Randomised controlled feasibility trial of a web-based weight management intervention with nurse support for obese patients in primary care

<b>Background</b><p></p> There is a need for cost-effective weight management interventions that primary care can deliver to reduce the morbidity caused by obesity. Automated web-based interventions might provide a solution, but evidence suggests that they may be ineffective without additional human support. The main aim of this study was to carry out a feasibility trial of a web-based weight management intervention in primary care, comparing different levels of nurse support, to determine the optimal combination of web-based and personal support to be tested in a full trial.<p></p> <b>Methods</b><p></p> This was an individually randomised four arm parallel non-blinded trial, recruiting obese patients in primary care. Following online registration, patients were randomly allocated by the automated intervention to either usual care, the web-based intervention only, or the web-based intervention with either basic nurse support (3 sessions in 3 months) or regular nurse support (7 sessions in 6 months). The main outcome measure (intended as the primary outcome for the main trial) was weight loss in kg at 12 months. As this was a feasibility trial no statistical analyses were carried out, but we present means, confidence intervals and effect sizes for weight loss in each group, uptake and retention, and completion of intervention components and outcome measures.<p></p> <b>Results</b><p></p> All randomised patients were included in the weight loss analyses (using Last Observation Carried Forward). At 12 months mean weight loss was: usual care group (n = 43) 2.44 kg; web-based only group (n = 45) 2.30 kg; basic nurse support group (n = 44) 4.31 kg; regular nurse support group (n = 47) 2.50 kg. Intervention effect sizes compared with usual care were: d = 0.01 web-based; d = 0.34 basic nurse support; d = 0.02 regular nurse support. Two practices deviated from protocol by providing considerable weight management support to their usual care patients.<p></p> <b>Conclusions</b><p></p> This study demonstrated the feasibility of delivering a web-based weight management intervention supported by practice nurses in primary care, and suggests that the combination of the web-based intervention with basic nurse support could provide an effective solution to weight management support in a primary care context

Abstracts from the NIHR INVOLVE Conference 2017

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Web-based resources to assist the statistical analysis and presentation of data.

The intention of this article is to highlight sources of web-based reference material, courses and software that will aid statisticians and researchers. The article includes websites that: assist in writing a protocol or proposal; link to online statistical textbooks; and provide statistical calculators or links to free statistical software and other guidance documents

Explaining the rise in antidepressant prescribing: a descriptive study using the general practice research database

Objective: to explore the reasons behind the recent increase in antidepressant prescribing in the United Kingdom. Design: detailed retrospective analysis of data on general practitioner consultations and antidepressant prescribing. Data source: data were obtained from the general practice research database, which contains linked anonymised records of over 3 million patients registered in the UK. Data were extracted for all new incident cases of depression between 1993 and 2005. Review methods: detailed analysis of general practitioner consultations and antidepressant prescribing was restricted to 170 practices that were contributing data for the full duration of the study. Results: in total, 189 851 people within the general practice research database experienced their first episode of depression between 1993 and 2005, of whom 150 825 (79.4%) received a prescription for antidepressants in the first year of diagnosis. This proportion remained stable across all the years examined. The incidence of new cases of depression rose in young women but fell slightly in other groups such that overall incidence increased then declined slightly (men: 7.83 cases per 1000 patient years in 1993 to 5.97 in 2005, women: 15.83 cases per 1000 patient years in 1993 to 10.06 in 2005). Antidepressant prescribing nearly doubled during the study period—the average number of prescriptions issued per patient increased from 2.8 in 1993 to 5.6 in 2004. The majority of antidepressant prescriptions were given as long term treatment or as intermittent treatment to patients with multiple episodes of depression. Conclusions: the rise in antidepressant prescribing is mainly explained by small changes in the proportion of patients receiving long term treatment. Previous clinical guidelines have focused on antidepressant initiation and appropriate targeting of antidepressants. To address the costly rise in antidepressant prescribing, future research and guidance needs to concentrate on appropriate long term prescribing for depression and regular review of medication<br/

Technical and measurement report. Simple anatomical information improves the accuracy of locating specific spinous processes during manual examination of the low back

The objective of the study was to test whether a teaching protocol including simple anatomical information on the surface anatomy of spinous processes, improves physiotherapy students' ability to accurately locate selected thoracic and lumbar spinal segments - T12 and L3. First year physiotherapy students were allocated to Group 1 (n=35) and Group 2 (n=34). Both groups were taught to identify spinous processes by counting up from the sacrum, but Group 2 received supplementary anatomical information on the shapes and vertical length of the tips of L5 to T12 spinous processes. The spinous processes of L3 and T12 were located by two experienced physiotherapists and marked on a model using an invisible skin marker. Volunteer students were asked to locate these spinous processes and accuracy was confirmed using an ultraviolet lamp. Students with supplementary anatomical information (Group 2) were significantly better at locating T12 (difference in proportions 36% (95% confidence interval 14 to 51%)) and both T12 and L3 (difference in proportions 33% (11 to 48%)). Group 2 students were also better than Group 1 students at locating L3 (difference in proportions 28% (4 to 48%)), but the difference was not significant. Including simple anatomical information when teaching manual examination skills improved the accuracy of locating specific low back spinal levels

Suicide in schizophrenia: a retrospective case-control study of 51 suicides

The aim of this study was to identify factors associated with suicide in patients with schizophrenia who required inpatient admission and to compare these factors with the risk profile of patients with other diagnoses also requiring inpatient care. A retrospective, matched case-control study of 51 patients with schizophrenia requiring psychiatric inpatient care was undertaken. A priori specified risk factors were investigated within the schizophrenia group and compared with those of patients with other psychiatric diagnoses. The results show that previous suicide attempts are associated with an increased risk of suicide across all diagnoses. The presence of depressive symptoms and involvement of police with the index admission become more significant factors in patients with schizophrenia, compared to those with other diagnoses. Supportive mental health accommodation is associated with a reduced risk of suicide. Suicide of individuals is difficult to predict in patients with schizophrenia. Young men appear particularly vulnerable at times of inpatient care. Depressive symptoms and previous suicide attempts are significant risk factors

Needs of carers of severely disabled people: are they identified and met adequately?

Objective:To examine the unmet needs of informal carers of community dwelling disabled people and to compare their perspectives to those of disabled people and nominated professionals. It was hypothesised that a poor recognition of carers' needs could have implications for carers' well- being and thus their ability to maintain their caring role. Need was defined as a service or a resource that would confer a health or rehabilitation gain.Design:Face to face interviews with carers and disabled participants, telephone interviews with professionals (Southern England). Disabled participants had been selected randomly from two disability registers.Main outcome measures:The Southampton Needs Assessment Questionnaire (carers version), SF-36 (carers' health status).Results:Carers experienced similar health status to people in the general population. The most frequently carer-reported unmet needs were for short breaks, domestic help and respite care. Carers who had reported unmet need for short breaks had significantly poorer levels of mental health and vitality (SF-36) than carers who had not reported this. Similar numbers of unmet carers' needs were reported by disabled participants, professionals and carers themselves. In terms of type of unmet needs, poor concordance between carers and disabled participants occurred in 52% of cases: carers reported more unmet needs than disabled participants for short breaks and domestic help. Poor concordance scores between carers and professionals occurred in 59% of cases: carers reported more unmet needs for short breaks than professionals and professionals reported more unmet needs for formal respite care.Conclusion:In line with recent legislation, carers' needs must be independently addressed and services, especially for flexible community support such as short break services, must be developed specifically to meet the needs of carers. Further research is warranted to evaluate whether recent legislation for carers has any effect on carers' well-being and ability to cope with their caring role

Patient characteristics and outcomes of cardiac rehabilitation

PURPOSE: To investigate changes in physical fitness and psychological characteristics of patients after cardiac rehabilitation, and to assess predictors of defaulting from the program.METHODS: A prospective study of 1902 consecutive patients admitted to a community-based, hospital-linked cardiac rehabilitation program was conducted over a period of 6 years and 7 months. The cardiac rehabilitation program centered on a 2-to 6-month circuit training course with education, stress management, relaxation, and risk factor monitoring. Before and after the program, measures of physical fitness and of hospital anxiety and depression were performed.RESULTS: The course was completed by 1443 patients (76%), with 240 patients (13%) defaulting. For those who completed the course, peak oxygen consumption per minute increased by 3.2 mL/min/kg (95% confidence interval [CI], 3.1-3.4) or 19% (95% CI, 17.7%-20.3%). According to the hospital anxiety and depression scores, anxiety fell by 1.1 (95% CI, -1.3 to -0.98) and depression by 1.3 (95% CI, -1.4 to -1.2). The main predictors of defaulting were depression (patients with depression were twice as likely to default as nondepressed patients) and diagnosis (patients who had experienced angina or percutaneous transluminal coronary angioplasty were twice as likely to default as those who had experienced infarct or coronary artery bypass graft).CONCLUSIONS: The identification of depressed coronary patients known to be at increased risk should be a priority for cardiac rehabilitation coordinators. Every effort should be made to keep them in the cardiac rehabilitation program

Frequency and impact of nonadherence to immunosuppressants after renal transplantation: a systematic review

Nonadherence to immunosuppressants is recognized to occur after renal transplantation, but the size of its impact on transplant survival is not known. A systematic literature search identified 325 studies (in 324 articles) published from 1980 to 2001 reporting the frequency and impact of nonadherence in adult renal transplant recipients. Thirty-six studies meeting the inclusion criteria for further review were grouped into cross-sectional and cohort studies and case series. Meta-analysis was used to estimate the size of the impact of nonadherence on graft failure. Only two studies measured adherence using electronic monitoring, which is currently thought to be the most accurate measure. Cross-sectional studies (n=15) tended to rely on self-report questionnaires, but these were poorly described; a median (interquartile range) of 22% (18%-26%) of recipients were nonadherent. Cohort studies (n=10) indicated that nonadherence contributes substantially to graft loss; a median (interquartile range) of 36% (14%-65%) of graft losses were associated with prior nonadherence. Meta-analysis of these studies showed that the odds of graft failure increased sevenfold (95% confidence interval, 4%-12%) in nonadherent subjects compared with adherent subjects. Standardized methods of assessing adherence in clinical populations need to be developed, and future studies should attempt to identify the level of adherence that increases the risk of graft failure. However, this review shows nonadherence to be common and to have a large impact on transplant survival. Therefore, significant improvements in graft survival could be expected from effective interventions to improve adherence