Tolerability of topical NSAIDs in the elderly - Do they really convey a safety advantage?

Non-steroidal anti-inflammatory drugs (NSAIDs) are very widely prescribed but they have a poor safety profile, with a range of potential adverse effects. NSAIDs that are used in topical formulation have been developed in the last fifteen years and their use is increasing. The purpose is to achieve a high local concentration of the active ingredient at the affected site, with as low a plasma concentration as possible to minimise possible systemic side-effects. This paper reviews the evidence available regarding the safety of topical NSAIDs, with particular reference to gastrointestinal and renal toxicity which have recently been highlighted in the medical press. The effects on the elderly are also discussed. The authors conclude that more formal epidemiological evaluation of the safety of topical NSAIDs is required in the post-marketing situation

Self-monitoring of blood glucose in insulin-treated diabetes: a multicase study

Objective To explore how and why self-monitoring of blood glucose (SMBG) is carried out in a real-world context. Research design and methods We conducted a multicase study among ten people with type 1 and insulin-treated type 2 diabetes mellitus in Scotland, alongside seven nominated support people and four healthcare professionals. All participants were interviewed in depth and six participants provided SMBG diaries. Stones' version of structuration theory informed the analysis. Results People with diabetes were able to provide immediate motives for SMBG at particular times, often having different motives on different occasions. We identified six such motives, including routine, in response to symptoms, associated with a diabetes review, to facilitate lifestyle, when a 'good' result was expected, and higher level motives for longer term glycemic control. These motives were influenced by underlying attitudes toward diabetes that included level of engagement and responsibility for diabetes, a desire not to be controlled by diabetes, resistance to diabetes, diabetes education and relationship with the health service, fear of hypoglycemia, and prevention of diabetes complications. Five responses to test results were identified, depending on the immediate motive and underlying attitudes. Conclusions People with insulin-treated diabetes do not necessarily self-monitor with an explicit goal of improving long-term glycemic control, but may have other motives that are important to them. An individualized understanding is therefore needed to advise people with diabetes how SMBG can be optimized for them

Health and health behaviours among a cohort of first year nursing students in Scotland: A self-report survey

The study aim was to collect data on the health and health-related behaviours of undergraduate nursing students at a Higher Education Institution in Scotland, to identify the need for potential health behaviour change interventions as part of their undergraduate course. An anonymous self-report questionnaire (with questions about physical activity, diet, sleep, alcohol, smoking, mental health) was administered to first year nursing students at a Scottish university. The response rate was 88%, with 207 respondents (26 male, 178 female, 3 other). Age ranged from 16 to 45 years (mean 24.5 years). Overall, 48 (23.1%) students rated their physical health as excellent/very good, and 100 (48.3%) their mental health as such. 157 (76.2%) students were achieving 150 min of physical activity per week. There were 48 (29%) and 30 (18.2%) overweight and obese students respectively. 129 (62.6%) students viewed a mobile device for > 30 min before sleep. 176 (86.3%) students consumed alcohol, with 32 (15.4%) reporting binge drinking. The prevalence of current smoking was 24.8%. The students’ health behaviour profile was therefore broadly similar to that of the general population in Scotland, but smoking, diet, sleep practices and binge-drinking were identified as priority areas for health education and intervention

The development of an intervention for diabetes prevention among people with impaired glucose regulation:feasibility and acceptability of an intervention component

Background As part of the design process of a low-cost minimal-contact diabetes prevention intervention, we issued a blood glucose meter to people with impaired glucose regulation (who are at high risk of type 2 diabetes). We conducted a feasibility study to assess the acceptability of this intervention component and whether and how recipients engaged with it. Methods A blood glucose meter was given to 19 people identified through primary care, who were asked to use the meter in an exploratory way during a 4-week trial period, to try to understand the effect of different foods on the body. They were advised that they could test as often or as little as they liked and were also asked to keep a food/exercise diary for at least 1 week. They were interviewed about their experiences afterwards. Results There was a high level of engagement with testing, with the total number of tests recorded ranging from 11 to 114 (median 74) among 18 participants. Fifteen participants tested almost every day during the 4-week period. The cognitive engagement was more limited. All participants commented on their own results, and most were able to relate high or low results to foods eaten and exercise taken, usually in response to prompting. However, there was limited thought or understanding beyond this in terms of longer-term patterns of diet and exercise, and testing was routine rather than experimental. Some participants were confused by conflicting or unexpected results. A few minor problems were reported by participants, such as soreness, inconvenience, and difficulty in getting blood, but never enough to discontinue testing. Several participants stated that the meter was a useful aid as a reminder that they were at high risk of diabetes and served as a prompt that needed to make and/or maintain behaviour changes. Conclusions The study suggests that blood glucose monitoring is acceptable to people with impaired glucose regulation and that they would engage with it as part of an intervention to improve their diet. The study has also uncovered potential mechanisms of action for behaviour change

Self-monitoring of blood glucose in Type 2 diabetes: cross-sectional analyses in 1993, 1999 and 2009

Aim: To characterize the numbers of reagent strips dispensed for self-monitoring of blood glucose to patients with Type 2 diabetes in Tayside, Scotland, in 1993, 1999 and 2009. Methods: A diabetes clinical information system in Tayside, record-linked to electronic dispensed prescribing records, was used to collate all dispensed prescribing records for three cross-sectional samples of patients with Type 2 diabetes in 1993 (n = 5728), 1999 (n = 8109) and at 1 January 2009 (n = 16450). The numbers of reagent strips dispensed during the relevant calendar year were calculated and patients stratified by treatment. We also explored whether age, sex or material and social deprivation were associated with whether a patient received strips. Results: Proportions of people who received self-monitoring reagent strips increased from 15.5% in 1993, to 24.2% in 1999 to 29.8% in 2009, as did numbers of strips dispensed. While the proportion of diet-treated patients who received reagent strips was still very low in 2009 (5.6%), the proportion among those treated with oral agents tripled from 9.4 to 27.4% between 1993 and 2009. Over 90% of patients treated with insulin received reagent strips and, among non-insulin-treated patients, this was more common among women, younger people and less deprived groups. Conclusions: The numbers of reagent strips dispensed for self-monitoring of blood glucose has increased and almost all insulin-treated patients receive strips. While few diet-treated patients receive strips, they are more extensively dispensed to those treated with oral agents. Given that self-monitoring of blood glucose is no longer routinely recommended in non-insulin treated patients, strategies to reduce unnecessary dispensing of reagent strips are needed

Violence experienced by undergraduate nursing students during clinical placements: An online survey at a Scottish University

Aim To assess the prevalence of violence and experiences of violence during clinical placements, among nursing students at a Higher Education Institution (HEI) in Scotland. Design Cross-sectional survey, using an opt-in online questionnaire. Participants All 950 undergraduate nursing students aged 18 + years were eligible. Methods The survey, with 24 open and closed format questions, was advertised over a 6-week period via the students’ virual learning platform. Potential participants were provided with study information before giving (electronic) informed consent. The questionnaire used was adapted from two other surveys and piloted prior to administration. Open-ended questions were fully transcribed and categorised and data analysed using SPSS. Results There were 138 completed questionnaires (approx. 15% response rate); respondents were mainly female (92%). 77% had experienced verbal violence directed at them while on placement, most commonly swearing, shouting and insults. 70% of respondents had experienced physical violence, most commonly hitting, grabbing, kicking and spitting. By the fourth year of study, all 10 students who responded (out of 17 enrolled) had experienced violence. In general, patients (with a mental illness) were perceived to be the most likely perpetrators. The five most commonly reported feelings by respondents during the incident were: anxious (65), understanding (58), vulnerable (54), unsafe (50) and scared (45) and those after the incident were understanding (70), anxious (59), guilty (37), vulnerable (36), incompetent (34). 55 (47.8%) respondents felt supported during this ‘significant’ incident, 23 (20.0%) were unsure and 28 (24.3%) did not feel supported. There was a trend towards younger respondents and those with fewer years of care experience experiencing more violence. Conclusion This study indicates that there is a high prevalence of violence experienced by student nurses that can have significant emotional consequences. There is scope to provide more training and support for them to deal with frequent incidents of violence

How does the self-reported health of undergraduate nursing students change during their degree programme? Survey results from a Scottish University

Background The lifestyle behaviours, and the physical and mental health of nurses, are poorer than those of other allied health professionals, and of the general population. However, these were no less favourable among first year undergraduate nursing students at a Scottish Higher Education Institution (HEI) than among similar people of the same age. We compared health and health behaviours among the same cohort of undergraduate nursing students over the course of their degree. Methods An anonymous self-complete repeat cross-sectional survey was administered during a timetabled teaching session at three time-points to undergraduate nursing students at the start of Years 1, 2 and 3 of their programme. They had received written information about the study previously. Results Self-reported health did not change significantly over time, but there was a clear decline over the 3 years in the proportions of students rating their mental health as excellent/very good/good and a concomitant increase in those rating their mental health as fair/poor. Correspondingly, the mean WEMWBS wellbeing score declined over the 3 years, with the proportion of students with a score of less than 46 (indicating either high risk of major depression, or in high risk of psychological distress and increased risk of depression) increasing from one quarter to one half. This effect was captured and described using a Bayesian regression analysis. The most noticeable change in health behaviours was a decline in physical activity levels over the study period. The proportion of students managing 150 min of weekly physical activity decreased from three quarters to two thirds. This was reflected in higher self-reported sedentary time, although there were no observable trends over time in mean BMI, or proportions of students categorised as overweight or obese. Conclusions: This paper suggests that there may be a decline in mental health and in participation in physical activity among nursing students over the course of their degree. We recommend the incorporation of an intervention into the undergraduate nursing curriculum that promotes and encourages regular physical activity, offering students the opportunity to learn about health promotion and lifestyle change in practice, to improve their own physical health, and to address mental wellbeing

Analysis of spontaneous, user-generated data about gestational diabetes on online forums: implications for diabetes prevention

Aims To explore the experiences and perceptions of gestational diabetes mellitus reported by women within online parental‐support forums and, specifically, to analyse what women say about a diagnosis of gestational diabetes, their future risk of type 2 diabetes, and lifestyle behaviour for management of gestational diabetes and prevention of type 2 diabetes. Methods The discussion boards of two parenting websites (Mumsnet and Netmums) were searched using the search term 'gestational diabetes or GD' in February 2019. Relevant posts made by users with gestational diabetes on or after 1 January 2017 were retained for analysis. Framework analysis using pre‐existing framework from a previous study was used to organize and analyse the data. Results A total of 646 posts generated by 282 unique users were included in the analysis. Analysis of the online content identified three important implicit messages that may be being conveyed to readers. The first is that gestational diabetes is not a serious diagnosis that warrants undue concern. Secondly, few users recognized the importance of their own behaviours or lifestyle, with others minimizing personal responsibility or attributing gestational diabetes to non‐modifiable factors. Finally, there was a lack of acknowledgment of heightened risk of type 2 diabetes. These three messages will all directly mitigate against the efforts of clinicians (and others) to encourage women with gestational diabetes to improve their lifestyle behaviours in the longer term. Conclusions These findings highlight messages that are being widely disseminated and that are unlikely to support prevention of type 2 diabetes

Frequency of blood glucose monitoring in relation to glycaemic control: observational study with diabetes database

Objectives: To investigate patterns of self monitoring of blood glucose concentration in diabetic patients who use insulin and to determine whether frequency of self monitoring is related to glycaemic control. Setting: Diabetes database, Tayside, Scotland. Subjects: Patients resident in Tayside in 1993­-5 who were using insulin and were registered on the database and diagnosed with insulin dependent (type 1) or non­insulin dependent (type 2) diabetes before 1993. Main outcome measures: Number of glucose monitoring reagent strips dispensed (reagent strip uptake) derived from records of prescriptions. First recorded haemoglobin A1c concentration in the study period, and reagent strips dispensed in the previous 6 months. Results: Among 807 patients with type 1 diabetes, 128 (16%) did not redeem any prescriptions for glucose monitoring reagent strips in the 3 year study period. Only 161 (20%) redeemed prescriptions for enough reagent strips to test glucose daily. The corresponding figures for the 790 patients with type 2 diabetes who used insulin were 162 (21%; no strips) and 131 (17%; daily tests). Reagent strip uptake was influenced both by age and by deprivation category. There was a direct relation between uptake and glycaemic control for 258 patients (with recorded haemoglobin A1c concentrations) with type 1 diabetes. In a linear regression model the decrease in haemoglobin A1c concentration for every extra 180 reagent strips dispensed was 0.7%. For the 290 patients with type 2 diabetes who used insulin there was no such relation. Conclusions: Self monitoring of blood glucose concentration is associated with improved glycaemic control in patients with type 1 diabetes. Regular self monitoring in patients with type 1 and type 2 diabetes is uncommon

Postpartum opportunistic advice in primary care for women who have had gestational diabetes: a qualitative study of health care professionals' views

Background Women who have had gestational diabetes during pregnancy are at very high risk of developing type 2 diabetes later in life, but their understanding of the risks is often limited. In this study we explored the views of health care professionals regarding offering brief opportunistic advice to women after their pregnancy, during unrelated consultations in primary care, relating to reducing diabetes risk. Methods The study took place in three Health Boards in Scotland. We conducted semi-structured one-to-one interviews (either face-to-face or telephone) with two health visitors, three practice nurses, two GPs, two diabetes consultants and two obstetricians. A focus group with five health visitors was also held. A topic guide was followed, covering the feasibility and acceptability of delivering brief opportunistic advice during a routine consultation, the optimal way to identify and recall women with previous gestational diabetes, and the possible content and timing of any such intervention. A thematic approach was used to analyse the qualitative data generated. Results The interviews/discussion lasted from 15 to 51 min. There was widespread support from all participants for offering opportunistic advice, and general consensus that health visitors would be best placed to do this as part of the Universal Health Visiting Pathway in Scotland. Thematic analysis generated three significant points of discussion: implications for training of health visitors, the need for a systematic approach to identifying women with gestational diabetes, and the optimal timing of delivery. Despite an already demanding schedule of providing advice and education to women, health visitors were confident that they could offer educational advice, provided that they received appropriate training to do so. However, there would need to be a watertight system for identifying women in their care who had had gestational diabetes. In terms of timing, later visits around 6–8 months after delivery were considered most suitable. Conclusions There is support from health care professionals, and most pertinently from health visitors, that the frequency of routine visits with women during the Universal Health Visiting Pathway programme in Scotland provides potential opportunities for education around future diabetes risk to women who have had gestational diabetes