Challenges of managing people with multimorbidity in today’s healthcare systems

Multimorbidity is a growing issue and poses a major challenge to health care systems around the world. Multimorbidity is related to ageing but many studies have now shown that it is also socially patterned, being more common and occurring at an earlier age in areas of high socioeconomic deprivation. There is lack of research on patients with multimorbidity, and thus guidelines are based on single-conditions. Polypharmacy is common in multimorbidity, increasing drug-disease and drug-drug interactions. Multimorbid patients need holistic care, but secondary care services are highly specialised and thus are often duplicative and fragmented and thus increase treatment burden in multimorbid patients. The cost of care is high in multimorbidity, due to high rates of primary and secondary care consultations and unplanned hospital admissions. The combination of mental and physical conditions increases complexity of care, and costs. Mental-physical multimorbidity is especially common in deprived areas. General practitioners and primary care teams have a key role in managing patients with multimorbidity, using a patient-centred generalist approach. Consultation length and continuity of care may need to be substantially enhanced in order to enable such patients. This will require a radical change in how health care systems are organised and funded in order to effectively meet the challenges of multimorbidity

Improving management of gout in primary care using a customised electronic records template

It is known that the management of chronic gout in relation to serum uric acid (SUA) monitoring, allopurinol dosing, and lifestyle advice is often sub-optimal in primary care.[1] A quality improvement project in the form of a criterion based audit was carried out in an urban general practice to improve the care of patients being treated for gout. Baseline searching of EMIS confirmed that management of patients with gout who were taking allopurinol was not in line with current guidance. 51(40%) had a SUA checked in the past 12 months, 88(25%) had a SUA below target level, and gout lifestyle advice was not being recorded. An audit was performed to measure and improve the following criteria: •Monitoring of SUA levels in the past 12 months •Titration of urate lowering therapy to bring the SUA below target level •Lifestyle advice in the past 12 months An audit standard of 60% achievement at 2 months and 80% achievement at 4 months was set. The intervention consisted of a custom electronic template within EMIS which allowed guidance of gout management to be displayed and for data to be entered. All members of the team including GPs and administrative staff were educated regarding the intervention. This resulted in a sustained improvement over a 6 month period in all 3 components of the audit with 112(84%) having a SUA level checked, 79(51%) having a SUA below target level and 76(57%) receiving lifestyle advice. Although the improvement did not reach the audit standard in 2 of the criteria it would be expected that outcomes would continue given the systems changes which have been made.Publisher PDFPeer reviewe

Insights into specificity of cleavage and mechanism of cell entry from the crystal structure of the highly specific Aspergillus ribotoxin, restrictocin

AbstractBackground: Restrictocin, a highly specific ribotoxin made by the fungus Aspergillus restrictus, cleaves a single phosphodiester bond in the 28S RNA of eukaryotic ribosomes, inhibiting protein synthesis. The sequence around this cleavage site is a binding site for elongation factors, and is conserved in all cytoplasmic ribosomes. The catalytic mechanism of restrictocin and the reasons for its high substrate specificity are unknown. No structure has been determined for any other member of the Aspergillus ribotoxin family.Results The crystal structure of restrictocin was determined at 2.1 å resolution by single isomorphous replacement and anomalous scattering techniques, and refined to 1.7 å resolution using synchrotron Laue data. The structural core of the protein, in which a three-turn α helix is packed against a five-stranded antiparallel β sheet, can be well aligned with that of ribonuclease T1. Large positively charged peripheral loops near the active site construct a platform with a concave surface for RNA binding.Conclusion Restrictocin appears to combine the catalytic components of T1 ribonucleases with the base recognition components of Sa ribonucleases. Modeling studies using an NMR structure of an RNA substrate analog suggest that the tertiary structure of the substrate RNA is important in protein–RNA recognition, fitting closely into the concavity of the presumed binding site. We speculate that the large 39-residue loop L3, which has similarities to loops found in lectin sugar-binding domains, may be responsible for restrictocin's ability to cross cell membranes

Challenges of managing people with multimorbidity in today's healthcare systems

Multimorbidity is a growing issue and poses a major challenge to health care systems around the world. Multimorbidity is related to ageing but many studies have now shown that it is also socially patterned, being more common and occurring at an earlier age in areas of high socioeconomic deprivation. There is lack of research on patients with multimorbidity, and thus guidelines are based on single-conditions. Polypharmacy is common in multimorbidity, increasing drug-disease and drug-drug interactions. Multimorbid patients need holistic care, but secondary care services are highly specialised and thus are often duplicative and fragmented and thus increase treatment burden in multimorbid patients. The cost of care is high in multimorbidity, due to high rates of primary and secondary care consultations and unplanned hospital admissions. The combination of mental and physical conditions increases complexity of care, and costs. Mental-physical multimorbidity is especially common in deprived areas. General practitioners and primary care teams have a key role in managing patients with multimorbidity, using a patient-centred generalist approach. Consultation length and continuity of care may need to be substantially enhanced in order to enable such patients. This will require a radical change in how health care systems are organised and funded in order to effectively meet the challenges of multimorbidity.Publisher PDFPeer reviewe

Multimorbidity: Technical Series on Safer Primary Care

No abstract available

Single-pulse Laue diffraction, stroboscopic data collection and femtosecond flash photolysis on macromolecules

We review the time structure of synchrotron radiation and its use for fast time-resolved diffraction experiments in macromolecular photo-cycles using flash photolysis to initiate the reaction. The source parameters and optics for ID09 at ESRF are presented together with the phase-locked chopper and femtosecond laser. The chopper can set up a 900 Hz pulse train of 100 ps pulses from the hybrid bunch-mode and, in conjunction with a femtosecond laser, it can be used for stroboscopic data collection with both monochromatic and polychromatic beams. Single-pulse Laue data from Cutinase, a 22 kD lipolic enzyme, are presented which show that the quality of single-pulse Laue patterns is sufficient to refine the excited state(s) in a reaction pathway from a known ground state. The flash photolysis technique is discussed and an example is given for heme proteins. The radiation damage from a laser pulse in the femto and picosecond range can be reduced by triggering at a wavelength where the interaction is strong. We propose the use of microcrystals between 25–50 μm for efficient photolysis with femto and picosecond pulses. The performance of circular storage rings is compared with the predicted performance of an X-ray free electron laser (XFEL). The combination of micro beams, a gain of 105105 photons per pulse and an ultrashort pulse length of 100 fs is likely to improve pulsed diffraction data very substantially. It may be used to image coherent nuclear motion at atomic resolution in ultrafast uni-molecular reactions. © 1997 American Institute of Physics.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/87418/2/267_1.pd

What do we know about demand, use and outcomes in primary care out-of-hours services? A systematic scoping review of international literature

This study was funded by the Scottish Government through the Primary Care Division and Health Improvement Scotland.Objective To synthesise international evidence for demand, use and outcomes of primary care out-of-hours health services (OOHS). Design Systematic scoping review. Data sources CINAHL; Medline; PsyARTICLES; PsycINFO; SocINDEX; and Embase from 1995 to 2019. Study selection English language studies in UK or similar international settings, focused on services in or directly impacting primary care. Results 105 studies included: 54% from mainland Europe/Republic of Ireland; 37% from UK. Most focused on general practitioner-led out-of-hours cooperatives. Evidence for increasing patient demand over time was weak due to data heterogeneity, infrequent reporting of population denominators and little adjustment for population sociodemographics. There was consistent evidence of higher OOHS use in the evening compared with overnight, at weekends and by certain groups (children aged 65, women, those from socioeconomically deprived areas, with chronic diseases or mental health problems). Contact with OOHS was driven by problems perceived as urgent by patients. Respiratory, musculoskeletal, skin and abdominal symptoms were the most common reasons for contact in adults; fever and gastrointestinal symptoms were the most common in the under-5s. Frequent users of daytime services were also frequent OOHS users; difficulty accessing daytime services was also associated with OOHS use. There is some evidence to suggest that OOHS colocated in emergency departments (ED) can reduce demand in EDs. Conclusions Policy changes have impacted on OOHS over the past two decades. While there are generalisable lessons, a lack of comparable data makes it difficult to judge how demand has changed over time. Agreement on collection of OOHS data would allow robust comparisons within and across countries and across new models of care. Future developments in OOHS should also pay more attention to the relationship with daytime primary care and other services.Publisher PDFPeer reviewe

Factors associated with recruitment to randomised controlled trials in general practice : protocol for a systematic review

This study is supported by a PhD studentship provided by the University of St Andrews.Background: Randomised controlled trials (RCTs) are frequently unable to recruit sufficient numbers of participants. This affects the trial’s ability to answer the proposed research question, wastes resources and can be unethical. RCTs within a general practice setting are increasingly common and similarly face recruitment challenges. The aim of the proposed review is to identify factors that are associated with recruitment rates to RCTs in a general practice setting. These results will be used in further research to predict recruitment to RCTs. Methods/design: The electronic databases Medline, EMBASE, Cochrane Database of Systematic Reviews, NTIS and OpenGrey will be searched for relevant articles with no limit on the date of publication. BMC Trials will be manually searched for the past 5 years. Both quantitative and qualitative studies will be included if they have studied recruitment within a general practice RCT. Only English language publications will be included. Screening, quality assessment and data extraction will be conducted by two review authors not blinded to study characteristics. Disagreement will be resolved by discussion and the involvement of a third review author if required. A narrative synthesis of the studies included will be performed. Discussion: The review will, for the first time, systematically synthesise existing research on factors associated with recruitment rates to RCTs in general practice. By identifying research gaps to be prioritised in further research, it will be of interest to academics. It will also be of value to clinical trialists who are involved in the complex task of improving trial recruitment. Our team will use the findings to inform a prediction model of trial recruitment using machine learning.Publisher PDFPeer reviewe