A cluster randomised controlled trial of a pharmacist-led collaborative intervention to improve statin prescribing and attainment of cholesterol targets in primary care

Background: Small trials with short term follow up suggest pharmacists’ interventions targeted at healthcare professionals can improve prescribing. In comparison with clinical guidance, contemporary statin prescribing is sub-optimal and achievement of cholesterol targets falls short of accepted standards, for patients with atherosclerotic vascular disease who are at highest absolute risk and who stand to obtain greatest benefit. We hypothesised that a pharmacist-led complex intervention delivered to doctors and nurses in primary care, would improve statin prescribing and achievement of cholesterol targets for incident and prevalent patients with vascular disease, beyond one year.<p></p> Methods: We allocated general practices to a 12-month Statin Outreach Support (SOS) intervention or usual care. SOS was delivered by one of 11 pharmacists who had received additional training. SOS comprised academic detailing and practical support to identify patients with vascular disease who were not prescribed a statin at optimal dose or did not have cholesterol at target, followed by individualised recommendations for changes to management. The primary outcome was the proportion of patients achieving cholesterol targets. Secondary outcomes were: the proportion of patients prescribed simvastatin 40 mg with target cholesterol achieved; cholesterol levels; prescribing of simvastatin 40 mg; prescribing of any statin and the proportion of patients with cholesterol tested. Outcomes were assessed after an average of 1.7 years (range 1.4–2.2 years), and practice level simvastatin 40 mg prescribing was assessed after 10 years.<p></p> Findings: We randomised 31 practices (72 General Practitioners (GPs), 40 nurses). Prior to randomisation a subset of eligible patients were identified to characterise practices; 40% had cholesterol levels below the target threshold. Improvements in data collection procedures allowed identification of all eligible patients (n = 7586) at follow up. Patients in practices allocated to SOS were significantly more likely to have cholesterol at target (69.5% vs 63.5%; OR 1.11, CI 1.00–1.23; p = 0.043) as a result of improved simvastatin prescribing. Subgroup analysis showed the primary outcome was achieved by prevalent but not incident patients. Statistically significant improvements occurred in all secondary outcomes for prevalent patients and all but one secondary outcome (the proportion of patients with cholesterol tested) for incident patients. SOS practices prescribed more simvastatin 40 mg than usual care practices, up to 10 years later.<p></p> Interpretation: Through a combination of educational and organisational support, a general practice based pharmacist led collaborative intervention can improve statin prescribing and achievement of cholesterol targets in a high-risk primary care based population

How accurately do adult sons and daughters report and perceive parental deaths from coronary disease?

<b>OBJECTIVES</b>: To describe how adult sons and daughters report and perceive parental deaths from heart disease <b>DESIGN</b>: Two generation family study. <b>SETTING</b>: West of Scotland. <b>SUBJECTS</b>: 1040 sons and 1298 daughters aged 30-59 from 1477 families, whose fathers and mothers were aged 45-64 in 1972-76 and have been followed up for mortality over 20 years. <b>OUTCOME</b> : Perception of a "family weakness" attributable to heart disease. RESULTS : 26% of sons and daughters had a parent who had died of coronary heart disease (CHD). The proportion was higher in older offspring (+18% per 10 year age difference) and in manual compared with non-manual groups (+37%). Eighty nine per cent of parental deaths from CHD were correctly reported by offspring. Only 23% of sons and 34% of daughters with at least one parent who had died of CHD considered that they had a family weakness attributable to heart disease. Perceptions of a family weakness were higher when one or both parents had died of CHD, when parental deaths occurred at a younger age, in daughters compared with sons and in offspring in non-manual compared with manual occupations. <b>CONCLUSIONS</b>: Only a minority of sons and daughters with experience of a parent having died from CHD perceive this in terms of a family weakness attributable to heart disease. Although men in manual occupations are most likely to develop CHD, they are least likely to interpret a parental death from CHD in terms of a family weakness. Health professionals giving advice to patients on their familial risks need to be aware of the difference between clinical definitions and lay perceptions of a family history of heart disease

Mortality from head injury over four decades in Scotland

Although the causes of head injury, the population at risk and approaches to prevention and treatment are continually evolving, there is little information about how these are reflected in patterns of mortality over time. We used population based comprehensive data uniquely available in Scotland to investigate changes in the total numbers of deaths from 1974 to 2012, as well as the rates of head injury death, from different causes, overall and in relation to age and gender. Total mortality fell from an annual average of 503 to 339 with a corresponding annual decrease in rate from 9.6 to 6.4 per 100,000 population, the decline substantially occurring between 1974 and 1990. Deaths in children fell strikingly but rose in older people. Deaths in males fell to a greater extent than females but remained at a higher rate overall. Initially, a transport accident accounted for most deaths but these fell by 80%, from 325 per year to 65 per year over the 39 year period. Deaths from falling and all other causes did not decline, coming to outnumber transport accident deaths by 1998, which accounts for the overall absence of change in total mortality in recent years. In order to reduce mortality in the future, more effective measures to prevent falls are needed and these strategies will vary in younger adults (where alcohol is often a factor), and in older adults where infirmity can be a cause. In addition, measures to sustain reductions in transport accidents need to be maintained and further developed

A Keck/DEIMOS spectroscopic survey of the faint M31 satellites And IX, And XI, And XII, and And XIII

We present the first spectroscopic analysis of the faint M31 satellite galaxies, AndXI and AndXIII, and a reanalysis of existing spectroscopic data for two further faint companions, And IX and AndXII. By combining data obtained using the DEIMOS spectrograph mounted on the Keck II telescope with deep photometry from the Suprime-Cam instrument on Subaru, we have calculated global properties for the dwarfs, such as systemic velocities, metallicites and half-light radii.We find each dwarf to be very metal poor ([Fe/H] -2 both photometrically and spectroscopically, from their stacked spectrum), and as such, they continue to follow the luminosity-metallicity relationship established with brighter dwarfs. We are unable to resolve a dispersion for And XI due to small sample size and low S/N, but we set a one sigma upper limit of sigma-v <5 km/s. For And IX, And XII and And XIII we resolve velocity dispersions of v=4.5 (+3.4,-3.2), 2.6(+5.1,-2.6) and 9.7(+8.9,-4.5) km/s, and derive masses within the half light radii of 6.2(+5.3,-5.1)x10^6 Msun, 2.4 (+6.5,-2.4)x10^6 Msun and 1.1(+1.4,-0.7)x10^7 Msun respectively. We discuss each satellite in the context of the Mateo relations for dwarf spheroidal galaxies, and the Universal halo profiles established for Milky Way dwarfs (Walker et al. 2009). For both galaxies, this sees them fall below the Universal halo profiles of Walker et al. (2009). When combined with the findings of McConnachie & Irwin (2006a), which reveal that the M31 satellites are twice as extended (in terms of both half-light and tidal radii) as their Milky Way counterparts, these results suggest that the satellite population of the Andromeda system could inhabit halos that are significantly different from those of the Milky Way in terms of their central densities (abridged).Comment: 26 pages, 18 figures, MNRAS submitte

The Tidal Evolution of Local Group Dwarf Spheroidals

(Abridged) We use N-body simulations to study the evolution of dwarf spheroidal galaxies (dSphs) driven by galactic tides. We adopt a cosmologically-motivated model where dSphs are approximated by a King model embedded within an NFW halo. We find that these NFW-embedded King models are extraordinarily resilient to tides; the stellar density profile still resembles a King model even after losing more than 99% of the stars. As tides strip the galaxy, the stellar luminosity, velocity dispersion, central surface brightness, and core radius decrease monotonically. Remarkably, we find that the evolution of these parameters is solely controlled by the total amount of mass lost from within the luminous radius. Of all parameters, the core radius is the least affected: after losing 99% of the stars, R_c decreases by just a factor of ~2. Interestingly, tides tend to make dSphs more dark-matter dominated because the tightly bound central dark matter ``cusp'' is more resilient to disruption than the ``cored'' King profile. We examine whether the extremely large M/L ratios of the newly-discovered ultra-faint dSphs might have been caused by tidal stripping of once brighter systems. Although dSph tidal evolutionary tracks parallel the observed scaling relations in the luminosity-radius plane, they predict too steep a change in velocity dispersion compared with the observational estimates hitherto reported in the literature. The ultra-faint dwarfs are thus unlikely to be the tidal remnants of systems like Fornax, Draco, or Sagittarius. Despite spanning four decades in luminosity, dSphs appear to inhabit halos of comparable peak circular velocity, lending support to scenarios that envision dwarf spheroidals as able to form only in halos above a certain mass threshold.Comment: 17 pages, 12 figs., accepted by Ap

Can we evaluate population screening strategies in UK general practice? A pilot randomised controlled trial comparing postal and opportunistic screening for genital chlamydial infection

STUDY OBJECTIVE: To assess whether opportunistic and postal screening strategies for Chlamydia trachomatis can be compared with usual care in a randomised trial in general practice DESIGN: Feasibility study for a randomised controlled trial. SETTING: Three West of Scotland general medical practices: one rural, one urban/deprived and one urban/affluent. PARTICIPANTS: 600 women aged 16-30 years, 200 from each of three participating practices selected at random from a sample of West of Scotland practices that had expressed interest in the study. The women could opt out of the study. Those who did not were randomly assigned to one of three groups: postal screening, opportunistic screening or usual care. MAIN RESULTS: 38% (85/221) of the approached practices expressed interest in the study. Data were collected successfully from the 3 participating practices, although intensive support was required. There were considerable workload implications for staff, both in relation to implementing the screening strategies and managing the research process. 124 of the 600 women opted out of the study. During the four-month study period, 55% (81/146) of the control group attended their practice but none was offered screening. 59% (80/136) women in the opportunistic group attended their practice of whom 55% (44/80) were offered screening. Of those, 64% (28/44) accepted, representing 21% of the opportunistic group. 48% (59/124) of the postal group returned samples. CONCLUSION: A randomised controlled trial comparing postal and opportunistic screening for chlamydial infection in general practice is feasible, though resource intensive. There may be problems with generalising from screening trials in which patients may opt out from the offer of screening

Public green space inequality in small towns in South Africa

The distribution of public green space within towns is frequently uneven, and influenced by attributes such as its location relative to the commercial core, as well as the ethnicity and relative wealth and education of the residents. Yet most studies are from large cities in developed countries. In contrast, this study reports on the distribution of public green space across 9 small towns in a developing country, namely South Africa, which offers a unique case study because of its former racially defined settlement patterns. We do so using GIS analysis of aerial photographs focusing on 3 types of suburbs in each town, defined on the basis of wealth as well as race-based history under the previous apartheid regime. The more affluent suburbs, inhabited mainly by whites, have the lowest density of housing and the highest area of green space per capita. Proportionally, they have a similar area under public green space as to the previously racially defined townships, but because of the lower housing density, they have a greater area per person. The newly built low-cost housing areas (termed RDP suburbs), occupied largely by poor black South Africans, are poorly endowed with public green space, and fare worse than the other 2 suburb types on all attributes measured. This needs to be addressed in further low-cost housing developments

Dynamics in the satellite system of Triangulum: Is AndXXII a dwarf satellite of M33?

We present results from a spectroscopic survey of the dwarf spheroidal And XXII and the two extended clusters EC1 and EC2. These three objects are candidate satellites of the Triangulum galaxy, M33, which itself is likely a satellite of M31. We use the DEep Imaging Multi-Object Spectrograph mounted on the Keck-II telescope to derive radial velocities for candidate member stars of these objects and thereby identify the stars that are most likely actual members. Eleven most probable stellar members (of 13 candidates) are found for AndXXII. We obtain an upper limit of sigma_v < 6.0 km s-1 for the velocity dispersion of AndXXII, [Fe/H] ~ -1.6 for its metallicity, and 255pc for the Plummer radius of its projected density profile. We construct a colour magnitude diagram for AndXXII and identify both the red giant branch and the horizontal branch. The position of the latter is used to derive a heliocentric distance to And XXII of 853 pm 26 kpc. The combination of the radial velocity, distance, and angular position of AndXXII indicates that it is a strong candidate for being the first known satellite of M33 and one of the very few examples of a galactic satellite of a satellite. N-body simulations imply that this conclusion is unchanged even if M31 and M33 had a strong encounter in the past few Gyr. We test the hypothesis that the extended clusters highlight tidally stripped galaxies by searching for an excess cloud of halo-like stars in their vicinity. We find such a cloud for the case of EC1 but not EC2. The three objects imply a dynamical mass for M33 that is consistent with previous estimates.Comment: 14 pages, 14 figures, revised for MNRAS publicatio

The photometric properties of a vast stellar substructure in the outskirts of M33

We have surveyed $\sim40$sq.degrees surrounding M33 with CFHT MegaCam in the g and i filters, as part of the Pan-Andromeda Archaeological Survey. Our observations are deep enough to resolve the top 4mags of the red giant branch population in this galaxy. We have previously shown that the disk of M33 is surrounded by a large, irregular, low-surface brightness substructure. Here, we quantify the stellar populations and structure of this feature using the PAndAS data. We show that the stellar populations of this feature are consistent with an old population with $\sim-1.6$dex and an interquartile range in metallicity of $\sim0.5$dex. We construct a surface brightness map of M33 that traces this feature to $\mu_V\simeq33$mags\,arcsec$^{-2}$. At these low surface brightness levels, the structure extends to projected radii of $\sim40$kpc from the center of M33 in both the north-west and south-east quadrants of the galaxy. Overall, the structure has an "S-shaped" appearance that broadly aligns with the orientation of the HI disk warp. We calculate a lower limit to the integrated luminosity of the structure of $-12.7\pm0.5$mags, comparable to a bright dwarf galaxy such as Fornax or AndII and slightly less than $1\$ of the total luminosity of M33. Further, we show that there is tentative evidence for a distortion in the distribution of young stars near the edge of the HI disk that occurs at similar azimuth to the warp in HI. The data also hint at a low-level, extended stellar component at larger radius that may be a M33 halo component. We revisit studies of M33 and its stellar populations in light of these new results, and we discuss possible formation scenarios for the vast stellar structure. Our favored model is that of the tidal disruption of M33 in its orbit around M31.Comment: Accepted for publication in ApJ. 17 figures. ApJ preprint forma

The Andromeda Stream

The existence of a stream of tidally stripped stars from the Sagittarius Dwarf galaxy demonstrates that the Milky Way is still in the process of accreting mass. More recently, an extensive stream of stars has been uncovered in the halo of the Andromeda galaxy (M31), revealing that it too is cannibalizing a small companion. This paper reports the recent observations of this stream, determining it spatial and kinematic properties, and tracing its three-dimensional structure, as well as describing future observations and what we may learn about the Andromeda galaxy from this giant tidal stream.Comment: 3 Pages. Refereed contribution to the 5th Galacto Chemodynamics conference held in Swinburne, July 2003. Accepted for publication in PAS