Blood pressure control in patients with a previous stroke/transient ischaemic attack in primary care in Ireland: a cross sectional study

Background: Uncontrolled blood pressure (BP) is an important modifiable risk factor for recurrent stroke. Secondary prevention measures when implemented can reduce stroke re-occurrence by 80%. However, hypertension control rates remain sub-optimal, and little data is available from primary care where most management occurs. The aim of this study was to describe BP control in primary care-based patients with a previous stroke or transient ischaemic attack (TIA) in Ireland, and to concurrently examine antihypertensive medication-dosing. Methods: Study participants most recent office-based BP reading was compared with the NICE (NG136) and European Society of Hypertension/ European Society of Cardiology (ESH/ESC 2013) goal of BP < 140/90 mmHg. Optimal anti-hypertensive medication dosing was determined by benchmarking prescribed doses for each drug with the World Health Organisation-Defined Daily Dosing (WHO-DDD) recommendations. Results: We identified 328 patients with a previous stroke or TIA in 10 practices. Blood pressure was controlled in almost two thirds of patients when measured against the ESH/ESC and NICE guidelines (63.1%, n = 207). Of those with BP ≥140/90 (n = 116), just under half (n = 44, 47.3%) were adequately dosed in all anti-hypertensive medications when compared with the WHO-DDD recommendations. Conclusion: Blood pressure control in patients post stroke/TIA appears sub-optimal in over one third of patients. A comparison of drug doses with WHO-DDD recommendations suggests that 47% of patients may benefit from drug-dose improvements. Further work is required to assess how best to manage blood pressure in patients with a previous stroke or TIA in Primary Care, as most consultations for hypertension take place in this setting

Exploration of GP perspectives on deprescribing antidepressants: a qualitative study

Objective Our aim was to explore general practitioners’ (GPs) perceptions and experiences of discontinuing antidepressants. Study design A qualitative study using semi structured interviews was undertaken between July 2019 and March 2020. The interviews were transcribed and analysed using a thematic analysis framework. Setting GPs affiliated with a university education and research network for general practice in Ireland. Participants A purposive sample of GPs (n=10). Results Five themes emerged: shared decision-making; personalised therapy; medication-tapering toolkit; health service factors and concerns around tapering. GPs described being less likely to engage in deprescribing for patients with long-term and/or recurrent depression, older patients and those with comorbidities due to fear of relapse. Access to evidence-based psychological therapies, guidelines, information on rates of relapse, patient leaflets on discontinuing antidepressants and reminder prompts on GP-prescribing software were suggested to optimise appropriate antidepressant discontinuation. There was some suggestion that patients may use antidepressants for longer when talk therapy is not available or taken up. Conclusions GPs are largely confident in their role of managing mild-to-moderate depression and deprescribing antidepressants. This study provides an insight into factors that influence GPs’ decisions to deprescribe antidepressants. More information on rates of relapse after discontinuation would be helpful to inform decision-makin

Prognosis of patients with apparent treatment-resistant hypertension—a feasibility study

Background: Most cases of hypertension can be effectively treated with lifestyle changes together with medications, but within this population lies a group with more difficult to treat hypertension—those with apparent treatment-resistant hypertension (aTRH). The American Heart Association and the UK National Institute for Health and Care Excellence have both highlighted the need for further research into the prognosis of patients with resistant hypertension, both apparent and true. Methods: In 16 practices affiliated to a university research network, 646 patients had been identified with apparent treatment-resistant hypertension. To inform a planned full cohort study of these patients, we conducted a feasibility study within three practices to determine participation of practices and patients, availability of outcome measures and data collection times. Results: All three practices fully participated and 205/210 (98%) patients were followed up for a median of 23 months. Thirty-five outcome events of interest occurred—the most common was the new onset of retinopathy (9 cases). Eight percent (17/210) had the main composite outcome of death or serious incident cardiovascular event. Of the six patients who died, identification of cause of death was possible from practice records in five; the national General Register Office was successfully used for the final patient. There were 123 admissions, both day and overnight, recorded in 94 individual patients. Average manual systolic blood pressure measurements improved from baseline by 5 mmHg to 138 (SD 19) mmHg; diastolic remained the same at 75 (SD 12) mmHg. Average eGFR increased from 58.8 (SD17.4) to 66 (SD19.7) mls/min/1.73m2. The average time for data collection per patient was 12 mins. Conclusions: This study demonstrates that the proposed methodology for a full cohort study within general practice of patients with apparent treatment hypertension is both acceptable to practices and feasible. An adequately powered subsequent follow-up study of the entire cohort appears possible

Prevalence of treatment-resistant hypertension after considering pseudo-resistance and morbidity: a cross-sectional study in Irish primary care

Background To confirm treatment-resistant hypertension (TRH), ambulatory blood pressure measurement (ABPM) must exclude white-coat hypertension (WCH), three or more medications should be prescribed at the optimal doses tolerated, and non-adherence and lifestyle should be examined. Most previous studies have not adequately considered pseudo-resistance and merely provide an apparent TRH (aTRH) prevalence figure. Aim To conduct a cross-sectional study of the prevalence of aTRH in general practice, and then consider pseudo-resistance and morbidity. Design and setting With support, 16 practices ran an anatomical therapeutic chemical (ATC) drug search, identifying patients on any possible hypertensive medications, and then a search of individual patients' electronic records took place. Method ABPM was used to rule out WCH. The World Health Organization-defined daily dosing guidelines determined adequate dosing. Adherence was defined as whether patients requested nine or more repeat monthly prescriptions within the past year. Results Sixteen practices participated (n = 50 172), and 646 patients had aTRH. Dosing was adequate in 19% of patients, 84% were adherent to medications, as defined by prescription refill, and 43% had ever had an ABPM. Using a BP cut-off of 140/90 mmHg, the prevalence of aTRH was 9% (95% confidence interval [CI] = 9.0 to 10.0). Consideration of pseudo-resistance further reduced prevalence rates to 3% (95% CI = 3.0 to 4.0). Conclusion Reviewing individual patient records results in a lower estimate of prevalence of TRH than has been previously reported. Further consideration for individual patients of pseudo-resistance additionally lowers these estimates, and may be all that is required for management in the vast majority of cases

A feasibility study of an exercise intervention to educate and promote health and well-being among medical students: the ‘MED-WELL’ programme

Background: Medical School programme workloads challenge the physical and mental health of students particularly in compressed graduate entry programmes. There is evidence that physical activity (PA) can improve holistic care and help maintain wellness among medical students. We tested the feasibility of introducing an exercise programme to the medical school curriculum which would educate and promote health and well-being among its students. Methods: This study was conducted in a single graduate entry medical school at the University of Limerick (UL). The ‘MED-WELL’ programme was a six-week programme of 1 hour-long weekly sessions, each involving a different type of PA (45 min). These sessions were prefaced by an interactive lecture about how to incorporate exercise theory into daily medical practice (15 min). The study was conducted in a single graduate entry medical school at UL and involved year one and year two graduate entry medical students. Three parameters were used to test feasibility: 1. Recruitment and retention of participants, 2. Acceptability of the programme and 3. Efficacy in terms of health and well-being. The latter was assessed by administering questionnaires pre and post the intervention. The questionnaires used the following validated measurement scales: EQ-VAS; WHO-5 Well-Being Index; 3-item Loneliness Scale; Social Support Measure 3-item scale. Free text boxes also encouraged participants to discuss the merits of the programme Results: In total, 26% (74/286 students) participated in the programme. Of those who participated, 69 students (93%) attended one or more sessions of the programme and completed questionnaires at baseline and at followup. Significant improvements were seen in scores after the programme in the WHO-5 Well-Being Index which increased from 63.2 (95%CI: 48–78.4) to 67.5 (95%CI: 55.1–79.9); (P < 0.01), the sleep scale which increased from 3.1 (95%CI: 2.2–4.0) to 3.5 (95%CI: 2.5–4.5); (P < 0.001), and the loneliness scale which decreased from 4.1 (95%CI: 2.7– 5.5) to 3.5 (95%CI: 2.5–4.5); (P < 0.005). Students level of PA during a typical week also increased from 3.7 (95%CI: 2.1–5.4) to 4.0 (95%CI, 3.5–4.5); (P < 0.05). Conclusion: This study has shown it is feasible to deliver this programme in a medical school’s curriculum. The programme seems to be of benefit and is acceptable to students. Well-designed randomised controlled trials are needed to measure outcomes, durability of effect, and cost effectivenes

Study subject disposition and allocation to dosing cohorts.

<p>(A): Thirty eight subjects were screened for the study, with 23 randomised and 18 completing the study. (B): Diagram showing the planned study allocation to dose escalating cohorts (5∶2) and with sentinel cohorts (1∶1) shown for the 12 mg, 24 mg and 48 mg dose groups.</p

OPAL-HIV-Gag(c) and CMV peptide pool specific CD4+ T-cell responses before and after vaccination.

<p>All six subjects from each dose group (0 mg, 12 mg and 24 mg) were tested for OPAL-HIV-Gag(c) specific or no peptide (mock) responses by ICS shown as IFNγ+/MIP1β+ double positive CD4+ T-cells processed from frozen PBMCs derived at week 0, 13 and 14 after first vaccination expressed as the mean of triplicate stimulations (A) and expressed as median values within dose groups with error bars representing inter quartile ranges for OPAL-HIV-Gag(c) (B) and for CMV specific CD4+ T-cell responses (C).</p

OPAL-HIV-Gag(c) and CMV peptide pool specific CD8+ T-cell responses before and after vaccination.

<p>All six subjects from each dose group (0 mg, 12 mg and 24 mg) were tested for OPAL-HIV-Gag(c) specific or no peptide (no stimulation) responses by ICS shown as IFNγ+/MIP1β+ double positive CD8+ T-cells processed from frozen PBMCs derived at week 0, 13 and 14 after first vaccination expressed as the mean of triplicate stimulations (A) and expressed as median values within dose groups with error bars representing inter quartile ranges for OPAL-HIV-Gag(c) (B) and for CMV specific CD8+ T-cell responses (C).</p

Transient and treatment specific lymphopenia after vaccination.

<p>Total lymphocyte counts were performed before, during and at follow up after vaccination as indicated on the x-axis for the three groups (0 mg, 12 mg and 24 mg) and shown as mean values (million lymphocytes per ml whole blood) for the 6 subjects within each group with normal high and low values for HIV positive individuals indicated by dotted lines (A). Arrows indicate vaccinations. The percent (%) change of lymphocyte count from baseline (week 0) is shown as mean values for the three dose groups with error bars representing standard error of mean (SEM) (B). Only one subject (024) was available for the 48 mg dose group at week 0 and 4.</p

OPAL-HIV-Gag(c) peptide pool specific responses before and after vaccination.

<p>All six subjects from each dose group (0 mg, 12 mg and 24 mg) were tested for OPAL-HIV-Gag(c) specific or no peptide (mock) responses by IFNγ ex vivo ELIspot performed from fresh cells at week 0, 10, 12, 13, 14 and 16 after first vaccination expressed as the mean SFU per million cells of triplicate stimulations (A) and expressed as median values within dose groups with error bars representing inter quartile ranges (B).</p