Effective UK weight management services for adults

A number of evidence-based weight management interventions are now available with different models, and serving different patient/client groups. While positive outcomes are key to the decision making process, so too is the information around how these outcomes were achieved, in what population, how transferable the outcomes would be to the population a service would be aiming to cover and at what cost to the service-provider and or the individual. This paper examines all the UK interventions with recent peer-reviewed evidence of their effectiveness in “realistic” settings and cost-effectiveness, in the context of NICE and SIGN guidelines. It concludes that the evidence-based approaches allow intervention at different stages in the disease-process of obesity which are effective in different settings. Self-referral to commercial agencies, by individuals with relatively low BMI and few medical complications is a reasonable first step. For more severely obese individuals (e.g. BMI >35kg/m2) requiring more medically complicated care, evidence is largely lacking for these services, but the community-based Counterweight Programme is effective and cost-effective in maintaining weight loss >5kg up to 2 years for 30-40% of attenders. For more complicated and resistant obesity, referral to a secondary care-based service can generate short-term weight loss, but 12 months data are unavailable

American Sign Language Club

The purpose of American Sign Language (ASL) Club is to get club members comfortable with signing an introduction of why they are and where they come from in order to feel prepared to engage in conversation with deaf or hard of hearing people

Predictors of Cardiac Rehabilitation Utilization in England: Results From the National Audit

Background-—Cardiac rehabilitation (CR) is grossly underused, with major inequities in access. However, use of CR and predictors of initiation in England where CR contracting is available is unknown. The aims were (1) to investigate CR utilization rates in England, and (2) to determine sociodemographic and clinical factors associated with CR initiation including social deprivation. Methods and Results-—Data from the National Audit of CR, between January 2012 and November 2015, were used. Utilization rates overall and by deprivation quintile were derived. Logistic regression was performed to identify predictors of initiation among enrollees,using the Huber–White–sandwich estimator robust standard errors method to account for the nested nature of the data. Of the 234 736 (81.5%) patients referred to CR, 141 648 enrolled, 97 406 initiated CR, and of those initiating, 37.2% completed a program of ≥8 weeks duration. The significant characteristics associated with CR initiation were younger age (odds ratio [OR] 0.98, 95% CI 0.98–0.99), having a partner (OR 1.31, 95% CI 1.17–1.48), not being employed (OR 0.86, 95% CI 0.77–0.96), not having diabetes mellitus (OR 0.84, 95% CI 0.77–0.92), greater anxiety (OR 1.02, 95% CI 1.003–1.04), not being a medically managed myocardial infarction patient (OR 0.57, 95% CI 0.42–0.76), and having had coronary artery bypass graft surgery (OR 1.64, 95% CI 1.09–2.47). Conclusions-—CR enrollment does not meet English National Health Service targets; however it compares with that in other countries. Evidence-based approaches increasing CR enrollment and initiation should be applied, focusing on the identified characteristics associated with CR initiation, specifically older, single, employed individuals with diabetes mellitus and those not revascularized

Preliminary evaluation of the performance of a new highly sensitive commercial immunoassay for serum ferritin determination

We evaluated the analytical performance of a new, commercial, fully automated immunoturbidimetric assay for the determination of ferritin [FERLatex(X2)CN SEIKEN, Denka Seiken, Japan] in serum on the Olympus AU2700 analyzer. The new assay is a latex-enhanced turbidimetric immunoassay with an analysis time of 10 min. The linearity of the assay was confirmed up to 2505 pmol/L (R-2 =0.999). The detection limit and the functional sensitivity were both 4.5 pmol/L. The intra- and inter-assay imprecision (CV) at 67, 506, 2186 pmol/L was < 1.8% and < 2.5%, respectively. Verification of the traceability to a WHO standard (80/578) showed a recovery of 102.6% (target value 449 pmol/L). No hook effect was observed in samples containing up to 33,705 pmol/L. The assay showed good correlation with the Beckman Immage nephelometric system (r=0.999). Hemoglobin <= 9.8 g/L), total bilirubin (<= 113 [Lmol/L), conjugated bilirubin (<= 109 mu mol/L) and rheumatoid factor (<= 5.2 x 10(5) IU/L) did not interfere with the assay. The reference interval (2.5-97.5 percentile) was 72-521 pmol/L for men and 27-267 pmol/L for women. The reference interval in patients with anemia, malignant tumors and hemochromatosis was 5.6-52, 130-2436 and 1465-2903 pmol/L, respectively. On the basis, of the receiver operating characteristic curve, the 90% sensitivity cut-off value to distinguish between patients with and without iron deficiency was 40 pmol/L. The new latex turbidimetric procedure for ferritin assay is an attractive alternative that avoids the need for dedicated instrumentation

Exploring the implementation of cognitive behaviour therapy for psychosis using the Normalization Process Theory framework

Objective: Evidence suggests that only a minority of service users experiencing psychosis have access to Cognitive Behavioural Therapy for psychosis (CBTp). Normalisation Process Theory (NPT) is a theoretical framework which focuses on processes by which interventions are implemented and normalised in clinical practice. This study explored the views and experiences of mental health professionals regarding the implementation of CBTp. Barriers and facilitators to implementation were explored using the NPT framework. Design: A qualitative methodology was adopted involving semi-structured focus groups and individual interviews. Methods: A total of 14 members of staff working in the community and crisis mental health teams were recruited. Thematic analysis was used to generate initial themes. The Framework approach was utilised to map initial themes to the NPT framework. Results: Inductive coding generated five overarching themes consisting of 15 individual subthemes which captured the perceived barriers to engagement; contextual barriers to implementation; optimisation of implementation; positive attitudes towards implementation; and expectations of implementing CBTp. All but two subthemes mapped on to the NPT framework. The deductive analysis suggested that difficulties in making sense of CBTp among professionals were reflected as service level barriers which impeded wider implementation. Conclusion: The results of this study suggested a mixture of barriers and facilitators to CBTp implementation. Interpreting our findings within an NPT framework indicates the importance of strong clinical leadership to address difficulties in sense-making and service investment in CBTp

Intelligent policy making? Key actors' perspectives on the development and implementation of a national early years' initiative

Increased political enthusiasm for evidence-based policy and action has re-ignited interest in the use of evidence within political and practitioner networks. Theories of evidence-based policy making and practice are being re-considered in an attempt to better understand the processes through which knowledge translation occurs. Understanding how policy develops, and practice results, has the potential to facilitate effective evidence use. Further knowledge of the factors which shape healthcare delivery and their influence in different contexts is needed.&lt;p&gt;&lt;/p&gt; This paper explores the processes involved in the development of a complex intervention in Scotland's National Health Service (NHS). It uses a national oral health programme for children (Childsmile) as a case study, drawing upon key actors' perceptions of the influence of different drivers (research evidence, practitioner knowledge and values, policy, and political and local context) to programme development. Framework analysis is used to analyse stakeholder accounts from in-depth interviews. Documentary review is also undertaken.&lt;p&gt;&lt;/p&gt; Findings suggest that Childsmile can be described as an ‘evidence-informed’ intervention, blending available research evidence with knowledge from practitioner experience and continual learning through evaluation, to plan delivery. The importance of context was underscored, in terms of the need to align with prevailing political ideology and in the facilitative strength of networks within the relatively small public health community in Scotland. Respondents' perceptions support several existing theoretical models of translation, however no single theory offered a comprehensive framework covering all aspects of the complex processes reported. Childsmile's use of best available evidence and on-going contribution to knowledge suggest that the programme is an example of intelligent policy making with international relevance.&lt;p&gt;&lt;/p&gt

Role of Blood Lipids in the Development of Ischemic Stroke and its Subtypes: A Mendelian Randomization Study.

BACKGROUND AND PURPOSE: Statin therapy is associated with a lower risk of ischemic stroke supporting a causal role of low-density lipoprotein (LDL) cholesterol. However, more evidence is needed to answer the question whether LDL cholesterol plays a causal role in ischemic stroke subtypes. In addition, it is unknown whether high-density lipoprotein cholesterol and triglycerides have a causal relationship to ischemic stroke and its subtypes. Our aim was to investigate the causal role of LDL cholesterol, high-density lipoprotein cholesterol, and triglycerides in ischemic stroke and its subtypes through Mendelian randomization (MR). METHODS: Summary data on 185 genome-wide lipids-associated single nucleotide polymorphisms were obtained from the Global Lipids Genetics Consortium and the Stroke Genetics Network for their association with ischemic stroke (n=16 851 cases and 32 473 controls) and its subtypes, including large artery atherosclerosis (n=2410), small artery occlusion (n=3186), and cardioembolic (n=3427) stroke. Inverse-variance-weighted MR was used to obtain the causal estimates. Inverse-variance-weighted multivariable MR, MR-Egger, and sensitivity exclusion of pleiotropic single nucleotide polymorphisms after Steiger filtering and MR-Pleiotropy Residual Sum and Outlier test were used to adjust for pleiotropic bias. RESULTS: A 1-SD genetically elevated LDL cholesterol was associated with an increased risk of ischemic stroke (odds ratio: 1.12; 95% confidence interval: 1.04-1.20) and large artery atherosclerosis stroke (odds ratio: 1.28; 95% confidence interval: 1.10-1.49) but not with small artery occlusion or cardioembolic stroke in multivariable MR. A 1-SD genetically elevated high-density lipoprotein cholesterol was associated with a decreased risk of small artery occlusion stroke (odds ratio: 0.79; 95% confidence interval: 0.67-0.90) in multivariable MR. MR-Egger indicated no pleiotropic bias, and results did not markedly change after sensitivity exclusion of pleiotropic single nucleotide polymorphisms. Genetically elevated triglycerides did not associate with ischemic stroke or its subtypes. CONCLUSIONS: LDL cholesterol lowering is likely to prevent large artery atherosclerosis but may not prevent small artery occlusion nor cardioembolic strokes. High-density lipoprotein cholesterol elevation may lead to benefits in small artery disease prevention. Finally, triglyceride lowering may not yield benefits in ischemic stroke and its subtypes

Why are eligible patients not prescribed aspirin in primary care? A qualitative study indicating measures for improvement

BACKGROUND: Despite evidence-based guidelines, aspirin prescribing for the secondary prevention of stroke is sub-optimal. Little is known about why general practitioners do not prescribe aspirin to indicated patients. We sought to identify and describe factors that lead general practitioners (GPs) not to prescribe aspirin to eligible stroke patients. This was the first stage of a study exploring the need for and means of improving levels of appropriate aspirin prescribing. METHOD: Qualitative interviews with 15 GPs in the West Midlands. RESULTS: Initially, many GPs did not regard their prescribing as difficult or sub-optimal. However on reflection, they gave several reasons that lead to them not prescribing aspirin for eligible patients or being uncertain. These include: difficulties in applying generic guidelines to individuals presenting in consultations, patient resistance to taking aspirin, the prioritisation of other issues in a time constrained consultation and problems in reviewing the medication of existing stroke patients. CONCLUSION: In order to improve levels of appropriate aspirin prescribing, the nature and presentation risk information available to GPs and patients must be improved. GPs need support in assessing the risks and benefits of prescribing for patients with combinations of complicating risk factors, while means of facilitating improved GP-patient dialogue are required to help address patient uncertainty. A decision analysis based support system is one option. Decision analysis could synthesise current evidence and identify risk data for a range of patient profiles commonly presenting in primary care. These data could then be incorporated into a user-friendly computerised decision support system to help facilitate improved GP-patient communication. Measures of optimum prescribing based upon aggregated prescribing data must be interpreted with caution. It is not possible to assess whether low levels of prescribing reflect appropriate or inappropriate use of aspirin in specific patients where concordance between the GP and the patient is practised

Presenting symptoms and long term survival in head and neck cancer

Objectives: To assess how type and number of symptoms are related to survival in patients with head and neck cancer. Design: Patients were followed up for over 10 years from the Scottish Audit of Head and Neck Cancer (national cohort of head and neck cancer patients in Scotland 1999-2001). September 2013, cohort was linked to national mortality data. First, second and third presenting symptoms were recorded at diagnosis. Setting: National prospective audit—Scotland. Participants: A subset of 1589 patients, from the original cohort of 1895, who had cancer arising from one of the four main subsites; larynx, oropharynx, oral cavity and hypopharynx. Main outcome measures: Median survival in relation to patients’ presenting symptoms. Results: A total of 1146 (72%) males and 443 (28%) females, mean age at diagnosis 64 years (13-95). There was a significant difference in survival in relation to the number of the patient's presenting symptoms; one symptom had a median survival of 5.3 years compared with 1.1 years for three symptoms. Patients who presented with weight loss had a median survival of 0.8 years, compared to 4.2 years if they did not (P &#60; .001). Patients who presented with hoarseness had a median survival of 5.9 years compared to 2.6 years without (P &#60; .001). There was no significant difference in long-term survival for patients who presented with an ulcer, compared to those that did not (P = .105). Conclusions: This study highlights the importance of patients’ presenting symptoms, giving valuable information in highlighting appropriate “red flag” symptoms and subsequent treatment planning and prognosis