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

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

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 extent of public green space and alien plant species in 10 small towns of the sub-tropical Thicket Biome, South Africa

Urban areas in developing countries will accommodate nearly 90% of the projected world population increase between 1995 and 2030. Despite this, few studies, especially in smaller towns, have been carried out on urban green space areas in the developing world. This paper makes a first step in this regard, reporting on the extent and state of urban green spaces within 10 small towns in the Eastern Cape (South Africa). After measuring the size and state (in terms of woody plant cover) of public green space, we then sought patterns across the 10 towns between green space attributes, such as area, density, mean size and proportion of alien or indigenous, with socio-economic attributes of the towns. The area and state of current public green space varied markedly between the towns, with the poorer towns faring the worst. Lower income levels were significantly negatively correlated with the area and quality of public green space. Despite this, human population density and per capita green space were the best predictors of the proportion and mean area of public green space present in the towns. The proportion of town green space and the per capita green space were the best predictors of changes in woody plant composition and density

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

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

Maternal thyroid function and child educational attainment: prospective cohort study

Objective: To determine if first trimester maternal thyroid dysfunction is a critical determinant of child scholastic performance and overall educational attainment. Design: Prospective cohort study. Setting: Avon Longitudinal Study of Parents and Children cohort in the UK. Participants: 4615 mother-child pairs with an available first trimester sample (median 10 weeks gestation, interquartile range 8-12). Exposures: Free thyroxine, thyroid stimulating hormone, and thyroid peroxidase antibodies assessed as continuous measures and the seven clinical categories of maternal thyroid function. Main outcome measures: Five age-specific national curriculum assessments in 3580 children at entry stage assessment at 54 months, increasing up to 4461 children at their final school assessment at age 15. Results: No strong evidence of clinically meaningful associations of first trimester free thyroxine and thyroid stimulating hormone levels with entry stage assessment score or Standard Assessment Test scores at any of the key stages was found. Associations of maternal free thyroxine or thyroid stimulating hormone with the total number of General Certificates of Secondary Education (GCSEs) passed (range 0-16) were all close to the null: free thyroxine, rate ratio per pmol/L 1.00 (95% confidence interval 1.00 to 1.01); and thyroid stimulating hormone, rate ratio 0.98 (0.94 to 1.02). No important relationship was observed when more detailed capped scores of GCSEs allowing for both the number and grade of pass or when language, mathematics, and science performance were examined individually or when all educational assessments undertaken by an individual from school entry to leaving were considered. 200 (4.3%) mothers were newly identified as having hypothyroidism or subclinical hypothyroidism and 97 (2.1%) subclinical hyperthyroidism or hyperthyroidism. Children of mothers with thyroid dysfunction attained an equivalent number of GCSEs and equivalent grades as children of mothers with euthyroidism. Conclusions: Maternal thyroid dysfunction in early pregnancy does not have a clinically important association with impaired child performance at school or educational achievement