Introducing Advanced Paramedics into the rural general practice team in Ireland – general practitioners attitudes

Introduction: As Ireland’s population increases and chronic disease becomes more prevalent, demand on limited  general practice services will increase. Nursing roles within general practice are now considered to be standard, yet  alternative allied health professional roles are under explored within an Irish context. Allied health personnel such as  Advanced Paramedics (APs) may have the capability to provide support to general practice. Aim: To explore General Practitioners’ (GPs) attitudes and opinions of integrating Advanced Paramedics (APs) into  rural general practice in Ireland. Methods: A sequential explanatory mixed methodology was adopted. A questionnaire was designed and distributed to a purposeful sample of GPs attending a rural conference followed by semi-structured interviews. Data was  recorded and transcribed verbatim and thematically analysed. Results: In total n=27 GPs responded to the survey and n=13 GPs were interviewed. The majority of GPs were  familiar with APs and were receptive to the concept of closely collaborating with APs within a variety of settings  including out-of-hours services, home visits, nursing homes and even roles within the general practice surgery. Conclusion: General Practitioner and Advanced Paramedic clinical practice dovetail within many facets of primary  care and emergency care. GPs recognise that current rural models are unsustainable and realise the potential of integrating APs into the general practice team to help support and sustain the future of rural general practice services in  Ireland. These interviews provided an exclusive, detailed insight into the world of general practice in Ireland that has  not been previously documented in this way. </p

Antidepressant medication prescribing patterns in Irish General Practice from 2016 to 2020 to assess for long term use

Background/aims The aim of this study was to identify the trends in antidepressant (AD) medication use in two Irish general practices over a 5-year period, 2016 to 2020. The rationale for this study is attributed to the growing prevalence of depression amongst the Irish general public as well as concerns surrounding long-term AD medication use. Methods The research was undertaken in 2021 examining AD prescription rates from 2016 to 2020. The medications of interest were selective serotonin and norepinephrine reuptake inhibitors (SSRI and SNRIs): sertraline, escitalopram, fuoxetine and venlafaxine. The number of medical card holders (MCH) and prescription dispensing rates were analysed for observable trends. Results AD medication use is rising amongst the Irish MCH population. The number of MCH prescribed AD grew from 9.42 to 12.3 per 100 MCH between the years 2016 and 2020, respectively. The year 2020 represented the largest proportion of MCH prescriptions, 6.32 AD prescriptions per 1000 MCH prescriptions. The years 2019 to 2020 represented the largest annual increase in prescription dispensing with a growth of 0.45 per 1000 MCH prescriptions. Annual fgures show a continual increase in AD dispensing refll rates from 4.14 to 5.67 per 1000 MCH prescriptions in 2016 and 2020, respectively. Conclusion This study illustrates a steady rise in AD medication within the general practice setting, with an observed rise in prescription dispensing rates. The high proportion of refll prescriptions demonstrates the long-term use of AD medications. This may be indicative of chronic depression or may highlight a lack of appropriate medication cessation strategies

Physical activity and hypertension

Hypertension and physical inactivity are leading causes of premature mortality. While both are modifiable risk factors for cardiovascular disease, their prevalence remains high. As populations grow older, they are more likely to develop hypertension and to become less physically active. Scientific advances have contributed to understanding of how physical activity improves blood pressure and the clinically relevant ambulatory blood pressure, but this is not reflected in hypertension guidelines for clinical management of hypertension. The aim of this paper is to clearly present up to date knowledge from scientific studies that underpin the role of physical activity in hypertension management. Longitudinal studies in this review demonstrate a protective effect of higher physical activity levels as well as higher levels of cardiorespiratory fitness. Interventional studies report improvements in blood pressure associated with aerobic, resistance and concurrent exercise; the improvements in some studies were greatest among participant groups with established hypertensions; the effect was observed for groups with treatment-resistant hypertension also, a clinically important subgroup. The most recent research provides evidence for the synergy between physical activity and pharmacotherapy for the treatment of hypertension, providing an opportunity for clinicians to promote physical activity as an adjunctive treatment for hypertension as well as a preventative strategy. This review critiques the evidence and summarises the most up to date literature in the field of physical activity and hypertension.</p

The effect of semaglutide on blood pressure in patients without diabetes: A systematic review and meta-analysis

(1) Background: Recent advances in the pharmacological treatment of obesity with glucagon-like peptide-1 receptor agonists (GLP-1 RA) highlight the potential to target excess body weight to improve blood pressure (BP). This review aimed to determine the BP reduction in trials of semaglutide for weight reduction in patients without diabetes. (2) Methods: Relevant studies were identified via a search of research databases. Studies were screened to include randomized controlled trials (RCTs) of semaglutide versus a placebo in adults. Pooled and sensitivity analyses were performed, and risk of bias was assessed. (3) Results: six RCTs, with 4744 participants, were included in the final analysis. At baseline, the cohorts in these studies had a mean BP in the normotensive range. The mean difference in systolic BP was −4.83 mmHg (95% CI: −5.65 to −4.02), while that for diastolic BP was −2.45 mmHg (95% CI: −3.65 to −1.24). All included studies were of a high methodological quality. (4) Conclusions: A clinically significant reduction in BP was evident following semaglutide treatment in normotensive populations without diabetes. The effect of semaglutide in those with obesity and hypertension is as yet undetermined. Targeting excess body weight may be a novel therapeutic strategy for these patients.</p

Towards an integrated blood pressure self-monitoring solution for stroke/TIA in Ireland: a mixed methods feasibility study for the TASMIN5S IRL randomised controlled trial

Background Optimising blood pressure (BP) control is one of the most important modifable risk factors in preventing subsequent stroke where the risk increases by one-third for every 10 mmHg rise in systolic BP. This study evaluated the feasibility and potential efectiveness of blood pressure self-monitoring with planned medication titration, to inform a defnitive trial of the intervention, in patients with a previous stroke or transient ischaemic attack (TIA). Methods Patients with a history of stroke/TIA and sub-optimal BP control were invited to take part in a mixed methods feasibility study for a randomised controlled trial. Those meeting the inclusion criteria with systolic BP >130 mmHg were randomised to a self-monitoring intervention group or usual care group. The intervention involved self-monitoring BP twice a day for 3 days within a 7-day period, every month, following text message reminders. Treatment escalation, based on a pre-agreed plan by the general practitioner (GP) and patient, was initiated according to the results of these readings. Semi-structured interviews were carried out with patients and clinicians and analysed thematically. Results Of those identifed, 47% (32/68) attended for assessment. Of those assessed, 15 were eligible for recruitment and were consented and randomised to the intervention or control group on a 2:1 basis. Of those randomised, 93% (14/15) completed the study and there were no adverse events. Systolic BP was lower in the intervention group at 3 months. Participants found the intervention acceptable and easy to use. GPs found it easy to incorporate into their practice activity without increasing workload. Conclusions TASMIN5S, an integrated blood pressure self-monitoring intervention in patients with a previous stroke/TIA, is feasible and safe to deliver in primary care. A pre-agreed three-step medication titration plan was easily implemented, increased patient involvement in their care, and had no adverse efects. This feasibility study provides important information to inform a defnitive trial to determine the potential efectiveness of the intervention in patients post-stroke or TIA.</p

Lessons learned from a pandemic: implications for a combined exercise and educational programme for medical students

Background: The ‘MED-WELL’ programme is a combined exercise and educational intervention designed to promote well-being among medical students and educate students about prescribing exercise as medicine in clinical practice. Due to COVID-19 public health restrictions of social distancing the ‘MED-WELL’ programme was ofered online instead  of in-person in 2021. The aim of this study is to compare the experiences of participants in the ‘MED-WELL’ programme  online to those that previously participated in the same programme in-person to understand the student experience  and optimize programme delivery. Methods: Purposive sampling was used to recruit 20 participants to a qualitative study using semi-structured interviews. Ten study participants took part in the ‘MED-WELL’ programme when it was ofered in-person, and the other ten  study participants took part in the programme when it was ofered online. All interviews were audio-recorded and  transcribed using Microsoft Teams. A combined inductive and deductive approach was used for analysis. An inductive  thematic analysis was utilized to categorize data into higher order codes, themes, and overarching themes. The theory  of online learning provided the theoretical framework for a deductive approach. Results: Analysis of the data produced fve overarching themes: ‘student-student’, ‘student-teacher’, ‘student-content’,  ‘student-environment’, and ‘efects of a pandemic’. The frst four themes detail distinct types of interaction that participants had with various entities of the 'MED-WELL’ programme and the efects that these interactions had on participant experiences. ‘Efects of a pandemic’ refers to the context of delivering the ‘MED-WELL’ programme online during  a pandemic and how this mode of delivery infuenced participants and the programme. Conclusions: Optimizing the ‘MED-WELL’ programme relies on an understanding of how participants interact with  diferent entities of the programme and are motivated to attend and engage. Participants tended to favour an in-person mode of delivery, however certain advantages of delivering the programme online were also identifed. The fndings from this study can be used to inform similar experiential and educational exercise interventions, and may  help plan for potential future restrictions on in-person educational and exercise-based programmes. </p

Measuring adherence to therapy in apparent treatment-resistant hypertension: a feasibility study in Irish primary care

BACKGROUND: Apparent treatment-resistant hypertension (aTRH) is defined as uncontrolled blood pressure (BP) in patients taking three or more antihypertensive medications. Some patients will have true treatment-resistant hypertension, some undiagnosed secondary hypertension, while others have pseudo-resistance. Pseudo-resistance occurs when non-adherence to medication, white-coat hypertension (WCH), lifestyle, and inadequate drug dosing are responsible for the poorly controlled BP. AIM: To examine the feasibility of establishing non-adherence to medication, for the first time in primary care, using mass spectrometry urine analysis. Operationalisation would be established by at least 50% of patients participating and 95% of samples being suitable for analysis. Clinical importance would be confirmed by >10% of patients being non-adherent. DESIGN AND SETTING: Eligible patients with aTRH (n = 453) in 15 university research-affiliated Irish general practices were invited to participate. METHOD: Participants underwent mass spectrometry urine analysis to test adherence and ambulatory BP monitoring (ABPM) to examine WCH. RESULTS: Of the eligible patients invited, 52% (n = 235) participated. All 235 urine samples (100%) were suitable for analysis: 174 (74%) patients were fully adherent, 56 (24%) partially adherent, and five (2%) fully non-adherent to therapy. A total of 206 patients also had ABPM, and in total 92 (45%) were categorised as pseudo-resistant. No significant associations were found between adherence status and patient characteristics or drug class. CONCLUSION: In patients with aTRH, the authors have established that it is feasible to examine non-adherence to medications using mass spectrometry urine analysis. One in four patients were found to be partially or fully non-adherent. Further research on how to incorporate this approach into individual patient consultations and its associated cost-effectiveness is now appropriate

The University of Limerick education and research network for general practice (ULEARN-GP): practice characteristics and general practitioner perspectives

Background: A well-functioning general practice sector that has a strong research component is recognised as a key foundation of any modern health system. General practitioners (GPs) are more likely to collaborate in research if they are part of an established research network. The primary aims of this study are to describe Ireland’s newest general practice-based research network and to analyse the perspectives of the network’s members on research engagement. Method: A survey was sent to all GPs participating in the network in order to document practice characteristics so that this research network’s profile could be compared to other national profiles of Irish general practice. In depth interviews were then conducted and analysed thematically to explore the experiences and views of a selection of these GPs on research engagement. Results: All 134 GPs responded to the survey. Practices have similar characteristics to the national profile in terms of location, size, computerisation, type of premises and out of hours arrangements. Twenty-two GPs were interviewed and the resulting data was categorised into subthemes and four related overarching themes: GPs described catalysts for research in their practices, the need for coherence in how research is understood in this context, systems failures, whereby the current health system design is prohibitive of GP participation and aspirations for a better future. Conclusion: This study has demonstrated that the research network under examination is representative of current trends in Irish general practice. It has elucidated a better understanding of factors that need to be addressed in order to encourage more GPs to engage in the research process