Publications by authors named "Phyo Kyaw Myint"

109 Publications

Barriers and facilitators to reducing anticholinergic burden: a qualitative systematic review.

Int J Clin Pharm 2021 Jun 25. Epub 2021 Jun 25.

General Practice and Primary Care, University of Glasgow, Glasgow, UK.

Background Despite common use, anticholinergic medications have been associated with serious health risks. Interventions to reduce their use are being developed and there is a need to understand their implementation into clinical care. Aim of review This systematic review aims to identify and analyse qualitative research studies exploring the barriers and facilitators to reducing anticholinergic burden. Methods Medline (OVID), EMBASE (OVID), CINAHL (EMBSCO) and PsycINFO (OVID) were searched using comprehensive search terms. Peer reviewed studies published in English presenting qualitative research in relation to the barriers and facilitators of deprescribing anticholinergic medications, involving patients, carers or health professionals were eligible. Normalization Process Theory was used to explore and explain the data. Results Of 1764 identified studies, two were eligible and both involved healthcare professionals (23 general practitioners, 13 specialist clinicians and 12 pharmacists). No studies were identified that involved patients or carers. Barriers to collaborative working often resulted in poor motivation to reduce anticholinergic use. Low confidence, system resources and organisation of care also hindered anticholinergic burden reduction. Good communication and relationships with patients, carers and other healthcare professionals were reported as important for successful anticholinergic burden reduction. Having a named person for prescribing decisions, and clear role boundaries, were also important facilitators. Conclusions This review identified important barriers and facilitators to anticholinergic burden reduction from healthcare provider perspectives which can inform implementation of such deprescribing interventions. Studies exploring patient and carer perspectives are presently absent but are required to ensure person-centeredness and feasibility of future interventions.
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http://dx.doi.org/10.1007/s11096-021-01293-4DOI Listing
June 2021

The relationship between alcohol intake and falls hospitalization: Results from the EPIC-Norfolk.

Geriatr Gerontol Int 2021 Aug 22;21(8):657-663. Epub 2021 Jun 22.

Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.

Aim: To evaluate the relationship between habitual alcohol consumption and the risk of falls hospitalization.

Methods: The EPIC-Norfolk is a prospective population-based cohort study in Norfolk, UK. In total, 25 637 community dwelling adults aged 40-79 years were recruited. Units of alcohol consumed per week were measured using a validated Food Frequency Questionnaire. The main outcome was the first hospital admission following a fall.

Results: Over a median follow-up period of 11.5 years (299 211 total person years), the cumulative incidence function (95% confidence interval) of hospitalized falls at 121-180 months for non-users, light (>0 to ≤7 units/week), moderate (>7 to ≤28 units/week) and heavy (>28 units/week) were 11.08 (9.94-12.35), 7.53 (7.02-8.08), 5.91 (5.29-6.59) and 8.20 (6.35-10.56), respectively. Moderate alcohol consumption was independently associated with a reduced risk of falls hospitalization after adjustment for most major confounders (hazard ratio = 0.88; 95% confidence interval 0.79-0.99). The relationship between light alcohol consumption and falls hospitalization was attenuated by gender differences. Alcohol intake higher than the recommended threshold of 28 units/week was associated with an increased risk of falls hospitalization (hazard ratio 1.40 [1.14-1.73]).

Conclusions: Moderate alcohol consumption appears to be associated with a reduced risk of falls hospitalization, and intake above the recommended limit is associated with an increased risk. This provides incentive to limit alcohol consumption within the recommended range and has important implications for public health policies for aging populations. Geriatr Gerontol Int 2021; 21: 657-663.
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http://dx.doi.org/10.1111/ggi.14219DOI Listing
August 2021

Anticholinergic burden measures and older people's falls risk: a systematic prognostic review.

Ther Adv Drug Saf 2021 31;12:20420986211016645. Epub 2021 May 31.

Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, UK.

Introduction: Several adverse outcomes have been associated with anticholinergic burden (ACB), and these risks increase with age. Several approaches to measuring this burden are available but, to date, no comparison of their prognostic abilities has been conducted. This PROSPERO-registered systematic review (CRD42019115918) compared the evidence behind ACB measures in relation to their ability to predict risk of falling in older people.

Methods: Medline (OVID), EMBASE (OVID), CINAHL (EMBSCO) and PsycINFO (OVID) were searched using comprehensive search terms and a validated search filter for prognostic studies. Inclusion criteria included: participants aged 65 years and older, use of one or more ACB measure(s) as a prognostic factor, cohort or case-control in design, and reporting falls as an outcome. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool.

Results: Eight studies reporting temporal associations between ACB and falls were included. All studies were rated high risk of bias in ⩾1 QUIPS tool categories, with five rated high risk ⩾3 categories. All studies (274,647 participants) showed some degree of association between anticholinergic score and increased risk of falls. Findings were most significant with moderate to high levels of ACB. Most studies (6/8) utilised the anticholinergic cognitive burden scale. No studies directly compared two or more ACB measures and there was variation in how falls were measured for analysis.

Conclusion: The evidence supports an association between moderate to high ACB and risk of falling in older people, but no conclusion can be made regarding which ACB scale offers best prognostic value in older people.

Plain Language Summary: One third of older people will experience a fall. Falls have many consequences including fractures, a loss of independence and being unable to enjoy life. Many things can increase the chances of having a fall. This includes some medications. One type of medication, known as anticholinergic medication, may increase the risk of falls. These medications are used to treat common health issues including depression and bladder problems. Anticholinergic burden is the term used to describe the total effects from taking these medications. Some people may use more than one of these medications. This would increase their anticholinergic burden. It is possible that reducing the use of these medications could reduce the risk of falls. We need to carry out studies to see if this is possible. To do this, we need to be able to measure anticholinergic burden. There are several scales available, but we do not know which is best. We wanted to answer: 'Which anticholinergic scale is best at predicting the risk of falling in older people?'. We reviewed studies that could answer this. We did this in a systematic way to capture all published studies. We restricted the search in several ways. We only included studies relevant to our question. We found eight studies. We learned that people who are moderate to high users of these medications (often people who will use more than one of these medications) had a higher risk of falling. It was less clear if people who have a lower burden (often people who only use one of these medications) had an increased risk of falling. The low number of studies prevented us from determining if one scale was better than another. These findings suggest that we should reduce use of these medications. This could reduce the number falls and improve the well-being of older people.
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http://dx.doi.org/10.1177/20420986211016645DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8170331PMC
May 2021

Clinical frailty scale as a point of care prognostic indicator of mortality in COVID-19: a systematic review and meta-analysis.

EClinicalMedicine 2021 Jun 23;36:100896. Epub 2021 May 23.

Medical Sciences & Nutrition, University of Aberdeen School of Medicine, Aberdeen, United Kingdom.

Background: COVID-19 has resulted in the largest pandemic experienced since 1918, accounting for over 2 million deaths globally. Frail and older people are at the highest risk of mortality. The main objective of the present research was to quantify the impact of clinical frailty scale (CFS) by increasing severity of frailty and to identify other personal prognostic factors associated with increased mortality from COVID-19.

Methods: This study offers a contemporary systematic review and meta-analysis to analyse the stratified mortality risk by increasing CFS sub-categories (1-3, 4-5 and 6-9). Databases searched included EMBASE, MEDLINE, CAB Abstracts, PsychInfo, and Web of Science with end-search restriction the 18th December 2020. Publications identified via MedRevix were followed up on the 23rd March 2021 in peer-reviewed database search, and citations were updated as published. Prospective and retrospective cohort studies which reported the association between CFS and COVID-19 mortality were included. Thirty-four studies were eligible for systematic review and seventeen for meta-analysis, with 81-87% (I) heterogeneity.

Findings: All studies [N: 34] included patients from a hospital setting, comprising a total of 18,042 patients with mean age 72.8 (Min: 56; Max: 86). The CFS 4-5 patient group had significantly increased mortality when compared to patients with CFS 1-3 [(RE) OR 1.95 (1.32 (95% CI), 2.87 (95% CI)); I 81%;  = 0.0008]. Furthermore, CFS 6-9 patient group displayed an even more noticeable mortality increase when compared to patients with CFS 1-3 [(RE) OR 3.09 (2.03, 4.71); I 87%; <0.0001]. Generic inverse variance analysis of adjusted hazard ratio among included studies highlighted that CFS ( = 0.0001), male gender ( = 0.0009), National Early Warning Score ( = 0.0001), Ischaemic Heart Disease (IHD) ( = 0.07), Hypertension (HT) (<0.0001), and Chronic Kidney Disease (CKD) ( = 0.0009) were associated with increased COVID-19 mortality.

Interpretation: Our findings suggest a differential stratification of CFS scores in the context of COVID-19 infection, in which CFS 1-3 patients may be considered at lower risk, CFS 4-5 at moderate risk, and CFS 6-9 at high risk of mortality regardless of age. Overall, our study not only aims to alert clinicians of the value of CFS scores, but also highlight the multiple dimensions to consider such as age, gender and co-morbidities, even among moderately frail patients in relation to COVID-19 mortality.

Funding: None.
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http://dx.doi.org/10.1016/j.eclinm.2021.100896DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141355PMC
June 2021

FMALE score: Combining practical risk scales to improve preoperative predictive accuracy in emergency general surgery: A multi-centre prospective cohort study.

Am J Surg 2021 Apr 27. Epub 2021 Apr 27.

Department of Population Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XW, Wales, United Kingdom. Electronic address:

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http://dx.doi.org/10.1016/j.amjsurg.2021.04.009DOI Listing
April 2021

Systematic review of immunosuppressant guidelines in the COVID-19 pandemic.

Ther Adv Drug Saf 2021 10;12:2042098620985687. Epub 2021 Feb 10.

Professor of Medicine of Old Age, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Room 4.013, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland.

Aims: Individuals taking immunosuppressants are at increased susceptibility to viral infections in general. However, due to the novel nature of the COVID-19, there is a lack of evidence about the specific risks of the disease in this patient group. This systematic review aims to summarize the current international clinical guidelines to highlight areas where research is needed through critical appraisal of the evidence base of these guidelines.

Methods: We conducted a systematic review of clinical practice guidelines about the usage of immunosuppressants during the COVID-19 pandemic. Electronic databases including MEDLINE and the websites of relevant professional bodies were searched for English language guidelines that were published or updated between March 2020 and May 2020 in this area. We assessed the quality and consistency of guidelines. The evidence base underpinning these guidelines was critically appraised using GRADE criteria.

Results: Twenty-three guidelines were included. Most guidelines ( = 15, 65.2%) informed and updated evidence based on expert opinion. The methodological quality of the guidelines varied, ranging from 'very low' to 'moderate'. Guidelines consistently recommended that high-risk patients, including those who are taking high doses of steroids for more than a month, or a combination of two or more immunosuppressants, should be shielding during the outbreak. Most guidelines stated that steroids usage should not be stopped abruptly and advised on individualized risk-benefit analysis considering the risk of the effect of COVID-19 infection and the relapse of the autoimmune condition in patients.

Discussion: Clinical practice guidelines on taking immunosuppressants during the COVID-19 outbreak vary in quality. The level of evidence informing the available guidelines was generally low. Given the novel nature of COVID-19, the guidelines draw on existing knowledge and data, refer to the use of immunosuppressants and risks of serious infections of other aetiologies and have extrapolated these to form their evidence base.
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http://dx.doi.org/10.1177/2042098620985687DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7882764PMC
February 2021

Modified early warning score and risk of mortality after acute stroke.

Clin Neurol Neurosurg 2021 Mar 6;202:106547. Epub 2021 Feb 6.

Institute of Applied Health Sciences, University of Aberdeen, AB25 2ZD, UK. Electronic address:

Objective: An accurate prediction tool may facilitate optimal management of patients with acute stroke from an early stage. We evaluated the association between admission modified early warning score (MEWS) and mortality in patients with acute stroke.

Method: Data from the Anglia Stroke Clinical Network Evaluation Study (ASCNES) were analysed. We evaluated the association between admission MEWS and four outcomes; in-patient, 7-day, 30-day and 1-year mortality. Logistic regression models were used to calculate the odds of all mortality timeframes, whereas Cox proportional hazards models were used to calculate mortality at 1 year. Five univariate and multivariate models were constructed, adjusting for confounders. Patients with a moderate (2-3) or high (≥4) scores were compared to patients with a low score (0-1).

Results: The study population consisted of 2006 patients. A total of 1196 patients had low MEWS, 666 had moderate MEWS and 144 had a high MEWS. A high MEWS was associated with increased mortality as an in-patient (OR 4.93, 95 % CI: 2.88-8.42), at 7 days (OR 7.53, 95 % CI: 4.24-13.38), at 30 days (OR 5.74, 95 % CI: 3.38-9.76) and 1-year (HR 2.52, 95 % CI 1.88-3.39). At 1 year, model 5 had a 1.02 OR (95 % CI 0.83-1.24) with moderate MEWS and 2.52 (95 % CI 1.88-3.39) with high MEWS.

Conclusion: Elevated MEWS on admission is a potential marker for acute-stroke mortality and may therefore be a useful risk prediction tool, able to guide clinicians attempting to prognosticate outcomes for patients with acute-stroke.
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http://dx.doi.org/10.1016/j.clineuro.2021.106547DOI Listing
March 2021

Calcium intake, calcium supplementation and cardiovascular disease and mortality in the British population: EPIC-norfolk prospective cohort study and meta-analysis.

Eur J Epidemiol 2020 Dec 31. Epub 2020 Dec 31.

Ageing Clinical and Experimental Research (ACER) Team, University of Aberdeen, Aberdeen, UK.

The role of dietary calcium in cardiovascular disease prevention is unclear. We aimed to determine the association between calcium intake and incident cardiovascular disease and mortality. Data were extracted from the European Prospective Investigation of Cancer, Norfolk (EPIC-Norfolk). Multivariable Cox regressions analysed associations between calcium intake (dietary and supplemental) and cardiovascular disease (myocardial infarction, stroke, heart failure, aortic stenosis, peripheral vascular disease) and mortality (cardiovascular and all-cause). The results of this study were pooled with those from published prospective cohort studies in a meta-analsyis, stratifying by average calcium intake using a 700 mg/day threshold. A total of 17,968 participants aged 40-79 years were followed up for a median of 20.36 years (20.32-20.38). Compared to the first quintile of calcium intake (< 770 mg/day), intakes between 771 and 926 mg/day (second quintile) and 1074-1254 mg/day (fourth quintile) were associated with reduced all-cause mortality (HR 0.91 (0.83-0.99) and 0.85 (0.77-0.93), respectively) and cardiovascular mortality [HR 0.95 (0.87-1.04) and 0.93 (0.83-1.04)]. Compared to the first quintile of calcium intake, second, third, fourth, but not fifth quintiles were associated with fewer incident strokes: respective HR 0.84 (0.72-0.97), 0.83 (0.71-0.97), 0.78 (0.66-0.92) and 0.95 (0.78-1.15). The meta-analysis results suggest that high levels of calcium intake were associated with decreased all-cause mortality, but not cardiovascular mortality, regardless of average calcium intake. Calcium supplementation was associated with cardiovascular and all-cause mortality amongst women, but not men. Moderate dietary calcium intake may protect against cardiovascular and all-cause mortality and incident stroke. Calcium supplementation may reduce mortality in women.
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http://dx.doi.org/10.1007/s10654-020-00710-8DOI Listing
December 2020

The influence of ACE inhibitors and ARBs on hospital length of stay and survival in people with COVID-19.

Int J Cardiol Heart Vasc 2020 Dec 15;31:100660. Epub 2020 Oct 15.

Cardiff University and Honorary Consultant Physician, Aneurin Bevan University Health Board, UK.

Objective: During the COVID-19 pandemic the continuation or cessation of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) has been contentious. Mechanisms have been proposed for both beneficial and detrimental effects. Recent studies have focused on mortality with no literature having examined length of hospital stay. The aim of this study was to determine the influence of ACEi and ARBs on COVID-19 mortality and length of hospital stay.

Methods: COPE (COVID-19 in Older People) is a multicenter observational study including adults of all ages admitted with either laboratory or clinically confirmed COVID-19. Routinely generated hospital data were collected. Primary outcome: mortality; secondary outcomes: Day-7 mortality and length of hospital stay. A mixed-effects multivariable Cox's proportional baseline hazards model and logistic equivalent were used.

Results: 1371 patients were included from eleven centres between 27th February to 25th April 2020. Median age was 74 years [IQR 61-83]. 28.6% of patients were taking an ACEi or ARB. There was no effect of ACEi or ARB on inpatient mortality (aHR = 0.85, 95%CI 0.65-1.11). For those prescribed an ACEi or ARB, hospital stay was significantly reduced (aHR = 1.25, 95%CI 1.02-1.54, p = 0.03) and in those with hypertension the effect was stronger (aHR = 1.39, 95%CI 1.09-1.77, p = 0.007).

Conclusions: Patients and clinicians can be reassured that prescription of an ACEi or ARB at the time of COVID-19 diagnosis is not harmful. The benefit of prescription of an ACEi or ARB in reducing hospital stay is a new finding.
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http://dx.doi.org/10.1016/j.ijcha.2020.100660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7561344PMC
December 2020

Variations in Rates of Discharges to Nursing Homes after Acute Hospitalization for Stroke and the Influence of Service Heterogeneity: An Anglia Stroke Clinical Network Evaluation Study.

Healthcare (Basel) 2020 Oct 9;8(4). Epub 2020 Oct 9.

Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland AB24 3FX, UK.

Nursing home placement after stroke indicates a poor outcome but numbers placed vary between hospitals. The aim of this study is to determine whether between-hospital variations in new nursing home placements post-stroke are reliant solely on case-mix differences or whether service heterogeneity plays a role. A prospective, multi-center cohort study of acute stroke patients admitted to eight National Health Service acute hospitals within the Anglia Stroke and Heart Clinical Network between 2009 and 2011 was conducted. We modeled the association between hospitals (as a fixed-effect) and rates of new discharges to nursing homes using multiple logistic regression, adjusting for important patient risk factors. Descriptive and graphical data analyses were undertaken to explore the role of hospital characteristics. Of 1335 stroke admissions, 135 (10%) were discharged to a nursing home but rates varied considerably from 6% to 19% between hospitals. The hospital with the highest adjusted odds ratio of nursing home discharges (OR 4.26; 95% CI 1.69 to 10.73), was the only hospital that did not provide rehabilitation beds in the stroke unit. Increasing hospital size appeared to be related to an increased odds of nursing home placement, although attenuated by the number of hospital stroke admissions. Our results highlight the potential influence of hospital characteristics on this important outcome, independently of patient-level factors.
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http://dx.doi.org/10.3390/healthcare8040390DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7712187PMC
October 2020

Study protocol for the COPE study: COVID-19 in Older PEople: the influence of frailty and multimorbidity on survival. A multicentre, European observational study.

BMJ Open 2020 09 29;10(9):e040569. Epub 2020 Sep 29.

Geriatric Medicine, Cardiff University, Cardiff, UK.

Introduction: This protocol describes an observational study which set out to assess whether frailty and/or multimorbidity correlates with short-term and medium-term outcomes in patients diagnosed with COVID-19 in a European, multicentre setting.

Methods And Analysis: Over a 3-month period we aim to recruit a minimum of 500 patients across 10 hospital sites, collecting baseline data including: patient demographics; presence of comorbidities; relevant blood tests on admission; prescription of ACE inhibitors/angiotensin receptor blockers/non-steroidal anti-inflammatory drugs/immunosuppressants; smoking status; Clinical Frailty Score (CFS); length of hospital stay; mortality and readmission. All patients receiving inpatient hospital care >18 years who receive a diagnosis of COVID-19 are eligible for inclusion. Long-term follow-up at 6 and 12 months is planned. This will assess frailty, quality of life and medical complications.Our primary analysis will be short-term and long-term mortality by CFS, adjusted for age (18-64, 65-80 and >80) and gender. We will carry out a secondary analysis of the primary outcome by including additional clinical mediators which are determined statistically important using a likelihood ratio test. All analyses will be presented as crude and adjusted HR and OR with associated 95% CIs and p values.

Ethics And Dissemination: This study has been registered, reviewed and approved by the following: Health Research Authority (20/HRA1898); Ethics Committee of Hospital Policlinico Modena, Italy (369/2020/OSS/AOUMO); Health and Care Research Permissions Service, Wales; and NHS Research Scotland Permissions Co-ordinating Centre, Scotland. All participating units obtained approval from their local Research and Development department consistent with the guidance from their relevant national organisation.Data will be reported as a whole cohort. This project will be submitted for presentation at a national or international surgical and geriatric conference. Manuscript(s) will be prepared following the close of the project.
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http://dx.doi.org/10.1136/bmjopen-2020-040569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526029PMC
September 2020

Prior Routine Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Important Outcomes in Hospitalised Patients with COVID-19.

J Clin Med 2020 Aug 10;9(8). Epub 2020 Aug 10.

Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, Scotland, UK.

Coronavirus disease 2019 (COVID-19) infection causes acute lung injury, resulting from aggressive inflammation initiated by viral replication. There has been much speculation about the potential role of non-steroidal inflammatory drugs (NSAIDs), which increase the expression of angiotensin-converting enzyme 2 (ACE2), a binding target for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to enter the host cell, which could lead to poorer outcomes in COVID-19 disease. The aim of this study was to examine the association between routine use of NSAIDs and outcomes in hospitalised patients with COVID-19. This was a multicentre, observational study, with data collected from adult patients with COVID-19 admitted to eight UK hospitals. Of 1222 patients eligible to be included, 54 (4.4%) were routinely prescribed NSAIDs prior to admission. Univariate results suggested a modest protective effect from the use of NSAIDs, but in the multivariable analysis, there was no association between prior NSAID use and time to mortality (adjusted HR (aHR) = 0.89, 95% CI 0.52-1.53, = 0.67) or length of stay (aHR 0.89, 95% CI 0.59-1.35, = 0.58). This study found no evidence that routine NSAID use was associated with higher COVID-19 mortality in hospitalised patients; therefore, patients should be advised to continue taking these medications until further evidence emerges. Our findings suggest that NSAID use might confer a modest benefit with regard to survival. However, as this finding was underpowered, further research is required.
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http://dx.doi.org/10.3390/jcm9082586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7465199PMC
August 2020

Baseline anticholinergic burden from medications predicts poorer baseline and long-term health-related quality of life in 16 675 men and women of EPIC-Norfolk prospective population-based cohort study.

Pharmacoepidemiol Drug Saf 2021 02 5;30(2):135-143. Epub 2020 Aug 5.

Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.

Purpose: Previous studies investigating the association between anticholinergic burden (ACB) and health-related quality of life (HRQoL) showed conflicting results and focused on older adults or specific patient groups only.

Methods: Participants from the European Prospective Investigation of Cancer-Norfolk study were divided into three groups according to their ACB from medications at baseline, representing ACB scores of 0, 1 and ≥2. Outcomes of interest were the physical and mental component summary scores (PCS and MCS) of the Short Form-36, collected at 18 months from the baseline and again after a mean 13 years of follow-up. Linear regression and logistic regression for cross-sectional and longitudinal associations between ACB and HRQoL were constructed adjusting for potential confounders.

Results: A total of 16 675 participants, mean age 58.9 ± 9.1 years (55.6% female) and 7133 participants, mean age at follow-up 69.1 ± 8.7 years (56.8% female), were included in the cross-sectional and longitudinal analyses, respectively. In cross-sectional analysis, higher anticholinergic burden was associated with higher odds of being in the lowest quartile of PCS (ACB = 1; OR, 1.85[1.64, 2.09] and ACB ≥ 2:2.19[1.85, 2.58] and MCS (ACB = 1:1.47[1.30, 1.66] and ACB ≥ 2:1.68[1.42, 1.98]). In longitudinal analysis, higher anticholinergic burden was similarly associated with higher odds of being in the lowest quartile of PCS (ACB = 1:1.56[1.24, 1.95] and ACB ≥ 2:1.48[1.07, 2.03]) compared with ACB 0 group. The association with MCS scores did not reach statistical significance.

Conclusion: The use of anticholinergic medications is associated with both short and long-term poorer physical functions but association with mental functioning appears more short-term.
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http://dx.doi.org/10.1002/pds.5085DOI Listing
February 2021

Anticholinergic Burden Measures Predict Older People's Physical Function and Quality of Life: A Systematic Review.

J Am Med Dir Assoc 2021 01 21;22(1):56-64. Epub 2020 Jul 21.

Aging Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK; Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, Scotland, UK.

Objectives: This systematic review (PROSPERO CRD42019115918) compared the evidence behind anticholinergic burden (ACB) measures and their ability to predict changes in older people's physical function and quality of life.

Design: Eligible cohort or case-control studies were identified systematically using comprehensive search terms and a validated search filter for prognostic studies. Medline (OVID), EMBASE (OVID), CINAHL (EMBSCO), and PsycINFO (OVID) databases were searched. Risk of bias, using Quality in Prognosis Studies tool, and quality of evidence, using the Grading of Recommendations, Assessment, Development and Evaluation, were assessed.

Setting And Participants: People aged 65 years and older from any clinical setting.

Measures: Any ACB measures were accepted (including the anticholinergic domain of the Drug Burden Index). Any global/multidimensional measure for physical function and/or quality of life was accepted for outcome.

Results: Thirteen studies reporting associations between ACB and physical function (n = 10) or quality of life (n = 4) were included. Exposure measures included Anticholinergic Cognitive Burden Scale, Anticholinergic Drug Scale, Anticholinergic Risk Scale, Clinician Rated Anticholinergic Score, and the anticholinergic domain of the Drug Burden Index. All studies were rated moderate risk of bias in ≥2 Quality in Prognosis Studies categories with 5 rated high risk in ≥1 categories. Seven of 10 studies (5251 of 7569 participants) reported significant decline in physical function with increased burden. All 4 studies (2635 participants) reporting quality of life demonstrated similar association with increased burden. High risk of biases and inadequate data reporting restricted analysis. There was no evidence to support one measure being superior to another.

Conclusions And Implications: The evidence supports association between increased ACB and future impairments in physical function and quality of life. No conclusion can be made regarding which ACB measure has the best prognostic value. Well-designed longitudinal studies are required to address this. Clinicians should be aware of patient's anticholinergic burden and consider alternative medications where appropriate.
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http://dx.doi.org/10.1016/j.jamda.2020.05.065DOI Listing
January 2021

Older patients are more likely to breach the 4-hour target in Scotland.

Emerg Med J 2020 Dec 1;37(12):807-810. Epub 2020 Jun 1.

School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK

Objective: To determine if age is a factor in a patients' likelihood of breaching the 4 hour time target to admission/discharge in emergency departments (EDs) within NHS Scotland.

Methods: We used data from the Information Service Division Scotland to analyse all ED attendances in Scotland between January 2015 and September 2018 (n=5 596 642). We assessed the likelihood of time to admission/discharge being within 4 hours, 8 hours and 12 hours for all age categories (reference category 20 to 24 years). Univariable logistic regressions were carried out for sex, Scottish Index of Multiple Deprivation level and both major (potentially life threatening) and minor (not immediately life threatening) incidences.

Results: The likelihood of breaching the 4-hour target increased linearly with age from 15 to 19 years upward. Patients ≥85 years were significantly (p<0.001) more likely to have breached than patients aged 20 to 24 years (OR 3.80, 95% CI: 3.73 to 3.86). When considering major incidents, patients aged ≥85 years were more likely to have breached than those aged 20 to 24 years (OR 2.05, 95% CI: 2.01 to 2.09, p<0.001). The same was true of minor incidents (OR 2.85, 95% CI: 2.73 to 2.98, p<0.001).

Conclusions: Older age is associated with a higher probability of breaching waiting time targets in a linear fashion within NHS Scotland, which is consistent with previous single hospital or regional studies. This association may be due to the higher proportion of elderly patients being admitted or a more systemic issue, but regardless, the elderly are being put more at risk.
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http://dx.doi.org/10.1136/emermed-2019-209099DOI Listing
December 2020

The Prognostic Value of Anticholinergic Burden Measures in Relation to Mortality in Older Individuals: A Systematic Review and Meta-Analysis.

Front Pharmacol 2020 29;11:570. Epub 2020 Apr 29.

Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.

Background: Greater anticholinergic burden (ACB) increases the risk of mortality in older individuals, yet the strength of this association varies between studies. One possible explanation for this variance is the use of different approaches to quantify ACB. This systematic review (PROSPERO number CRD42019115918) assessed the prognostic utility of ACB-specific measures on mortality in older individuals.

Methods: Multiple cross-disciplinary databases were searched from 2006-2018. Observational studies assessing the association between ACB and mortality utilizing ≥1 ACB measure, involving persons aged ≥65 years were included. Screening and data extraction were performed by two independent reviewers, with disagreements resolved by a third independent reviewer. Risk of bias and quality of evidence were assessed using Quality in Prognosis Studies (QUIPS) and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. Meta-analysis was conducted where appropriate.

Results: Of 19,224 titles, 20 articles describing 18 cohort studies involving 498,056 older individuals were eligible. Eight anticholinergic-specific measures were identified; the Anticholinergic Cognitive Burden Scale (ACBS, n=9) and Anticholinergic Risk scale (ARS, n=8) were most frequently reported. The evidence base was of poor quality, with moderate to high risk of bias. Meta-analysis showed increased mortality risk.

Conclusions: There was a modest association between some ACB measures and mortality, with most evidence derived from the ACBS. Studies comparing different measures within the same population were lacking. Analysis was limited by poor generalizability between studies, specifically regarding heterogeneity in methodology and reporting, as well as high risk of bias for most studies in the evidence base.
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http://dx.doi.org/10.3389/fphar.2020.00570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201087PMC
April 2020

Decision-Making in COVID-19 and Frailty.

Geriatrics (Basel) 2020 May 6;5(2). Epub 2020 May 6.

Department of Surgery, Salford Royal NHS Foundation Trust, Stott Ln, Salford M6 8HD, UK.

We write in response to the COVID-19 pandemic and the important recognition of co-existing frailty [COVID-19 rapid guideline: critical care in adults; NICE NG159] [...].
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http://dx.doi.org/10.3390/geriatrics5020030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344473PMC
May 2020

Managing heart failure with preserved ejection fraction.

Ann Transl Med 2020 Mar;8(6):395

Ageing Clinical and Experimental Research, University of Aberdeen, Scotland, UK.

Heart failure with preserved ejection fraction (HFpEF) is increasing in prevalence as the general population ages. Poorly managed heart failure symptoms of decompensated HFpEF is one of the most common reasons for prolonged hospital admission. The high rate of morbidity and mortality associated with HFpEF is compounded by a poor understanding of the underpinning pathophysiology. Randomized controlled trials have so far been unable to identify an evidence base for reducing morbidity and mortality in patients with HFpEF, although there is some evidence to support quality of life (QOL) improvement. In this review, we described the recent advances on the pathophysiological understanding of HFpEF, the current and emerging treatment strategies, and what this may mean for individual patients. Potential treatments for HFpEF were divided into their relative management strategies and the current evidence assessed for effect on HFpEF mortality, hospital admission frequency, and QOL improvement. Overall, the understanding of HFpEF pathophysiology is improving and has been made a priority in identifying potential therapeutic targets. There is growing evidence that patients with ejection fractions (EF) of less than 60% may obtain a mortality benefit from ACE-inhibitors, angiotensin-neprilysin inhibitors, Angiotensin Receptor Blockers, and Mineralocorticoid Receptor Antagonists. However, this covers only a small proportion of the HFpEF spectrum. Therefore, currently there are no universal treatment strategies recommended for HFpEF, and management should focus on an individualised approach and this should take into account the comorbidities of each patient.
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http://dx.doi.org/10.21037/atm.2020.03.18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186731PMC
March 2020

How to develop clinical reasoning in medical students and interns based on illness script theory: An experimental study.

Med J Islam Repub Iran 2020 20;34. Epub 2020 Feb 20.

Center for Educational Research in Medical Sciences (CERMS), Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.

Although theory explains the development of illness script, it does not provide answers how medical students develop scripts in their learning. To fill the knowledge gap of developing illness script in medical students and interns, this study aimed to investigate the impact of educational strategies inspired by theory in the development of illness scripts. A total of 15 medical students and 12 interns participated in an educational intervention that included theory-driven strategies. To evaluate the impact of this intervention, clinical reasoning problem (CRP) and key features (KF) tests were used for before and after the intervention. In addition to descriptive statistics, the differences in participants' pretest and posttest variables were tested using Wilcoxon. Significance level was set at p≤0.05 for all tests. Interns significantly recognized more KF in the posttest. However, no significant difference was found between the pretest and posttest scores in total diagnostic accuracy (5.41±1.16 vs 4.91±1.44; p=0.111) and total correct discriminating score (0.41±0.66 vs 1.41±2.06; p=0.146). Medical students produced less total key features in the posttest, indicating that they became less elaborate in their case processing. However, no significant difference was observed in common KF score (0.4 [0.25-0.78] vs 0.9 [0.6-1]; p=0.791) and discriminative key features score (0.33 [0.16-0.33] vs 0.22 [0.11-0.44]; p=0.972) in the posttest compared to the pretest. This study showed that theory-driven educational strategies have an impact on illness script development specifically in interns. It is recommended that this intervention would be tested on those in higher levels of expertise (ie, residents).
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http://dx.doi.org/10.34171/mjiri.34.9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139266PMC
February 2020

Association Between Hospital Cardiac Catheter Laboratory Status, Use of an Invasive Strategy, and Outcomes After NSTEMI.

Can J Cardiol 2020 06 16;36(6):868-877. Epub 2019 Oct 16.

Keele Cardiovascular Research Group, Centre of Prognosis Research, Institute of Primary Care Sciences, Keele University, Stoke on Trent, United Kingdom; Department of Cardiology, University Hospital of North Midlands, Stoke on Trent, United Kingdom; Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom.

Background: Increased use of invasive coronary strategies in patients admitted to hospitals with on-site cardiac catheter laboratory (CCL) facilities has been reported, but the utilisation of invasive coronary strategies according to types of CCL facilities at the first admitting hospital and clinical outcomes is unknown.

Methods: We included 452,216 patients admitted with a diagnosis of non-ST-segment-elevation myocardial infarction (NSTEMI) in England and Wales from 2007 to 2015. The admitting hospitals were categorized into no-laboratory, diagnostic, and PCI hospitals according to CCL facilities. Multilevel logistic regression models were used to study associations between CCL facilities and in-hospital outcomes.

Results: A total of 97,777 (21.6%) of the patients were admitted to no-laboratory hospitals, and 134,381 (29.7%) and 220,058 (48.7%) were admitted to diagnostic and PCI hospitals, respectively. Use of coronary angiography was significantly higher in PCI hospitals (77.3%) than in diagnostic (63.2%) and no-laboratory (61.4%) hospitals. The adjusted odds of in-hospital mortality were similar for diagnostic (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.83-1.04) and PCI hospitals (OR 1.09, 95% CI 0.96-1.24) compared with no-laboratory hospitals. However, in high-risk NSTEMI subgroup (defined as Global Registry of Acute Coronary Events score > 140), an admission to diagnostic hospitals was associated with significantly increased in-hospital mortality (OR 1.36, 95% CI 1.06-1.75) compared with no-laboratory and PCI hospitals.

Conclusions: This study highlights important differences in both the utilisation of invasive coronary strategies and subsequent management and outcomes of NSTEMI patients according to admitting hospital CCL facilities. High-risk NSTEMI patients admitted to diagnostic hospitals had greater in-hospital mortality, possibly because of reduced PCI use, which needs to be addressed.
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http://dx.doi.org/10.1016/j.cjca.2019.10.010DOI Listing
June 2020

Neuropathological Correlates of Cumulative Benzodiazepine and Anticholinergic Drug Use.

J Alzheimers Dis 2020 ;74(3):999-1009

School of Health Sciences, University of East Anglia, Norwich, UK.

Background: Benzodiazepines and anticholinergic drugs have been implicated in causing cognitive decline and potentially increasing dementia risk. However, evidence for an association with neuropathology is limited.

Objective: To estimate the correlation between neuropathology at death and prior use of benzodiazepines and anticholinergic drugs.

Methods: We categorized 298 brain donors from the population-based Medical Research Council Cognitive Function and Ageing Study, according to their history of benzodiazepine (including Z-drugs) or anticholinergic medication (drugs scoring 3 on the Anticholinergic Cognitive Burden scale) use. We used logistic regression to compare dichotomized neuropathological features for those with and without history of benzodiazepine and anticholinergic drug use before dementia, adjusted for confounders.

Results: Forty-nine (16%) and 51 (17%) participants reported benzodiazepine and anticholinergic drug use. Alzheimer's disease neuropathologic change was similar whether or not exposed to either drug, for example 46% and 57% had intermediate/high levels among those with and without anticholinergic drug use. Although not significant after multiple testing adjustments, we estimated an odds ratio (OR) of 0.40 (95% confidence interval [95% CI] 0.18-0.87) for anticholinergic use and cortical atrophy. For benzodiazepine use, we estimated ORs of 4.63 (1.11-19.24) and 3.30 (1.02-10.68) for neuronal loss in the nucleus basalis and substantial nigra. There was evidence of neuronal loss in the nucleus basalis with anticholinergic drug use, but the association reduced when adjusted for confounders.

Conclusions: We found no evidence that benzodiazepine or anticholinergic drug use is associated with typical pathological features of Alzheimer's disease; however, we cannot rule out effects owing to small numbers.
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http://dx.doi.org/10.3233/JAD-191199DOI Listing
April 2021

Anaemia and incidence of post stroke dementia.

Clin Neurol Neurosurg 2020 04 23;191:105688. Epub 2020 Jan 23.

Norwich Medical School, University of East Anglia, UK; Norfolk and Norwich University Hospital, Norwich, UK.

Objectives: To assess the impact of anaemia on incidence of post-stroke dementia.

Patients And Methods: We used data from a UK regional stroke register. To be eligible, patient must have survived to discharge and had anaemia by WHO criteria. Dementia status and other prevalent co-morbidities were assessed using ICD-10 codes. Patients were followed till May 2015 (mean follow-up 3.7 years, total person years = 27,769). Hazard Ratio for incident dementia was calculated using Cox-proportional hazards model controlling for potential confounders. Fine and Gray model was additionally constructed using mortality as the competing risk.

Results: A total of 7454 stroke patients were included with mean age SD of 75.912.3 years 50.2 % men). Those with anaemia were older, has higher disability and co-morbidity burden prior to stroke. We observed a large amount of variation in the dementia incidence rates over time and that the hazard ratio increased every year. The significant association between anaemia and dementia incidence was lost after controlling for pre-stroke Modified Rankin score (HR1.17(0.97,1.40)). With every 20 g/dL increase in Hb was associated with a significant reduction in the risk of dementia after adjustment for age, sex, stroke factors and disability but lost significance after adjustment for vascular risk factors. Competing risk analyses showed similar results.

Conclusion: Whilst we found no evidence of anaemia as a risk factor for post-stroke dementia, the findings may be limited by potential under recognition of post stroke dementia.
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http://dx.doi.org/10.1016/j.clineuro.2020.105688DOI Listing
April 2020

Use of Medications with Anticholinergic Properties and the Long-Term Risk of Hospitalization for Falls and Fractures in the EPIC-Norfolk Longitudinal Cohort Study.

Drugs Aging 2020 02;37(2):105-114

Clinical Gerontology Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK.

The consumption of medications with anticholinergic activity has been suggested to result in the adverse effects of mental confusion, visual disturbance, and muscle weakness, which may lead to falls. Existing published evidence linking anticholinergic drugs with falls, however, remains weak. This study was conducted to evaluate the relationship between anticholinergic cognitive burden (ACB) and the long-term risk of hospitalization with falls and fractures in a large population study. The dataset comprised information from 25,639 men and women (aged 40-79 years) recruited from 1993 to 1997 from Norfolk, United Kingdom into the European Prospective Investigation into Cancer (EPIC)-Norfolk study. The time to first hospital admission with a fall with or without fracture was obtained from the National Health Service hospital information system. Cox-proportional hazards analyses were conducted to adjust for confounders and competing risks. The fall hospitalization rate was 5.8% over a median follow-up of ~ 19.4 years. The unadjusted incidence rate ratio for the use of any drugs with anticholinergic properties was 1.79 (95% CI 1.66-1.93). The hazard ratios (95% CI) for ACB scores of 1, 2-3, and ≥ 4 compared with ACB = 0 for fall hospitalization were 1.20 (1.09-1.33), 1.42 (1.25-1.60), and 1.39 (1.21-1.60) after adjustment for age, gender, medical conditions, physical activity, and blood pressure. Medications with anticholinergic activity are associated with an increased risk of subsequent hospitalization with a fall over a 19-year follow-up period. The biological mechanisms underlying the long-term risk of hospitalization with a fall or fracture following baseline ACB exposure remains unclear and requires further evaluation.
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http://dx.doi.org/10.1007/s40266-019-00731-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7115837PMC
February 2020

Anticholinergic and benzodiazepine medication use and risk of incident dementia: a UK cohort study.

BMC Geriatr 2019 10 21;19(1):276. Epub 2019 Oct 21.

School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK.

Background: Studies suggest that anticholinergic medication or benzodiazepine use could increase dementia risk. We tested this hypothesis using data from a UK cohort study.

Methods: We used data from the baseline (Y0), 2-year (Y2) and 10-year (Y10) waves of the Medical Research Council Cognitive Function and Ageing Study. Participants without dementia at Y2 were included (n = 8216). Use of benzodiazepines (including nonbenzodiazepine Z-drugs), anticholinergics with score 3 (ACB3) and anticholinergics with score 1 or 2 (ACB12) according to the Anticholinergic Cognitive Burden scale were coded as ever use (use at Y0 or Y2), recurrent use (Y0 and Y2), new use (Y2, but not Y0) or discontinued use (Y0, but not Y2). The outcome was incident dementia by Y10. Incidence rate ratios (IRR) were estimated using Poisson regression adjusted for potential confounders. Pre-planned subgroup analyses were conducted by age, sex and Y2 Mini-Mental State Examination (MMSE) score.

Results: Dementia incidence was 9.3% (N = 220 cases) between Y2 and Y10. The adjusted IRRs (95%CI) of developing dementia were 1.06 (0.72, 1.60), 1.28 (0.82, 2.00) and 0.89 (0.68, 1.17) for benzodiazepines, ACB3 and ACB12 ever-users compared with non-users. For recurrent users the respective IRRs were 1.30 (0.79, 2.14), 1.68 (1.00, 2.82) and 0.95 (0.71, 1.28). ACB3 ever-use was associated with dementia among those with Y2 MMSE> 25 (IRR = 2.28 [1.32-3.92]), but not if Y2 MMSE≤25 (IRR = 0.94 [0.51-1.73]).

Conclusions: Neither benzodiazepines nor ACB12 medications were associated with dementia. Recurrent use of ACB3 anticholinergics was associated with dementia, particularly in those with good baseline cognitive function. The long-term prescribing of anticholinergics should be avoided in older people.
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http://dx.doi.org/10.1186/s12877-019-1280-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802337PMC
October 2019

Now is the time to address the Culture of Residential Aged Care Facilities to support Pharmacists in reducing psychotropic prescribing.

Int J Pharm Pract 2019 Oct;27(5):404-405

NHMRC Cognitive Decline Partnership Centre, Kolling Institute, Sydney University, St Leonards, NSW, Australia.

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http://dx.doi.org/10.1111/ijpp.12501DOI Listing
October 2019

Hospital-Level Variations in Rates of Inpatient Urinary Tract Infections in Stroke.

Front Neurol 2019 6;10:827. Epub 2019 Aug 6.

Ageing Clinical and Experimental Research Group, School of Medicine, Medical Sciences and Nutrition, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.

Urinary tract infection (UTI) is one of the most common complications following stroke and has prognostic significance. UTI rates have been shown to vary between hospitals, but it is unclear whether this is due to case-mix differences or heterogeneities in care among hospitals. A prospective multi-center cohort study of acute stroke patients admitted to eight National Health Service (NHS) acute hospital trusts within the Anglia Stroke & Heart Clinical Network between 2009 and 2011 was conducted. We modeled the association between hospital (as a fixed-effect) and inpatient UTI using a multivariable logistic regression model, adjusting for established patient-level risk factors. We graphically and descriptively analyzed heterogeneities in hospital-level characteristics. We included 2,241 stroke admissions in our analysis; 171 (7.6%) acquired UTI as an inpatient. UTI rates varied significantly between the eight hospitals, ranging from 3 to 11%. The hospital that had the lowest odds of UTI [odds ratio (OR) = 0.50 (95% confidence interval (CI) 0.22-.11)] in adjusted analysis, had the highest number of junior doctors and occupational therapists per five beds of all hospitals. The hospital with the highest adjusted UTI rate [OR=2.69 (1.56-4.64)] was tertiary, the largest and had the highest volume of stroke patients, lowest number of stroke unit beds per 100 admissions, and the highest number of hospital beds per CT scanner. There is hospital-level variation in post-stroke UTI. Our results suggest the potential influence of service characteristics independently of patient-level factors which may be amenable to be addressed to improve the ultimate stroke outcome.
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http://dx.doi.org/10.3389/fneur.2019.00827DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6691802PMC
August 2019

Barriers and facilitators to reducing anticholinergic burden from the perspectives of patients, their carers, and healthcare professionals: A protocol for qualitative evidence synthesis.

J Evid Based Med 2019 Aug;12(3):227-231

General Practice and Primary Care, University of Glasgow, Glasgow, UK.

Anticholinergic drugs are prescribed for a range of conditions including gastrointestinal disorders, overactive bladder, allergies, and depression. While in some circumstances anticholinergic effects are therapeutic, they also pose many undesired or adverse effects. The overall impact from concomitant use of multiple medications with anticholinergic properties is termed anticholinergic burden (ACB). Greater ACB is associated with increased risks of impaired physical and cognitive function, falls, cardiovascular events, and mortality. This has led to the development of interventions aimed at reducing ACB through the deprescribing of anticholinergic drugs. However, little is known about the implementation issues that may influence successful embedding and integration of such interventions into routine clinical practice. In this paper, we present the protocol for our systematic review that aims to identify the qualitative evidence for the barriers and facilitators to reduce ACB from the perspectives of patients, carers, and healthcare professionals. A comprehensive search strategy will be conducted across OVID Medline, EMBASE, PsycInfo, and CINAHL. The review will be conducted in accordance with ENTREQ (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) and has been registered with PROSPERO (Registration CRD42018109084). Normalization process theory (NPT) will be used to explore, understand, and explain qualitative data in relation to factors that act as barriers or facilitators to ACB reduction.
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http://dx.doi.org/10.1111/jebm.12359DOI Listing
August 2019

Shock Index Predicts Outcome in Patients with Suspected Sepsis or Community-Acquired Pneumonia: A Systematic Review.

J Clin Med 2019 Jul 31;8(8). Epub 2019 Jul 31.

Institute of Applied Health Sciences, University of Aberdeen, AB25 2ZD, Scotland, UK.

Background: To improve outcomes for patients who present to hospital with suspected sepsis, it is necessary to accurately identify those at high risk of adverse outcomes as early and swiftly as possible. To assess the prognostic accuracy of shock index (heart rate divided by systolic blood pressure) and its modifications in patients with sepsis or community-acquired pneumonia.

Methods: An electronic search of MEDLINE, EMBASE, Allie and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Open Grey, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (WHO ITRP) was conducted from conception to 26th March 2019. Eligible studies were required to assess the prognostic accuracy of shock index or its modifications for outcomes of death or requirement for organ support either in sepsis or pneumonia. The methodological appraisal was carried out using the Downs and Black checklist. Evidence was synthesised using a narrative approach due to heterogeneity.

Results: Of 759 records screened, 15 studies (8697 patients) were included in this review. Shock index ≥ 1 at time of hospital presentation was a moderately accurate predictor of mortality in patients with sepsis or community-acquired pneumonia, with high specificity and low sensitivity. Only one study reported outcomes related to organ support.

Conclusions: Elevated shock index at time of hospital presentation predicts mortality in sepsis with high specificity. Shock index may offer benefits over existing sepsis scoring systems due to its simplicity.
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http://dx.doi.org/10.3390/jcm8081144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723191PMC
July 2019

Plasma Vitamin C Levels: Risk Factors for Deficiency and Association with Self-Reported Functional Health in the European Prospective Investigation into Cancer-Norfolk.

Nutrients 2019 Jul 9;11(7). Epub 2019 Jul 9.

Ageing Clinical & Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK.

Background: To investigate the demographic and lifestyles factors associated with vitamin C deficiency and to examine the association between plasma vitamin C level and self-reported physical functional health.

Methods: A population-based cross-sectional study using the European Prospective Investigation into Cancer-Norfolk study. Plasma vitamin C level < 11 µmol/L indicated vitamin C deficiency. Unconditional logistic regression models assessed the association between vitamin C deficiency and potential risk factors. Associations between quartiles of vitamin C and self-reported functional health measured by the 36-item short-form questionnaire (SF-36) were assessed.

Results: After adjustment, vitamin C deficiency was associated with older age, being male, lower physical activity, smoking, more socially deprived area (Townsend index) and a lower educational attainment. Compared to the highest, those in the lowest quartile of vitamin C were more likely to score in the lowest decile of physical function (adjusted odds ratio (aOR): 1.43 (95%CI: 1.21-1.70)), bodily pain (aOR: 1.29 (95% CI: 1.07-1.56)), general health (aOR: 1.4 (95%CI: 1.18-1.66)), and vitality (aOR: 1.23 (95%CI: 1.04-1.45)) SF-36 scores.

Conclusions: Simple public health interventions should be aimed at populations with risk factors for vitamin C deficiency. Poor self-reported functional health was associated with lower plasma vitamin C levels, which may reflect symptoms of latent scurvy.
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http://dx.doi.org/10.3390/nu11071552DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682997PMC
July 2019

Variation in acute and community service provision of care of the elderly services across Scotland: findings from the Scottish Care of Older People (SCoOP) initial scoping survey.

J R Coll Physicians Edinb 2019 Jun;49(2):105-111

Room 4.013, Polwarth Building, Forester Hill, University of Aberdeen, Aberdeen AB25 2ZD, UK,

Background: This scoping survey is a preliminary part of the Scottish Care of Older People (SCoOP) audit programme, which aims to assess specialist service provision for older people with frailty in Scotland, and provide benchmarking data for improving services.

Methods: The survey was distributed to nominated consultant geriatricians based in 12 of the 14 Scottish health boards who completed data to the 'best of their knowledge'. Data collected were: consultant and specialty doctor level workforce; days of frailty unit operation; multidisciplinary team discussion frequency; and, physiotherapy and occupational therapy availability. Consultant cover was correlated with population data, and scores for service components used to derive separate acute and community service provision scores.

Results: Consultant geriatrician availability varies widely across Scottish health boards with a median of 1.45 [range: 0.54-2.40; interquartile range (IQR): 0.71-2.28] full-time equivalent consultant geriatricians per 10,000 people ≥65 years. Variation was also present in the service provision scores [score range 0 (none) to 1.0 (very good)]: for acute services, the median national service provision score was 0.81 (range: 0.50-0.89; IQR: 0.75-0.85) and for community services 0.60 (range: 0.48-0.82; IQR: 0.52-0.65).

Conclusions: This report clearly demonstrates mismatch between workforce and services in both acute and community settings in the context of the population size. Future surveys will build on this preliminary information to audit service provision for older people at an individual hospital level.
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http://dx.doi.org/10.4997/JRCPE.2019.204DOI Listing
June 2019
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