How data visualisation using historical medical journals can contribute to current debates around antibiotic use and antimicrobial resistance in primary care

BackgroundThe early years of antibiotic use in primary care (c1950-1969) has received little attention. Medical journals provide a rich source for studying historic healthcare practitioners’ views and interests, with the potential to inform contemporary debate around issues of overuse and antimicrobial resistance. AimsPilot study to test the application of digital methods to interrogate historical medical journal data in relation to antibiotic use.Methods / ApproachMeta-data and scanned articles were extracted from the online British Journal of General Practice (BJGP) archive from inception (1953) to 1969. Searchable text was generated using an application called ABBYY optical character recognition, and Python used to generate data visualisations exploring (1) how BJGP changed during the period, (2) mentions of terms ‘antibiotic(s)’, ‘penicillin’, ‘resistance/resistant’ and mapping when and where they occurred.Results / EvaluationFrom 1953-1969, BJGP expanded in terms of number of annual issues (4 to 17) and annual pages (&lt;25 to &gt;1100). Heatmap visualisations were used to facilitate understanding of the frequency with which use of the term ‘antibiotic(s)’ occurred. By 1969 an article mentioning ‘antibiotic(s)’ was published monthly. Bigram searches found ‘treatment’ and ‘therapy’ to be the two most common terms that appeared with ‘antibiotic(s)’. The fourth and seventh most common terms were ‘resistant’ (first appearing in 1955) and ‘resistance’ (1962).ConclusionsThis pilot work shows that primary care publications increased considerably between 1953-1969. Articles on antibiotics featured frequently in relation to therapeutic intervention, and concerns around resistance occurred at an early stage. This approach provides new insights into how attitudes and behaviours around antibiotic use by primary care have evolved over time. It may also have the potential to inform study of the future use of antibiotics in primary care. <br/

Measuring the complexity of general practice consultations:development and validation of a complexity measure

Background: The complexity of general practice consultations may be increasing and varies in different settings. A measure of complexity is required to test these hypotheses. Aim: To develop a valid measure of general practice consultation complexity applicable to routine medical records. Design and setting: Delphi study to select potential indicators of complexity followed by a cross-sectional study in English general practices to develop and validate a complexity measure. Method: The online Delphi study over two rounds identified potential indicators of consultation complexity. The cross-sectional study used an age–sex stratified random sample of patients and general practice face-to-face consultations from 2013/2014 in the Clinical Practice Research Datalink. The authors explored independent relationships between each indicator and consultation duration using mixed-effects regression models, and revalidated findings using data from 2017/2018. The proportion of complex consultations in different age–sex groups was assessed. Results: A total of 32 GPs participated in the Delphi study. The Delphi panel endorsed 34 of 45 possible complexity indicators after two rounds. After excluding factors because of low prevalence or confounding, 17 indicators were retained in the cross-sectional study. The study used data from 173 130 patients and 725 616 face-to-face GP consultations. On defining complexity as the presence of any of these 17 factors, 308 370 consultations (42.5%) were found to be complex. Mean duration of complex consultations was 10.49 minutes, compared to 9.64 minutes for non-complex consultations. The proportion of complex consultations was similar in males and females but increased with age. Conclusion: The present consultation complexity measure has face and construct validity. It may be useful for research, management and policy, and for informing decisions about the range of resources needed in different practices

Collaborative discussions between pharmacists and general practitioners to optimise patient medication: a qualitative study within a clinical trial.

There has been significant investment in pharmacists working in UK general practice to improve the effective and safe use of medicines. However, evidence of how to optimise collaboration between GPs and pharmacists in the context of polypharmacy (multiple medication) is lacking. To explore GP and pharmacist views and experiences of in-person, inter-professional collaborative discussions (IPCDs) as part of a complex intervention to optimise medication use for patients with polypharmacy in general practice. A mixed-method process evaluation embedded within the Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP) trial conducted in Bristol and the West Midlands. Audio-recordings of IPCDs between GPs and pharmacists, and individual semi-structured interviews exploring their reflections on these discussions. All recordings were transcribed verbatim and analysed thematically. Fourteen practices took part in the process evaluation (Feb 2021- Sept 2023). Seventeen IPCD meetings were audio recorded discussing 30 patients (range of 1-6 patients per meeting). Six GPs and 13 pharmacists were interviewed. The IPCD was highly valued by GPs and pharmacists who described benefits including: strengthening their working relationship; learning from each other; and gaining in confidence to manage more complex patients. It was often challenging, however, to find time for the IPCDs. The model of IPCD studied provided protected time for GPs and pharmacists to work together to deliver whole-patient care, with both professions finding this beneficial. Protected time for inter-professional liaison and collaboration, and structured interventions may facilitate improved patient care. [Abstract copyright: Copyright © 2024, The Authors.

Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP): Protocol for a multicentre cluster randomised trial comparing a complex intervention for medication optimization against usual care.

IntroductionPolypharmacy is increasingly common, and associated with undesirable consequences. Polypharmacy management necessitates balancing therapeutic benefits and risks, and varying clinical and patient priorities. Current guidance for managing polypharmacy is not supported by high quality evidence. The aim of the Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP) trial is to evaluate the effectiveness of an intervention to optimise medication use for patients with polypharmacy in a general practice setting.MethodsThis trial will use a multicentre, open-label, cluster-randomised controlled approach, with two parallel groups. Practices will be randomised to a complex intervention comprising structured medication review (including interprofessional GP/pharmacist treatment planning and patient-facing review) supported by performance feedback, financial incentivisation, clinician training and clinical informatics (intervention), or usual care (control). Patients with polypharmacy and triggering potentially inappropriate prescribing (PIP) indicators will be recruited in each practice using a computerised search of health records. 37 practices will recruit 50 patients, and review them over a 26-week intervention delivery period. The primary outcome is the mean number of PIP indicators triggered per patient at 26 weeks follow-up, determined objectively from coded GP electronic health records. Secondary outcomes will include patient reported outcome measures, and health and care service use. The main intention-to-treat analysis will use linear mixed effects regression to compare number of PIP indicators triggered at 26 weeks post-review between groups, adjusted for baseline (pre-randomisation) values. A nested process evaluation will explore implementation of the intervention in primary care.Ethics and disseminationThe protocol and associated study materials have been approved by the Wales REC 6, NHS Research Ethics Committee (REC reference 19/WA/0090), host institution and Health Research Authority. Research outputs will be published in peer-reviewed journals and relevant conferences, and additionally disseminated to patients and the public, clinicians, commissioners and policy makers.Isrctn registration90146150 (28/03/2019)

The Lectin Receptor Kinase LecRK-I.9 Is a Novel Phytophthora Resistance Component and a Potential Host Target for a RXLR Effector

In plants, an active defense against biotrophic pathogens is dependent on a functional continuum between the cell wall (CW) and the plasma membrane (PM). It is thus anticipated that proteins maintaining this continuum also function in defense. The legume-like lectin receptor kinase LecRK-I.9 is a putative mediator of CW-PM adhesions in Arabidopsis and is known to bind in vitro to the Phytophthora infestans RXLR-dEER effector IPI-O via a RGD cell attachment motif present in IPI-O. Here we show that LecRK-I.9 is associated with the plasma membrane, and that two T-DNA insertions lines deficient in LecRK-I.9 (lecrk-I.9) have a ‘gain-of-susceptibility’ phenotype specifically towards the oomycete Phytophthora brassicae. Accordingly, overexpression of LecRK-I.9 leads to enhanced resistance to P. brassicae. A similar ‘gain-of-susceptibility’ phenotype was observed in transgenic Arabidopsis lines expressing ipiO (35S-ipiO1). This phenocopy behavior was also observed with respect to other defense-related functions; lecrk-I.9 and 35S-ipiO1 were both disturbed in pathogen- and MAMP-triggered callose deposition. By site-directed mutagenesis, we demonstrated that the RGD cell attachment motif in IPI-O is not only essential for disrupting the CW-PM adhesions, but also for disease suppression. These results suggest that destabilizing the CW-PM continuum is one of the tactics used by Phytophthora to promote infection. As countermeasure the host may want to strengthen CW-PM adhesions and the novel Phytophthora resistance component LecRK-I.9 seems to function in this process