Exploring the equity of GP practice prescribing rates for selected coronary heart disease drugs: a multiple regression analysis with proxies of healthcare need

Background There is a small, but growing body of literature highlighting inequities in GP practice prescribing rates for many drug therapies. The aim of this paper is to further explore the equity of prescribing for five major CHD drug groups and to explain the amount of variation in GP practice prescribing rates that can be explained by a range of healthcare needs indicators (HCNIs). Methods The study involved a cross-sectional secondary analysis in four primary care trusts (PCTs 1–4) in the North West of England, including 132 GP practices. Prescribing rates (average daily quantities per registered patient aged over 35 years) and HCNIs were developed for all GP practices. Analysis was undertaken using multiple linear regression. Results Between 22–25% of the variation in prescribing rates for statins, beta-blockers and bendrofluazide was explained in the multiple regression models. Slightly more variation was explained for ACE inhibitors (31.6%) and considerably more for aspirin (51.2%). Prescribing rates were positively associated with CHD hospital diagnoses and procedures for all drug groups other than ACE inhibitors. The proportion of patients aged 55–74 years was positively related to all prescribing rates other than aspirin, where they were positively related to the proportion of patients aged >75 years. However, prescribing rates for statins and ACE inhibitors were negatively associated with the proportion of patients aged >75 years in addition to the proportion of patients from minority ethnic groups. Prescribing rates for aspirin, bendrofluazide and all CHD drugs combined were negatively associated with deprivation. Conclusion Although around 25–50% of the variation in prescribing rates was explained by HCNIs, this varied markedly between PCTs and drug groups. Prescribing rates were generally characterised by both positive and negative associations with HCNIs, suggesting possible inequities in prescribing rates on the basis of ethnicity, deprivation and the proportion of patients aged over 75 years (for statins and ACE inhibitors, but not for aspirin)

The systematic guideline review: method, rationale, and test on chronic heart failure

Background: Evidence-based guidelines have the potential to improve healthcare. However, their de-novo-development requires substantial resources-especially for complex conditions, and adaptation may be biased by contextually influenced recommendations in source guidelines. In this paper we describe a new approach to guideline development-the systematic guideline review method (SGR), and its application in the development of an evidence-based guideline for family physicians on chronic heart failure (CHF). Methods: A systematic search for guidelines was carried out. Evidence-based guidelines on CHF management in adults in ambulatory care published in English or German between the years 2000 and 2004 were included. Guidelines on acute or right heart failure were excluded. Eligibility was assessed by two reviewers, methodological quality of selected guidelines was appraised using the AGREE instrument, and a framework of relevant clinical questions for diagnostics and treatment was derived. Data were extracted into evidence tables, systematically compared by means of a consistency analysis and synthesized in a preliminary draft. Most relevant primary sources were re-assessed to verify the cited evidence. Evidence and recommendations were summarized in a draft guideline. Results: Of 16 included guidelines five were of good quality. A total of 35 recommendations were systematically compared: 25/35 were consistent, 9/35 inconsistent, and 1/35 un-rateable (derived from a single guideline). Of the 25 consistencies, 14 were based on consensus, seven on evidence and four differed in grading. Major inconsistencies were found in 3/9 of the inconsistent recommendations. We re-evaluated the evidence for 17 recommendations (evidence-based, differing evidence levels and minor inconsistencies) - the majority was congruent. Incongruity was found where the stated evidence could not be verified in the cited primary sources, or where the evaluation in the source guidelines focused on treatment benefits and underestimated the risks. The draft guideline was completed in 8.5 man-months. The main limitation to this study was the lack of a second reviewer. Conclusion: The systematic guideline review including framework development, consistency analysis and validation is an effective, valid, and resource saving-approach to the development of evidence-based guidelines

Eating for 1, Healthy and Active for 2; feasibility of delivering novel, compact training for midwives to build knowledge and confidence in giving nutrition, physical activity and weight management advice during pregnancy

Gold OABackground: Women in Wales are more likely to be obese in pregnancy than in any other United Kingdom (UK) country. Midwives are ideally placed to explore nutrition, physical activity and weight management concerns however qualitative studies indicate they lack confidence in raising the sensitive issue of weight. Acknowledging this and the reality of finite time and resources, this study aimed to deliver compact training on nutrition, physical activity and weight management during pregnancy to increase the knowledge and confidence of midwives in this subject. Methods A compact training package for midwives was developed comprising of evidence based nutrition, physical activity and weight management guidance for pregnancy. Training was promoted via midwifery leads and delivered within the Health Board. Questionnaires based on statements from national public health guidance were used to assess changes in self-reported knowledge and confidence pre and post training. Descriptive statistics were applied and 95% confidence intervals were calculated. Results 43 midwives registered for training, 32 (74%) attended and completed the questionnaires. Although, pre training knowledge and confidence varied between participants, statistically significant improvements in self-reported knowledge and confidence were observed post training. 97% indicated knowledge of pregnancy specific food and nutrition messages as ‘better’ (95% CI 85 to 100), as opposed to 3% stating ‘stayed the same’ – 60% stated ‘much better’. 83% indicated confidence to explain the risks of raised BMI in pregnancy was either ‘much’ or ‘somewhat better’ (95% CI 66 to 93), as opposed to 17% stating ‘stayed the same’. 89% indicated confidence to discuss eating habits and physical activity was ‘much’ or ‘somewhat better’ (95% CI 73 to 97) as opposed to 11% stating ‘stayed the same’. Emergent themes highlighted that training was positively received and relevant to midwifery practice. Conclusions This study provides early indications that a compact nutrition, physical activity and weight management training package improves midwives self-reported knowledge and confidence. Cascading training across the midwifery service in the Health Board and conducting further studies to elicit longer term impact on midwifery practice and patient outcomes are recommended

Understanding resilience of female adolescents towards teenage pregnancy: a cross-sectional survey in Dar es Salaam, Tanzania

Abstract Background In Tanzania, teenage pregnancy rates are still high despite the efforts being made to reduce them. Not enough is known about how adolescents experience and cope with sexuality and teenage pregnancy. Over the past few decades, most studies have focused on vulnerability and risk among youth. The concept of ‘reproductive resilience’ is a new way of looking at teenage pregnancy. It shifts the perspective from a deficit-based to a strength-based approach. The study presented here aimed to identify factors that could contribute to strengthening the reproductive resilience of girls in Dar es Salaam, Tanzania. Methods Using a cross-sectional cluster sampling approach, 750 female adolescents aged 15–19 years were interviewed about how they mobilize resources to avoid or deal with teenage pregnancy. The main focus of the study was to examine how social capital (relations with significant others), economic capital (command over economic resources), cultural capital (personal dispositions and habits), and symbolic capital (recognition and prestige) contribute to the development of adolescent competencies for avoiding or dealing with teenage pregnancy and childbirth. Results A cumulative competence scale was developed to assess reproductive resilience. The cumulative score was computed based on 10 competence indicators that refer to the re- and pro-active mobilization of resources. About half of the women who had never been pregnant fell into the category, ‘high competence’ (50.9%), meaning they could get the information and support needed to avoid pregnancies. Among pregnant women and young mothers, most were categorized as ‘high competence’ (70.5%) and stated that they know how to avoid or deal with health problems that might affect them or their babies, and could get the information and support required to do so. Cultural capital, in particular, contributed to the competence of never-pregnant girls [OR = 1.80, 95% CI = 1.06 to 3.07, p = 0.029], pregnant adolescents and young mothers [OR = 3.33, 95% CI = 1.15 to 9.60, p = 0.026]. Conclusions The reproductive resilience framework provides new insights into the reproductive health realities of adolescent girls from a strength-based perspective. While acknowledging that teenage pregnancy has serious negative implications for many female adolescents, the findings presented here highlight the importance of considering girls’ capacities to prevent or deal with teenage pregnancy

The implications of climate change for the water environment in England

This paper reviews the implications of climate change for the water environment and its management in England. There is a large literature, but most studies have looked at flow volumes or nutrients and none have considered explicitly the implications of climate change for the delivery of water management objectives. Studies have been undertaken in a small number of locations. Studies have used observations from the past to infer future changes, and have used numerical simulation models with climate change scenarios. The literature indicates that climate change poses risks to the delivery of water management objectives, but that these risks depend on local catchment and water body conditions. Climate change affects the status of water bodies, and it affects the effectiveness of measures to manage the water environment and meet policy objectives. The future impact of climate change on the water environment and its management is uncertain. Impacts are dependent on changes in the duration of dry spells and frequency of ‘flushing’ events, which are highly uncertain and not included in current climate scenarios. There is a good qualitative understanding of ways in which systems may change, but interactions between components of the water environment are poorly understood. Predictive models are only available for some components, and model parametric and structural uncertainty has not been evaluated. The impacts of climate change depend on other pressures on the water environment in a catchment, and also on the management interventions that are undertaken to achieve water management objectives. The paper has also developed a series of consistent conceptual models describing the implications of climate change for pressures on the water environment, based around the source-pathway-receptor concept. They provide a framework for a systematic assessment across catchments and pressures of the implications of climate change for the water environment and its management

First measurement of the Hubble Constant from a Dark Standard Siren using the Dark Energy Survey Galaxies and the LIGO/Virgo Binary–Black-hole Merger GW170814

International audienceWe present a multi-messenger measurement of the Hubble constant H 0 using the binary–black-hole merger GW170814 as a standard siren, combined with a photometric redshift catalog from the Dark Energy Survey (DES). The luminosity distance is obtained from the gravitational wave signal detected by the Laser Interferometer Gravitational-Wave Observatory (LIGO)/Virgo Collaboration (LVC) on 2017 August 14, and the redshift information is provided by the DES Year 3 data. Black hole mergers such as GW170814 are expected to lack bright electromagnetic emission to uniquely identify their host galaxies and build an object-by-object Hubble diagram. However, they are suitable for a statistical measurement, provided that a galaxy catalog of adequate depth and redshift completion is available. Here we present the first Hubble parameter measurement using a black hole merger. Our analysis results in , which is consistent with both SN Ia and cosmic microwave background measurements of the Hubble constant. The quoted 68% credible region comprises 60% of the uniform prior range [20, 140] km s−1 Mpc−1, and it depends on the assumed prior range. If we take a broader prior of [10, 220] km s−1 Mpc−1, we find (57% of the prior range). Although a weak constraint on the Hubble constant from a single event is expected using the dark siren method, a multifold increase in the LVC event rate is anticipated in the coming years and combinations of many sirens will lead to improved constraints on H 0

Impact of Chlamydia trachomatis in the reproductive setting: British Fertility Society Guidelines for practice

Chlamydia trachomatis infection of the genital tract is the most common sexually transmitted infection and has a world-wide distribution. The consequences of infection have an adverse effect on the reproductive health of women and are a common cause of infertility. Recent evidence also suggests an adverse effect on male reproduction. There is a need to standardise the approach in managing the impact of C. trachomatis infection on reproductive health. We have surveyed current UK practice towards screening and management of Chlamydia infections in the fertility setting. We found that at least 90% of clinicians surveyed offered screening. The literature on this topic was examined and revealed a paucity of solid evidence for estimating the risks of long-term reproductive sequelae following lower genital tract infection with C. trachomatis. The mechanism for the damage that occurs after Chlamydial infections is uncertain. However, instrumentation of the uterus in women with C. trachomatis infection is associated with a high risk of pelvic inflammatory disease, which can be prevented by appropriate antibiotic treatment and may prevent infected women from being at increased risk of the adverse sequelae, such as ectopic pregnancy and tubal factor infertility. Recommendations for practice have been proposed and the need for further studies is identified

GW170104: Observation of a 50-Solar-Mass Binary Black Hole Coalescence at Redshift 0.2

We describe the observation of GW170104, a gravitational-wave signal produced by the coalescence of a pair of stellar-mass black holes. The signal was measured on January 4, 2017 at 10: 11: 58.6 UTC by the twin advanced detectors of the Laser Interferometer Gravitational-Wave Observatory during their second observing run, with a network signal-to-noise ratio of 13 and a false alarm rate less than 1 in 70 000 years. The inferred component black hole masses are 31.2(-6.0)(+8.4)M-circle dot and 19.4(-5.9)(+5.3)M(circle dot) (at the 90% credible level). The black hole spins are best constrained through measurement of the effective inspiral spin parameter, a mass-weighted combination of the spin components perpendicular to the orbital plane, chi(eff) = -0.12(-0.30)(+0.21) . This result implies that spin configurations with both component spins positively aligned with the orbital angular momentum are disfavored. The source luminosity distance is 880(-390)(+450) Mpc corresponding to a redshift of z = 0.18(-0.07)(+0.08) . We constrain the magnitude of modifications to the gravitational-wave dispersion relation and perform null tests of general relativity. Assuming that gravitons are dispersed in vacuum like massive particles, we bound the graviton mass to m(g) <= 7.7 x 10(-23) eV/c(2). In all cases, we find that GW170104 is consistent with general relativity

Influence of compost on the physical properties and organic matter fractions of a fine sandy loam throughout the cycle of a potato rotation

. 2004. Influence of compost on the physical properties and organic matter fractions of a fine sandy loam throughout the cycle of a potato rotation. Can. J. Soil Sci. 84: 211-218. Potato (Solanum tuberosum L.) rotations often require organic amendments to maintain or improve soil organic matter levels and soil physical properties. However, beneficial effects of compost can be modified by time of application and rotating tillage depth and intensity. This study was conducted to evaluate the effect of compost applied once at different phases in a 3-yr potato, barley (Hordeum vulgare L.), and red clover (Trifolium pretense L.) rotation on a range of soil physical properties and organic matter fractions for a Charlottetown fine sandy loam (Orthic Humo-Ferric Podzol) in Prince Edward Island. Soil samples (0-8 cm) were obtained during the second cycle of the rotation (after two compost applications) in the fifth year of the experiment. Soil properties were influenced by compost addition, time of compost addition, and crop phase. Compost-induced benefits in soil physical properties (bulk density, macro-porosity, oxygen diffusion rate, shear vane strength, water-filled pore space) were mainly expressed in the red clover phase of the rotation, where soil density was relatively high compared to the barley and potato phases, due to the absence of tillage. The soil physical parameters, however, were mainly within their established optimum ranges for this soil type. Soil water content at -0.033 MPa was increased by compost in the potato phase, compared to the control. Soil organic matter was influenced by both compost and crop C inputs. Compost increased soil particulate organic matter (POM) in the potato and barley phases. Due to differences in crop residue inputs, compost-related differences in organic matter were minimized in the red clover phase of the rotation. Compost addition increased potato tuber yield above the maximum yield obtained with nitrogen application. This "non-nitrogen" compost yield effect may be related to the slight, but significant, improvement in soil water-holding capacity. Overall, compost application in an intensive 3-yr potato rotation provided benefits for potato productivity and in both soil physical and biological properties. 211-218. Les assolements avec pomme de terre (Solanum tuberosum L.) exigent souvent des amendements organiques pour que le sol garde ou améliore la quantité de matière organique et ses propriétés physiques. Toutefois, le moment de l'application ainsi que la profondeur et l'intensité des labours peuvent modifier les avantages du compost. La présente étude devait préciser les conséquences de l'application de compost à divers moments lors d'un assolement de trois ans incluant la pomme de terre, l'orge (Hordeum vulgare L.) et le trèfle rouge (Trifolium pratense L.) sur diverses propriétés physiques du sol et sur les fractions de la matière organique dans un fin loam sablonneux Charlottetown (podzol orthique humo-ferrique) de l'Île-du-Prince-Édouard. Les auteurs ont prélevé des échantillons (de 0 à 8 cm de profondeur) pendant la deuxième partie de l'assolement (après deux applications de compost), la cinquième année de l'expérience. L'addition de compost, le moment où l'on ajoute ce dernier et le type de culture exercent une influence sur les propriétés du sol. Les propriétés physiques (masse volumique apparente, proportion de pores macroscopiques, taux de diffusion de l'oxygène, résistance au soc de charrue, proportion de pores remplis d'eau) qu'améliore le compost se remarquent surtout durant la culture du trèfle rouge, où le sol est relativement plus compact que durant la culture de la pomme de terre ou de l'orge, parce qu'il n'y a pas eu labour. Les paramètres physiques du sol restent néanmoins à l'intérieur de leur fourchette optimale pour ce type de sol. L'addition de compost lors de la culture de la pomme de terre porte la teneur en eau du sol à -0,033 MPa comparativement au sol témoin. La concentration de matière organique subit l'influence du compost et du C apporté par la culture. Le compost augmente la concentration de particules de matière organiques lors de la culture de la pomme de terre et de l'orge. La diversité des déchets de culture a minimisé la variation de la concentration de matière organique attribuable au compost durant la culture du trèfle rouge. L'addition de compost porte le rendement de tubercules de pommes de terre au-delà du rendement maximal obtenu avec l'application d'un engrais azoté. Cet effet pourrait résulter de la légère mais significative amélioration de la capacité de rétention de l'eau attribuable au compost. En général, l'application de compost dans le cadre d'une rotation intensive de trois ans se traduit par des avantages au niveau de la productivité et des propriétés physiques et biologiques du sol. For personal use only