Acute kidney injury: an acceptable risk of treatment with renin-angiotensin system blockade in primary care?

Background: Use of renin-angiotensin system (RAS) blockade has become increasingly widespread driven by evidence-based guidance. There is concern about the role of these agents in the genesis of avoidable acute kidney injury (AKI). Objectives: To investigate the association between AKI and use of RAS blockade. Design: Multilevel hierarchical analysis of a large cohort of patients registered with UK general practitioners. Setting: Primary care practices in East and West Kent, United Kingdom. Patients: 244,715 patients from 27 practices. Measurements: Demographic, clinical, biochemical and prescription data. Methods: Analyses of data acquired between 02/3/2004 and 17/04/2012 using multilevel logistic regression to determine the relationship between AKI and use of RAS blockade; further analysed by indication for treatment with RAS blockade. Results: Sufficient serum creatinine data were available to define AKI in 63,735 patients with 208,275 blood test instances. In 95,569 instances the patient was prescribed a RAS antagonist of which 5.4% fulfilled criteria for AKI. The unadjusted odds ratio (OR) for AKI in those prescribed RAS blockade was 1.93 (1.81-2.06, 95%CI) falling to 1.11 (1.02-1.20, 95%CI) when adjusted for age, gender, co-morbidity, GFR category, proteinuria, systolic blood pressure and diuretic therapy. In patients with an evidence-based indication there was no difference in absolute risk of AKI. However, prescription of RAS blockade in the absence of indication appeared to be associated with greater risk of AKI. When analysis was repeated with AKIN2/AKIN3 as the outcome, although risk of AKI remained significant when unadjusted (OR 1.73, 95%CI 1.42-2.11, p<0.001), after full adjustment there was no increased risk (OR 0.83, 95%CI 0.63-1.09) in those taking RAS antagonists. However, when analysed by indication AKIN2/AKIN3 was significantly more likely in those prescribed RAS antagonists without indication (OR 2.04, 95%CI 1.41-2.94, p<0.001). Limitations: Observational database study. No information concerning hospitalisation. Prescribing assumptions and potential inaccurate coding. Potential survival bias; patients surviving longer will contribute more data. Conclusions: Use of RAS antagonists increased the risk of AKI, independent of common confounding variables. After correction for confounders the risk fell away and became non-significant for moderate and severe AKI. However, where there was no evidence-based indication for RAS antagonists the risk of AKI, whether mild, moderate or severe, remained greater

When does NICE recommend the use of health technologies within a programme of evidence development?

This article is made available through the Brunel Open Access Publishing Fund. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.This article has been made available through the Brunel Open Access Publishing Fund.Background: There is growing interest internationally in linking reimbursement decisions with recommendations for further research. In the UK, the National Institute for Health and Clinical Excellence (NICE) can issue guidance to approve the routine use of a health intervention, reject routine use or recommend use within a research programme. These latter recommendations have restricted use to ‘only in research’ (OIR) or have recommended further research alongside routine use (‘approval with research’ or AWR). However, it is not currently clear when such recommendations are likely to be made. Objectives: This study aims to identify NICE technology appraisals where OIR or AWR recommendations were made and to examine the key considerations that led to those decisions. Methods: Draft and final guidance including OIR/AWR recommendations were identified. The documents were reviewed to establish the characteristics of the technology appraisal, the cost effectiveness of the technologies, the key considerations that led to the recommendations and the types of research required. Results: In total, 29 final and 31 draft guidance documents included OIR/AWR recommendations up to January 2010. Overall, 86 % of final guidance included OIR recommendations. Of these, the majority were for technologies considered to be cost ineffective (83 %) and the majority of final guidance (66 %) specified the need for further evidence on relative effectiveness. The use of OIR/AWR recommendations is decreasing over time and they have rarely been used in appraisals conducted through the single technology appraisal process. Conclusion: NICE has used its ability to recommend technologies within research programmes, although predominantly within the multiple technology appraisal process. OIR recommendations have been most frequently issued for technologies considered cost ineffective and the most frequently cited consideration is uncertainty related to relative effectiveness. Key considerations cited for most AWR recommendations and some OIR recommendations included a need for further evidence on long-term outcomes and adverse effects of treatment.Medical Research Counci

Recommended Practices: Protecting Temporary Workers

[Excerpt] Workers employed through staffing agencies are generally called temporary or supplied workers. For the purposes of these recommended practices, “temporary workers” are those supplied to a host employer and paid by a staffing agency, whether or not the job is actually temporary. Whether temporary or permanent, all workers always have a right to a safe and healthy workplace. The staffing agency and the staffing agency’s client (the host employer) are joint employers of temporary workers and, therefore, both are responsible for providing and maintaining a safe work environment for those workers. The staffing agency and the host employer must work together to ensure that the Occupational Safety and Health Act of 1970 (the OSH Act) requirements are fully met. See 29 U.S.C. § 651. The extent of the obligations of each employer will vary depending on workplace conditions and should therefore be described in the agreement or contract between the employers. Their safety and health responsibilities will sometimes overlap. Either the staffing agency or the host employer may be better suited to ensure compliance with a particular requirement, and may assume primary responsibility for it. The joint employment structure requires effective communication and a common understanding of the division of responsibilities for safety and health. Ideally, these will be set forth in a written contract. OSHA and NIOSH recommend the following practices to staffing agencies and host employers so that they may better protect temporary workers through mutual cooperation and collaboration. Unless otherwise legally required, these recommendations are for the purpose of guidance and in some cases represent best practices

The Ten Essential Shared Capabilities: a framework for mental health practice

The 10 Essential Shared Capabilities (ESC) are a description of the core aspects of practice that support effective implementation and delivery of mental health care. The ESC have been derived directly from work with users, carers and mental health personnel. To support their introduction a learning pack was developed giving examples of the 10 ESC as they relate to current practice. A pilot programme across England was developed to test the acceptability and potential utility of these materials and this paper reports on the evaluation of that pilot programme. Facilitators (n=75) and learners (n=579) were asked to rate each of the seven modules contained in the learning pack. A number of recommendations have been made to improve the materials that are being acted upon

NHMRC information paper: evidence on the effectiveness of homeopathy for treating health conditions

This paper provides a summary of evidence from research on the effectiveness of homeopathy in treating health conditions in humans. Findings There was no reliable evidence from research in humans that homeopathy was effective for treating the range of health conditions considered: no good-quality, well-designed studies with enough participants for a meaningful result reported either that homeopathy caused greater health improvements than placebo, or caused health improvements equal to those of another treatment. For some health conditions, studies reported that homeopathy was not more effective than placebo. For other health conditions, there were poor-quality studies that reported homeopathy was more effective than placebo, or as effective as another treatment. However, based on their limitations, those studies were not reliable for making conclusions about whether homeopathy was effective. For the remaining health conditions it was not possible to make any conclusion about whether homeopathy was effective or not, because there was not enough evidence. Conclusions Based on the assessment of the evidence of effectiveness of homeopathy, NHMRC concludes that there are no health conditions for which there is reliable evidence that homeopathy is effective. Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness. People who are considering whether to use homeopathy should first get advice from a registered health practitioner. Those who use homeopathy should tell their health practitioner and should keep taking any prescribed treatments

User involvement and desired service developments in drug treatment: Service user and provider views

Aims - To investigate the existing level of user involvement at selected agencies, to examine views about user involvement from both service-user and provider perspectives and to compare desired service developments. Design/Measurements - As part of a larger project, a series of semi-structured interviews was carried out between 2001 and 2003. Setting - Community-based drug services in Northern England. Participants - Service users (46) and service providers (51). Findings - Overall, the level of service-user involvement was low, with 16% of services having no user involvement at all. Nevertheless, service users expressed a desire for a high level of user involvement, compared with the low aspirations expressed by service providers. Service users' first priority for desired service developments was reduced waiting times, whereas service providers wished for increased provision of complementary therapies. Conclusions - The study highlighted important discrepancies regarding both desired level of user involvement and priorities for service developments between service users und providers. Given the current policies in this field and evidence that user involvement and closer partnerships between users and providers enhances treatment effectiveness, this lack of concurrence might be of major concern and working towards better understanding and balancing users' and providers' needs is highly recommended

Preparing young people with complex needs and their families for transition to adult services

© RCN Publishing Company Limited 2018Improving survival rates for children and young people with complex health needs requires a robust system for transition to adult services. Effective planning is essential to ensure a smooth transition process that is in the best interests of the young person and their family. This article discusses the needs and requirements for planned and purposeful transition processes to support young people with complex healthcare needs and their families. It considers the preparation of adult services, the team, the young person and their parents in line with an integrated approach and the nurse’s role. Recommendations for practice include the necessity for an integrated approach to ensure optimum outcomes and ascertaining the potential value of a nurse-led service in delivering the transition process. A carefully tailored planning strategy should be developed to prepare and support young people with complex health needs through transition

Improving the psychological evaluation of exercise referral: psychometric properties of the Exercise Referral Quality of Life Scale

There is a growing need to assess the psychological outcomes of exercise referral and the National Institute of Health and Care Excellence has called for the routine assessment of life-quality. However, a quality of life scale specific to the requirements of exercise referral is currently unavailable. Therefore, the aim of this study was to produce a quality of life measure for this purpose. The Exercise Referral Quality of Life Scale is a 22-item measure comprising three domains: mental and physical health, injury pain and illness and physical activity facilitators. Exploratory factor analysis determined the initial factor structure and was subsequently confirmed by confirmatory factor analysis. Additional scale properties were also assessed. The scale contributes to the global need for improved consistent psychological outcome assessment of exercise referral

Ebola hemorrhagic fever: case fatality rate 90%?

RevisiónSince 1976, most epidemiological studies about Ebola Hemorrhagic Fever have reported case fatality rate (CFR) of up to 90%. According to the report of WHO (1 August 2014) CFR is of 55–60% (total number of cases 1,603 – deaths 887).N