reported in 23 989 (39.2%) pregnancies. Over the counter (OTC) medications were reported in 11 970 (19.5%) pregnancies, illicit drugs or methadone in 545 (0.9%) and herbal medicines/supplements in 352 (0.58%). FDA category D and X medications were reported by 1532 (2.5%) and 1987 (3.2%) women. Asthma, depression and hypertension were among the most commonly reported chronic medical disorders. Medications with potential for foetal harm were reported by 86 (15.7%) women treated for depression and 68 (20%) women treated for hypertension. Factors associated with reporting the use of medications with potential for foetal harm included unplanned pregnancy (adjusted odds ratio [aOR] 1.31, 95% confidence interval [CI] 1.12–1.52), booking at less than 12 weeks gestation (aOR 1.83, 95%CI 1.58–2.13), being above 25 years of age, unemployed (aOR 2.58, 95%CI 2.03–3.29), nulliparous (aOR 1.41; 95%CI 1.22–1.63), single (aOR 1.28; 95%CI 1.06–1.54) or smoking during pregnancy (aOR 1.96, 95%CI 1.67–2.28). Conclusions Women frequently report medication use in early pregnancy. Women and prescribers need to be aware of the lack of pregnancy safety data for many medications, and the need for pre-pregnancy planning. Prescribers should ensure that optimal medications are used when treating women of childbearing potential with chronic medical disorders. Copyright © 2010 John Wiley & Sons, Ltd.

Background: Rectal bleeding is a recognised early symptom of colorectal cancer. This study aimed to assess the diagnostic accuracy of symptoms, signs and diagnostic tests in patients with rectal bleeding in relation to risk of colorectal cancer in primary care.\ud methods: Diagnostic accuracy systematic review. Medline (1966 to May 2009), Embase (1988 to May 2009), British Nursing Index (1991 to May 2009) and PsychINFO (1970 to May 2009) were searched. We included cohort studies that assessed the diagnostic utility of rectal bleeding in combination with other symptoms, signs and diagnostic tests in primary care. An eight-point quality assessment tool was produced to assess the quality of included studies. Pooled positive likelihood ratios (PLRs), sensitivities and specificities were calculated.\ud results: Eight studies incorporating 2323 patients were included. Average weighted prior probability of colorectal cancer was 7.0% (range: 3.3–15.4%, median: 8.1%). Age 60 years (pooled PLR: 2.79, 95% confidence interval (CI) 2.00–3.90), weight loss (pooled PLR: 1.89, 95% CI: 1.03–3.07) and change in bowel habit (pooled PLR: 1.92, 95% CI: 0.54–3.57) raise the probability of colorectal cancer into the range of referral to secondary care but do not conclusively ‘rule in’ the diagnosis. Presence of severe anaemia has the highest diagnostic value (pooled PLR: 3.67, 95% CI: 1.30–10.35), specificity 0.95 (95% CI: 0.93–0.96), but still only generates a post-test probability of 21.6%.\ud conclusions: In patients with rectal bleeding who present to their general practitioner, additional ‘red flag’ symptoms have modest diagnostic value. These findings have implications in relation to recommendations contained in clinical practice guidelines.

Background Acute cough due to upper respiratory tract infection (URTI) is a common symptom. Non-prescription over-the-counter (OTC) medicines are frequently recommended as a first-line treatment, but there is little evidence as to whether these drugs are effective. Objectives To assess the effects of oral OTC cough preparations for acute cough. Search strategy We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, issue 4); MEDLINE (January 1966 to January Week 1, 2007); EMBASE (January 1974 to January 2007); and the UK Department of Health National Research Register (June 2007). Selection criteria Randomised controlled trials (RCTs) comparing oral OTC cough preparations with placebo in children and adults suffering from acute cough in ambulatory settings. We considered all cough outcomes and second outcomes of interest were adverse effects. Data collection and analysis Two review authors independently screened potentially relevant citations and independently extracted data and assessed study quality. Quantitative analysis was performed where appropriate. Main results Twenty five trials (17 in adults, 8 in children) involving 3492 people (2876 adults and 616 children) were included. Results of studies in adults: Six trials compared antitussives with placebo and had variable results. Two trials compared the expectorant, guaifenesin with placebo, one indicated significant benefit whereas the other did not. One trial found that a mucolytic reduced cough frequency and symptom scores. Two studies examined antihistamine-decongestant combinations and found conflicting results. Three studies compared other combinations of drugs with placebo and indicated some benefit in reducing cough symptoms. Three trials found antihistamines were no more effective than placebo in relieving cough symptoms. Results of studies in children: Antitussives (two studies), antihistamines (two studies), antihistamine decongestants (two studies) and antitussive/bronchodilator combinations (one study) were no more effective than placebo. No studies using expectorants met our inclusion criteria. The results of one trial favoured active treatment with mucolytics over placebo. One trial tested two paediatric cough syrups and both preparations showed a 'satisfactory response' in 46% and 56% of children compared to 21% of children in the placebo group. Authors' conclusions There is no good evidence for or against the effectiveness of OTC medicines in acute cough. The results of this review have to be interpreted with caution due to differences in study characteristics and quality. Studies often showed conflicting results with uncertainty regarding clinical relevance. Higher quality evidence is needed to determine the effectiveness of self-care treatments for acute cough. Plain language summary The evidence for effectiveness of oral over-the-counter cough medicines is weak Acute cough is a common and troublesome symptom in people who suffer from acute upper respiratory tract infection (URTI). Many people self-prescribe over-the-counter (OTC) cough preparations and health practitioners often recommend their use for the initial treatment of cough. The results of this review suggest that there is no good evidence for or against the effectiveness of OTC medications in acute cough. The results of this review have to be interpreted with caution because the number of studies in each category of cough preparations was small. Many studies were of low quality and very different from each other, making evaluation of overall efficacy difficult.

We investigated the fetal outcomes of pregnancy in women with pre-existing diabetes in relation to pre-pregnancy risk factors using a community-based cohort of women in Tayside, Scotland. There were 211 pregnancies in 132 women with insulin-requiring type 1 and 2 diabetes between January 1993 and December 2005. Adverse fetal outcome was classified as spontaneous miscarriage, termination for medical reasons, stillbirth, neonatal death, or congenital malformation and occurred in 61 (29%) pregnancies. Mothers with poor glycemic control pre-conceptually and at booking (HbA(1c)=7.5%) had almost a three-fold increase in adverse fetal outcome compared with mothers having fair control, odds ratio (OR) 2.59 (95% CI 1.11-6.03), and 2.71 (95% CI 1.39-5.28), respectively. Mothers who were still smoking at the booking visit had a two-fold increase in adverse fetal outcome (OR 2.12, 95% CI 1.09-4.10). Further improvement in the management of diabetes and pregnancy is needed through enhanced preconception services addressing the full spectrum of modifiable risk factors.

BACKGROUND Echocardiographic (echo) left ventricular hypertrophy (LVH) is an independent predictor of mortality. Despite this, screening for LVH in patients with overt cardiovascular diseases is not universally done. To help target echo screening for LVH in patient population, we developed and validated a simple clinical score to help identify those likely to have echo LVH. METHODS We performed two studies. The development cohort consisted of 267 patients with angina. The validation cohort consisted of 227 patients with peripheral arterial disease. RESULTS The prevalence of echo LVH in both patient cohorts was 50%. Six independent predictors of LVH were identified in the development cohort: age >65 years (1 point), body mass index >30 kg/m2 (1 point), history of hypertension (1 point), previous myocardial infarction (1 point), clinic blood pressure >130/80 mm Hg (1 point) and bundle branch block (BBB) on electrocardiogram (4 points). Our clinical score was strongly associated with the presence of LVH in the validation cohort. It also showed a significant continuous positive relationship (P trend

Summary Background Coeliac disease is more prevalent than was previously thought. The association between coeliac disease and cardiovascular outcome is not clear. Aim To investigate whether coeliac disease patients have an increased risk of cardiovascular events. Methods A community-based cohort study using a record-linkage database. Three hundred and sixty-seven coeliac patients identified by a positive antiendomysial antibody test or a diagnosis with small bowel biopsy, and 5537 subjects who were tested and had a negative coeliac immunology, were included in the study. Results The crude rates of cardiovascular events were 9.5 per 1000 person-years (95% CI: 4.4–14.6) in the coeliac cohort and 8.9 per 1000 person-years (95% CI: 7.6–10.3) in the antiendomysial antibody-negative cohort. Compared with the antiendomysial antibody-negative cohort, the adjusted relative risk of cardiovascular events for coeliac cohort was 1.9 (95% CI: 1.00–3.60). When we excluded patients who had previous hospitalization for cardiovascular disease, the adjusted relative risk was 2.5 (95% CI: 1.22–5.01). The use of any cardiovascular drugs prior to and after entry to the study were 36% and 29% for the coeliac cohort (P = 0.05), and 34% and 26% for the antiendomysial antibody-negative cohort (P

Objectives This study aims to examine the extent to which statins are used by adults at high risk of cardiovascular disease (CVD) compared to European clinical guidelines. The high-risk groups examined are those with (1) known CVD, (2) known diabetes and (3) a high or very high risk (≥5%) of CVD mortality based on Systematic COronary Risk Evaluation (SCORE). Design This study is cross-sectional in design using data from the first wave (2009–2011) of The Irish Longitudinal Study on Ageing (TILDA). Setting and participants The sample (n=3372) is representative of community living adults aged 50–64 years in Ireland. Results Statins were used by 68.6% (95% CI 61.5% to 75.8%) of those with known CVD, 57.4% (95% CI 49.1% to 65.7%) of those with known diabetes and by 19.7% (95% CI 13.0% to 26.3%) of adults with a SCORE risk ≥5%. Over a third (38.5%, 95% CI 31.0% to 46.0%) of those with known CVD, 46.8% (95% CI 38.4% to 55.1%) of those with known diabetes and 85.2% (95% CI 79.3% to 91.1%) of those with a SCORE risk ≥5% were at or above the low-density lipoprotein cholesterol (LDL-C) target of 2.5 mmol/L specified in the 2007 European guidelines. Conclusions Despite strong evidence and clinical guidelines recommending the use of statins for secondary prevention, a gap exists between guidelines and practice in this cohort. It is also of concern that a low proportion of adults with a SCORE risk ≥5% were taking statins. A policy response that strengthens secondary prevention, and improves risk assessment and shared decision-making in the primary prevention of CVD is required.

peer-reviewed Background: To establish the prevalence and patterns of prescribing to pregnant women in an Irish primary care setting. Methods: We reviewed electronic healthcare records routinely collected in primary care, of pregnant women attending nine Dublin-based General Practices affiliated to the Irish Primary Care Research Network (IPCRN) for antenatal care between January 2007 and October 2013 (n = 2,361 pregnancies). Results: Excluding folic acid, 46.8% (n = 1,104) of pregnant women were prescribed at least one medication. Amoxicillin (11.1%, n = 263) and co-amoxiclav (8.0%, n = 190) were the most commonly prescribed medication followed by topical clotrimazole (4.9%, n = 117), salbutamol inhalers (4.1%, n = 96) and paracetamol (4.0%, n = 95). General Medical Services (GMS) patients were more likely to receive a prescription than private patients (OR 2.81; 95%CI (2.28, 3.47)). We applied the US FDA pregnancy-risk categories as a proxy measure of prescribing appropriateness, with FDA Category D and X medications considered inappropriate. FDA Category D drugs were prescribed in 5.9% (n = 140) of pregnancies. FDA Category X drugs were prescribed in 4.9% (n = 116) of pregnancies but after exclusion of oral contraceptives, progestogens, infertility treatments Category X medications were prescribed in 0.6% (n = 13) of pregnancies. After the initial antenatal consultation the prescribing prevalence of FDA Category D medications reduced to 4.7% (n = 110) and Category X to 3.1% (n = 72). Conclusions: The overall prevalence of prescribing to pregnant women in our cohort is low compared to studies internationally, however similar levels of prescribing for FDA Category D and X were found. Following the initial antenatal consultation levels of prescribing of the FDA Category D and X medications reduced, however there is potential to further reduce their use in early pregnancy. The IPCRN database has provided valuable information on the current practice of antenatal prescribing within this pilot group of practices however it is limited by the absence of morbidity and pregnancy outcome data.

The bottom line Multimorbidity, commonly defined as the presence of two or more chronic medical conditions in an individual,1 is associated with decreased quality of life, functional decline, and increased healthcare utilisation, including emergency admissions, particularly with higher numbers of coexisting conditions.2 3 4 5 6 The management of multimorbidity with drugs is often complex, resulting in polypharmacy with its attendant risks.7 8 9 Patients with multimorbidity have a high treatment burden in terms of understanding and self managing the conditions, attending multiple appointments, and managing complex drug regimens.10 Qualitative research highlights the “endless struggle” patients experience in trying to manage their conditions well.11 Psychological distress is common: in an Australian survey of 7620 patients in primary care, 23% of those with one chronic condition reported depression compared with 40% of those with five or more conditions.12 #### Sources and selection criteria We based this article on the authors’ experience and information from published literature. We carried out searches of PubMed and the Cochrane library using the search terms “co-morbidity” or “comorbidity” or “multimorbid” or “multimorbidity” or “multi-morbidity”. No MeSH term exists for multimorbidity. The searches were supplemented by a review of authors’ personal archives as well as relevant articles from the International Research …

Spontaneous intracerebral hemorrhage (SICH) has a high morbidity and mortality and places a huge significant economic burden on health care and social services. The role of surgery is still controversial as evidenced by wide variation internationally in management of SICH. Traditional surgery for SICH involved open craniotomy with hematoma evacuation. Using available evidence, this article assesses the efficacy of stereotactic-guided evacuation compared with medical treatment.A systematic review was performed comparing stereotactic-guided evacuation of SICH with conservative medical management. Eligible studies were identified using a text word search of an electronic journal database for randomized controlled trials. Extracted data outcomes were subjected to meta-analysis with a forest plot. Quality was assessed using Cochrane risk of bias analysis tools.There were 5 studies with 740 patients. There was a nonsignificant reduction in odds ratio (OR) for death at the end of the follow-up period (OR = 0.74, 95% confidence interval = 0.45-1.21) with no significant heterogeneity. Nonsignificant benefits were observed for dependent survival (OR = 2.14, 95% confidence interval = 0.31-0.58). In the subgroup analysis, stereotactic evacuation showed improved outcomes in patients with hematoma volume50 mL. In this review, the effectiveness of stereotactic evacuation plus subsequent thrombolysis was insignificant (OR = 1.34, 95% confidence interval = 0.57-3.12).The outcome of patients who had stereotactic-guided evacuation of SICH was not better compared with patients who received medical treatment; however, there was a trend toward better quality of survival and chance of survival in the stereotactic-guided evacuation group. This study identified areas for further research.

To analyse the diagnostic value of simple clinical measurements in ensuring an early and accurate detection of advanced appendicitis (perforation, mass and peri-appendicular abscess) and possible complications. A retrospective, single-centre study of all paediatric (age 0–14 years) appendicectomies was conducted over a 14-year period. Preoperative symptoms, signs and laboratory results, intra-operative findings and postoperative complications were analyzed. Receiver operating characteristic (ROC) curves were used to estimate sensitivity and specificity of significant (p ≤ 0.05) predictor variables based on multivariate logistic regression models. One thousand and thirty-seven patients were included. Perforations were seen in 88 (8.5 %) cases, and abscesses were seen in 35 (3.4 %) cases. Of all the clinical variables evaluated, preoperative temperature ≥37.5 °C was most discriminatory for advanced appendicitis. Significant other discriminatory clinical variables were WBC count ≥15,100/μL, preoperative anorexia and rebound tenderness. Postoperative complications occurred in 74 (7.1 %) patients and were associated with pre-operative temperature ≥37.5 °C and advanced appendicitis. Independent clinical predictors of advanced appendicitis exist but lack individual accuracy. In this study, preoperative pyrexia is shown to be highly associated with both advanced appendicitis and development of postoperative complications. This independent factor may point to early need for antibiotic treatment, urgent imaging and subsequent intervention in patients with appendicitis.

Background. Patient preferences and expert-generated clinical practice guidelines regarding treatment decisions may not be identical. The authors compared the thresholds for antithrombotic treatment from studies that determined or modeled the treatment preferences of patients with atrial fibrillation with recommendations from clinical practice guidelines. Methods. Methods included MEDLINE identification, systematic review, and pooling with some reanalysis of primary data from relevant studies. Results. Eight pertinent studies, including 890 patients, were identified. These studies used 3 methods (decision analysis, probability tradeoff, and decision aids) to determine or model patient preferences. All methods highlighted that the threshold above which warfarin was preferred over aspirin was highly variable. In 6 of 8 studies, patient preferences indicated that fewer patients would take warfarin compared to the recommendations of the guidelines. In general, at a stroke rate of 1% with aspirin, half of the participants would prefer warfarin, and at a rate of 2% with aspirin, two thirds would prefer warfarin. In 3 studies, warfarin must provide at least a 0.9% to 3.0% per year absolute reduction in stroke risk for patients to be willing to take it, corresponding to a stroke rate of 2% to 6% on aspirin. Conclusions. For patients with atrial fibrillation, treatment recommendations from clinical practice guidelines often differ from patient preferences, with substantial heterogeneity in their individual preferences. Since patient preferences can have a substantial impact on the clinical decision-making process, acknowledgment of their importance should be incorporated into clinical practice guidelines. Practicing physicians need to balance the patient preferences with the treatment recommendations from clinical practice guidelines.

Background. Professional and parental uncertainty about the natural history of cough in preschool children may in part be responsible for the high consultation and reconsultation rates and widespread antibiotic use in primary care. A recent systematic review of the natural history of cough included studies of unrepresentative, selected patients with heterogeneous measures and definitions of cough duration. Objectives. The aim of the present study was to describe the post-consultation duration of cough, compare this with clinician and parental prediction of cough duration, and to determine the clinical factors associated with prolonged cough. Methods. A prospective cohort study of children aged 0‐4 years with cough � 28 days without asthma presenting to eight general practices in Leicestershire, UK was carried out. Sociodemographic and clinical data were collected, and parents and clinicians were asked to predict the proportion recovering within 7, 14, 21 and 28 days. Parents used a symptom diary to record cough and five other symptoms. Survival analysis was used to describe cough duration, and multivariable Cox regression was used to identify the factors independently associated with prolonged cough. Results. Fifty percent of the children had recovered at 10 days and 90% at 25 days. Cough was associated with fever, breathlessness, disrupted sleep and reduced activity in a high proportion of children. Longer post-consultation cough was associated with longer pre-consultation cough and use of day care facilities. Clinicians overestimated how quickly children recovered from acute cough. Parents’ predictions were accurate within 2 weeks, but they underestimated the proportion recovering in weeks 3 and 4. Conclusions. Clinicians should be aware that from the parental perspective, acute cough is not a trivial illness and that some children remain unwell at 3‐4 weeks. For health professionals negotiating the use of antibiotics, this information may enable parental self-care, reduce medicalization and displace the need to prescribe.

Objectives Malignant melanoma has high morbidity and mortality rates. Early diagnosis improves prognosis. Clinical prediction rules (CPRs) can be used to stratify patients with symptoms of suspected malignant melanoma to improve early diagnosis. We conducted a systematic review of CPRs for melanoma diagnosis in ambulatory care. Design Systematic review. Data sources A comprehensive search of PubMed, EMBASE, PROSPERO, CINAHL, the Cochrane Library and SCOPUS was conducted in May 2015, using combinations of keywords and medical subject headings (MeSH) terms. Study selection and data extraction Studies deriving and validating, validating or assessing the impact of a CPR for predicting melanoma diagnosis in ambulatory care were included. Data extraction and methodological quality assessment were guided by the CHARMS checklist. Results From 16 334 studies reviewed, 51 were included, validating the performance of 24 unique CPRs. Three impact analysis studies were identified. Five studies were set in primary care. The most commonly evaluated CPRs were the ABCD, more than one or uneven distribution of Colour, or a large (greater than 6 mm) Diameter (ABCD) dermoscopy rule (at a cut-point of >4.75; 8 studies; pooled sensitivity 0.85, 95% CI 0.73 to 0.93, specificity 0.72, 95% CI 0.65 to 0.78) and the 7-point dermoscopy checklist (at a cut-point of ≥1 recommending ruling in melanoma; 11 studies; pooled sensitivity 0.77, 95% CI 0.61 to 0.88, specificity 0.80, 95% CI 0.59 to 0.92). The methodological quality of studies varied. Conclusions At their recommended cut-points, the ABCD dermoscopy rule is more useful for ruling out melanoma than the 7-point dermoscopy checklist. A focus on impact analysis will help translate melanoma risk prediction rules into useful tools for clinical practice.