Andy Meal

Sex inequalities in ischaemic heart disease in general practice: cross sectional survey

Abstract Objective: To study differences in treatment for men and women with ischaemic heart disease by using standards defined in Englands national service framework for coronary artery disease. Design: Cross sectional survey using routinely collected data. Setting: 18 practices in 18 primary care groups in Trent Region. Subjects: 5891 men and women aged over 35 years with a diagnosis of ischaemic heart disease or prescription for nitrates recorded on computer. Main outcome measure: Difference in the proportion of men and women with ischaemic heart disease and taking lipid lowering treatment. Results: Women were less likely than men to have a recording of body mass index (79% (2197/2783) v 82% (2552/3102), P=0.002), smoking (86% (2386) v 89% (2779), P<0.0001), and blood pressure (95% (2643) v 96% (2986), P=0.04). Women were also less likely to have a recording of fasting cholesterol concentration (35% (968) v 50% (1550), P<0.0001) but were more likely to be obese (25% (558/2197) v 20% (514/2552), P<0.0001) and have their most recently recorded blood pressure value over the recommended 140/85 mm Hg (60% (1598/2643) v 52% (1553/2986), P<0.0001). Although a higher proportion of women had a raised serum cholesterol concentration (77% (749/968) v 67% (1043/1550), P<0.0001), men were more likely to take aspirin (76% (2358) v 71% (1979), P<0.0001), have a recorded diagnosis of hyperlipidaemia (13% (418) v 10% (274), P<0.0001), and be prescribed lipid lowering drugs (31% (973) v 21% (596), P<0.0001). These differences remained despite adjustments for the practice where the patient is registered, age, smoking status, obesity, diabetes, and hypertension. Conclusion: The results suggest a systematic bias towards men compared with women in terms of secondary prevention of ischaemic heart disease. What is already known on this topic Englands national service framework for coronary artery disease requires general practitioners to identify and treat patients at high risk of ischaemic heart disease Substantial evidence of sex inequality for this disease exists for access to secondary care less but less is known about equity for its management in general practice What this study adds Among patients with ischaemic heart disease, men were more likely than women to have cardiovascular risk factors and serum cholesterol concentration recorded on computer A higher proportion of women, however, had raised cholesterol concentrations recorded on computer, but more men were treated with lipid lowering drugs The results suggest a systematic bias towards men compared with women in terms of secondary prevention of ischaemic heart disease.

Trends in incidence of skin basal cell carcinoma. Additional evidence from a UK primary care database study.

We determined the trends in incidence of skin basal cell carcinoma (BCC) using a primary care population‐based cohort study in the UK. 11,113 adults with a BCC diagnosis were identified from a total of 7.22 million person‐years of data between 1996 and 2003 from the Health Improvement Network database. From a random subsample of BCC cases identified from the database, 93% were confirmed by hospital letter and/or pathology report. The incidence of BCC was 153.9 per 100,000 person‐years (95% CI 151.1, 156.8) and was slightly higher in men as compared to women (Incidence Rate Ratio 1.10, 95% CI 1.06, 1.14). There was a 3% increase year on year across the study period (IRR 1.03, 95% CI 1.01, 1.04), with the largest increase in incidence seen in the 30–39 year age groups, although this did not reach statistical significance. Our study indicates 53,000 new cases of BCC are estimated every year in the UK and figures are continuing to rise on a yearly basis. Incidence rates are highest for men and in particular in the older age categories. These findings are consistent with those reported for various other populations. We have also found an increase in incidence in ages 30–39, which may suggest a cohort effect of increasing ultraviolet exposure in successive younger generations. This may have a huge public and service impact in future years in countries such as the UK, with predominantly fair‐skinned population, with high leisure exposure to ultraviolet light. Our findings underline the need for more elaborate preventive measures.

Antidepressants as risk factor for ischaemic heart disease: case-control study in primary care.

Abstract Objectives: To determine whether antidepressants are a risk factor for ischaemic heart disease and to compare the risk for different subgroups of antidepressants and individual antidepressants. Design: Case-control study. Setting: Nine general practices recruited from the Trent Focus Collaborative Research Network. Participants: 933 men and women with ischaemic heart disease matched by age, sex, and practice to 5516 controls. Main outcome measure: Adjusted odds ratio for ischaemic heart disease calculated by logistic regression. Results: Odds ratios for ischaemic heart disease were significantly raised for patients who had ever received a prescription for tricyclic antidepressants even after diabetes, hypertension, smoking, body mass index, and use of selective serotonin reuptake inhibitors had been adjusted for (1.56; 95% confidence interval 1.18 to 2.05). Patients who had ever taken dosulepin (dothiepin) had a significantly raised odds ratio for ischaemic heart disease after adjustment for confounding factors and use of other antidepressants (1.67, 1.17 to 2.36). There was no significant increase in the odds ratios for amitriptyline, lofepramine, and selective serotonin reuptake inhibitors in multivariate analysis. Increasing maximum doses of dosulepin were associated with increasing odds ratios for ischaemic heart disease. Similarly, there was a significant positive trend associated with increasing numbers of prescriptions of dosulepin (adjusted odds ratio 1.52 for 1 prescription, 1.39 for 2-3, and 1.96 for ≥4, P<0.002). Conclusion: There is good evidence for an association between dosulepin and subsequent ischaemic heart disease and for a dose-response relation. What is already known on this topic Over 45% of patients in hospital after myocardial infarction have depression Depression is an independent risk factor for increased mortality and morbidity after myocardial infarction What this study adds Patients who had ever taken dosulepin (dothiepin) had significantly increased risk of ischaemic heart disease after confounding factors had been adjusted for The association followed a dose-response relation The effect of other antidepressants was not significant after adjustment for confounders

Critical realist review: exploring the real, beyond the empirical

This article defines the ‘critical realist review’, a literature-based methodological approach to critical analysis of health care studies (or any discipline charged with social interventions) that is robust, insightful and essential for the complexities of twenty-first century evidence-based health and social care. We argue that this approach, underpinned by a critical realist philosophy and methodology, will facilitate students and researchers to employ relevant theoretical insights from a range of disciplines that have necessary contributions to make to our understanding of health and social care practice and provision. We explore the limitations of randomised controlled trials (RCTs) and the systematic review for informing evidence-based health and social care. The article also offers some suggestions on method, although, as we argue, the approach deliberately eschews a ‘cookbook’ approach. A glossary of terms is provided in the Appendix.

The use of posters in the teaching of biological sciences on an undergraduate nursing course

Posters are commonly used at research conferences for communicating information and in education as an alternative way of teaching and assessing students. We report the use of posters as a means of teaching and assessing part of the biological sciences component of an undergraduate nursing course. Tutors felt it was a valuable exercise enabling students to develop a number of skills, alongside the learning and revision of knowledge, including working as a team, condensing information and word and graphic processing. Students evaluated the exercise as being challenging but rewarding and preferred to be assessed by this method than by oral presentations or examinations. Lecturers and guided study/tutorials were preferred to posters as teaching methods.

Glargine and degludec: solution behaviour of higher dose synthetic insulins

Single, double and triple doses of the synthetic insulins glargine and degludec currently used in patient therapy are characterised using macromolecular hydrodynamic techniques (dynamic light scattering and analytical ultracentrifugation) in an attempt to provide the basis for improved personalised insulin profiling in patients with diabetes. Using dynamic light scattering and sedimentation velocity in the analytical ultracentrifuge glargine was shown to be primarily dimeric under solvent conditions used in current formulations whereas degludec behaved as a dihexamer with evidence of further association of the hexamers (“multi-hexamerisation”). Further analysis by sedimentation equilibrium showed that degludec exhibited reversible interaction between mono- and-di-hexamer forms. Unlike glargine, degludec showed strong thermodynamic non-ideality, but this was suppressed by the addition of salt. With such large injectable doses of synthetic insulins remaining in the physiological system for extended periods of time, in some case 24–40 hours, double and triple dose insulins may impact adversely on personalised insulin profiling in patients with diabetes.

Being human: Transdisciplinarity in nursing

Nursing as an academic discipline typically draws on a wide range of other disciplines. There is debate about whether this is a sound basis for the discipline, or whether nursing needs to develop a distinctive body of knowledge. The concept of transdisciplinarity, though little discussed in nursing, is of considerable value in understanding nursing as an academic discipline, and provides a possible resolution to the debate above. In order to get a better understanding of what transdisciplinarity might mean in a nursing context, we conducted a qualitative interview-based study of faculty in a UK school of nursing. The debate about nursing’s status as a discipline was reproduced by the interviewees. Despite these differences, a degree of consensus emerged about the concept of nursing as a transdisciplinary discipline. Transdisciplinarity in nursing offers an overarching approach that is applicable to a broader range of disciplines. This approach offers the possibility of moving beyond some of the major debates in nursing as an academic discipline. This broad and pragmatic approach grounds nursing knowledge in nursing practice, which means that as a transdisciplinary discipline it does not overstate its claims to knowledge, but instead explicitly acknowledges tacit and ‘craftsmanship’-type forms of knowledge.

Characterisation of insulin analogues therapeutically available to patients

The structure and function of clinical dosage insulin and its analogues were assessed. This included ‘native insulins’ (human recombinant, bovine, porcine), ‘fast-acting analogues’ (aspart, glulisine, lispro) and ‘slow-acting analogues’ (glargine, detemir, degludec). Analytical ultracentrifugation, both sedimentation velocity and equilibrium experiments, were employed to yield distributions of both molar mass and sedimentation coefficient of all nine insulins. Size exclusion chromatography, coupled to multi-angle light scattering, was also used to explore the function of these analogues. On ultracentrifugation analysis, the insulins under investigation were found to be in numerous conformational states, however the majority of insulins were present in a primarily hexameric conformation. This was true for all native insulins and two fast-acting analogues. However, glargine was present as a dimer, detemir was a multi-hexameric system, degludec was a dodecamer (di-hexamer) and glulisine was present as a dimer-hexamer-dihexamer system. However, size-exclusion chromatography showed that the two hexameric fast-acting analogues (aspart and lispro) dissociated into monomers and dimers due to the lack of zinc in the mobile phase. This comprehensive study is the first time all nine insulins have been characterised in this way, the first time that insulin detemir have been studied using analytical ultracentrifugation and the first time that insulins aspart and glulisine have been studied using sedimentation equilibrium. The structure and function of these clinically administered insulins is of critical importance and this research adds novel data to an otherwise complex functional physiological protein.

Outcomes of mindfulness-based stress reduction and mindfulness-based cognitive therapy in adults with diabetes: a systematic review

Objectives: Diabetes Mellitus (DM) is a global and progressive chronic medical condition with increasing prevalence and associated costs throughout the world. Psychological problems are common in people with DM and when they co-occur are associated with negative patient and societal outcomes. Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) were to be effective in treating a variety of psychological problems in various health conditions. Thus, using MBSR and MBCT in DM patients may help alleviate psychological problems of anxiety and depression and improve glycaemic control as a result. In this systematic review, we investigated the effectiveness of MBSR and MBCT in improving glycaemic control, anxiety and depression in adults with DM. Interventions: Randomised-Controlled Trials (RCTs) and Pilot Studies (RCPS) evaluated the effectiveness of MBSR or MBCT. Electronic searches were carried out of the following databases CINAHL, CENTRAL, EMBASE, MEDLINE, PsycINFO, PubMed, and ongoing clinical trials websites. Main outcomes: This research examined the effectiveness of MBSR and MBCT on depression, anxiety and glycaemic control in adults with T1DM or T2DM. Results: Research evidence has shown that patients with mental illnesses such as schizophrenia and anxiety disorders have a higher risk of developing DM than the general population. Explicitly, evidence indicates that the prevalence of psychological problems is much higher than in the general population and globally, with a two-fold increase in the prevalence of depression and anxiety in DM patients. 3 RCTs and 1 RCPS found a total of 365 participants. Narrative and data synthesis indicated significant reduction in levels of anxiety and depression at short-term and long-term time points. However, no significant effect on glycaemic control was established. MBSR and MBCT are feasible and efficacious methods for depression and anxiety treatment in adults with T1DM or T2DM.

A systematic review and meta-analysis of patient education in preventing and reducing the incidence or recurrence of adult diabetes foot ulcers (DFU)

Background The World Health Organization (WHO) states that diabetic foot ulcers (DFU) are associated with disability, death among patients with diabetes and substantial costs, if not prevented or managed effectively. The aim here is to examine the effectiveness of patient education in preventing and reducing the incidence or recurrence of adult DFU and amputation. Methods A systematic review and meta-analysis of randomised clinical trials (RCTs) in adults aged 18+ who have diabetes mellitus (type 1 or type 2) or DFU. CINAHL, EMBASE, MEDLINE, PSYCINFO, Cochrane Library and Evidence-Based Nursing, National Library for Health, Medica and Google Scholar were searched. Only English language studies were considered. Databases were searched from their inception to September 2017. Findings Six RCTs met the inclusion criteria. Only five RCTs reported on the incidence of DFU whilst only two reported on amputation rates. There was no advantage of combining different educational approaches in preventing/reducing DFU, relative risk (RR) of 0.50 (95%CI 0.21, 1.17) (P = 0.11). Two RCTs based on foot care education alone were compared with usual care; the result showed a non-significant effect (P = 0.57) with high heterogeneity of 77%. Analysis based on intensive versus brief educational approach showed a statistically reduced risk of incidence of DFU in the intervention group when compared to the control group; (RR, 0.37, 95%CI 0.14, 1.01) (P = 0.05) with high heterogeneity of 91%. Interpretation The intensive educational intervention was associated with reduced incidence of DFU.