Reducing antibiotic prescribing in general practice in Australia: a cluster randomised controlled trial of a multimodal intervention.

BACKGROUND: The health and economic burden of antimicrobial resistance (in Australia is significant. Interventions that help guide and improve appropriate prescribing for acute respiratory tract infections in the community represent an opportunity to slow the spread of resistant bacteria. Clinicians who work in primary care are potentially the most influential health care professionals to address the problem of antimicrobial resistance, because this is where most antibiotics are prescribed. METHODS: A cluster randomised trial was conducted comparing two parallel groups of 27 urban general practices in Queensland, Australia: 13 intervention and 14 control practices, with 56 and 54 general practitioners (GPs), respectively. This study evaluated an integrated, multifaceted evidence-based package of interventions implemented over a 6-month period. The evaluation included quantitative and qualitative components, and an economic analysis. RESULTS: A multimodal package of interventions resulted in a reduction of 3.81 prescriptions per GP per month. This equates to 1280.16 prescriptions for the 56GPs in the intervention practices over the 6-month period. The cost per prescription avoided was A$148. The qualitative feedback showed that the interventions were well received by the GPs and did not impact on consultation time. Providing GPs with a choice of tools might enhance their uptake and support for antimicrobial stewardship in the community. CONCLUSIONS: A multimodal package of interventions to enhance rational prescribing of antibiotics is effective, feasible and acceptable in general practice. Investment in antimicrobial stewardship strategies in primary care may ultimately provide the important returns for public health into the future.

Treatment for recurrent vulvovaginal candidiasis (thrush).

BACKGROUND: Recurrent vulvovaginal candidiasis (RVVC) affects up to 5% of women. No comprehensive systematic review of treatments for RVVC has been published. OBJECTIVES: The primary objective was to assess the effectiveness and safety of pharmacological and non-pharmacological treatments for RVVC. The secondary objective was to assess patient preference of treatment options. SEARCH METHODS: We conducted electronic searches of bibliographic databases, including CENTRAL, MEDLINE, Embase, and CINAHL (search date 6 October 2021). We also handsearched reference lists of identified trials and contacted authors of identified trials, experts in RVVC, and manufacturers of products for vulvovaginal candidiasis. SELECTION CRITERIA: We considered all published and unpublished randomised controlled trials evaluating RVVC treatments for at least six months, in women with four or more symptomatic episodes of vulvovaginal candidiasis in the past year. We excluded women with immunosuppressive disorders or taking immunosuppressant medication. We included women with diabetes mellitus and pregnant women. Diagnosis of RVVC must have been confirmed by presence of symptoms and a positive culture and/or microscopy. We included all drug and non-drug therapies and partner treatment, assessing the following primary outcomes: • number of clinical recurrences per participant per year (recurrence defined as clinical signs and positive culture/microscopy); • proportion of participants with at least one clinical recurrence during the treatment and follow-up period; and • adverse events. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed titles and abstracts to identify eligible trials. Duplicate data extraction was completed independently by two authors. We assessed risk of bias as described in the Cochrane Handbook for Systematic Reviews of Interventions. We used the fixed-effects model for pooling and expressed the results as risk ratio (RR) with 95% confidence intervals (CI). Where important statistical heterogeneity was present we either did not pool data (I2 > 70%) or used a random-effects model (I2 40-70%). We used the GRADE tool to assess overall certainty of the evidence for the pooled primary outcomes. MAIN RESULTS: Studies: Twenty-three studies involving 2212 women aged 17 to 67 years met the inclusion criteria. Most studies excluded pregnant women and women with diabetes or immunosuppression. The predominant species found on culture at study entry was Candida albicans. Overall, the included studies were small (<100 participants). Six studies compared antifungal treatment with placebo (607 participants); four studies compared oral versus topical antifungals (543 participants); one study compared different oral antifungals (45 participants); two studies compared different dosing regimens for antifungals (100 participants); one study compared two different dosing regimens of the same topical agent (23 participants); one study compared short versus longer treatment duration (26 participants); two studies assessed the effect of partner treatment (98 participants); one study compared a complementary treatment (Lactobacillus vaginal tablets and probiotic oral tablets) with placebo (34 participants); three studies compared complementary medicine with antifungals (354 participants); two studies compared 'dermasilk' briefs with cotton briefs (130 participants); one study examined Lactobacillus vaccination versus heliotherapy versus ciclopyroxolamine (90 participants); one study compared CAM treatments to an antifungal treatment combined with CAM treatments (68 participants). We did not find any studies comparing different topical antifungals. Nine studies reported industry funding, three were funded by an independent source and eleven did not report their funding source. Risk of bias: Overall, the risk of bias was high or unclear due to insufficient blinding of allocation and participants and poor reporting. Primary outcomes: Meta-analyses comparing drug treatments (oral and topical) with placebo or no treatment showed there may be a clinically relevant reduction in clinical recurrence at 6 months (RR 0.36, 95% CI 0.21 to 0.63; number needed to treat for an additional beneficial outcome (NNTB) = 2; participants = 607; studies = 6; I² = 82%; low-certainty evidence) and 12 months (RR 0.80, 95% CI 0.72 to 0.89; NNTB = 6; participants = 585; studies = 6; I² = 21%; low-certainty evidence). No study reported on the number of clinical recurrences per participant per year. We are very uncertain whether oral drug treatment compared to topical treatment increases the risk of clinical recurrence at 6 months (RR 1.66, 95% CI 0.83 to 3.31; participants = 206; studies = 3; I² = 0%; very low-certainty evidence) and reduces the risk of clinical recurrence at 12 months (RR 0.95, 95% CI 0.71 to 1.27; participants = 206; studies = 3; I² = 10%; very low-certainty evidence). No study reported on the number of clinical recurrences per participant per year. Adverse events were scarce across both treatment and control groups in both comparisons. The reporting of adverse events varied amongst studies, was generally of very low quality and could not be pooled. Overall the adverse event rate was low for both placebo and treatment arms and ranged from less than 5% to no side effects or complications. AUTHORS' CONCLUSIONS: In women with RVVC, treatment with oral or topical antifungals may reduce symptomatic clinical recurrences when compared to placebo or no treatment. We were unable to find clear differences between different treatment options (e.g. oral versus topical treatment, different doses and durations). These findings are not applicable to pregnant or immunocompromised women and women with diabetes as the studies did not include or report on them. More research is needed to determine the optimal medication, dose and frequency.

End-of-life care in general practice: clinic-based data collection.

BACKGROUND: There are no processes that routinely assess end-of-life care in Australian general practice. This study aimed to develop a data collection process which could collect observational data on end-of-life care from Australian general practitioners (GPs) via a questionnaire and clinical data from general practice software. METHODS: The data collection process was developed based on a modified Delphi study, then pilot tested with GPs through online surveys across three Australian states and data extraction from general practice software, and finally evaluated through participant interviews. RESULTS: The developed data collection process consisted of three questionnaires: Basic Practice Descriptors (32 items), Clinical Data Query (32 items) and GP-completed Questionnaire (21 items). Data extraction from general practice software was performed for 97 decedents of 10 GPs and gathered data on prescriptions, investigations and referral patterns. Reports on care of 272 decedents were provided by 63 GPs. The GP-completed Questionnaire achieved a satisfactory level of validity and reliability. Our interviews with 23 participating GPs demonstrated the feasibility and acceptability of this data collection process in Australian general practice. CONCLUSIONS: The data collection process developed and tested in this study is feasible and acceptable for Australian GPs, and comprehensively covers the major components of end-of-life care. Future studies could develop an automated data extraction tool to reduce the time and recall burden for GPs. These findings will help build a nationwide integrated information network for primary end-of-life care in Australia.

Impact of comorbidities on physical function and survival of middle-aged, as compared to older, individuals with cancer.

PURPOSE: To investigate if comorbidity predicts mortality and functional impairment in middle-aged individuals with cancer (50-64 years) as compared to older individuals. METHODS: A prospective cohort study. Outcomes were mortality and functional impairment at 5 years follow-up. Comorbidity was assessed using adjusted Charlson comorbidity index and polypharmacy (≥ 5 drugs) as surrogate for comorbidity. Multivariate Cox-proportional hazards and binary logit models were used to assess the risk of 5-year mortality and functional impairment respectively. RESULTS: We included 477 middle-aged (50-64 years) and 563 older (65 + years) individuals with cancer. The prevalence of comorbidity (at least one disease in addition to cancer) was 29% for middle-aged and 45% for older individuals, with polypharmacy observed in 15% and 31% respectively. Presence of ≥ 3 comorbidities was associated with nearly three times as high a risk of mortality in middle-aged individuals (HR 2.97, 95% CI: 1.43-6.16). In older individuals, the HR was 1.7 (95% CI 1.1-2.8). Polypharmacy was associated with a higher risk of mortality in middle-aged (HR 2.35, 95% CI 1.32-4.16) but not in older individuals (HR 1.2, 95% CI 0.9-1.8). Polypharmacy was associated with the four time the risk of functional impairment in middle-aged (OR 4.0, 95% CI 1.59-10.06) and older individuals (OR 4.4, 95% CI 1.6-11.7). CONCLUSION: This study of middle-aged and older adults with cancer shows that comorbid disease is common in younger and older individuals with cancer and are associated with inferior outcomes. Assessment and management of comorbidity should be a priority for cancer care across all age groups.

Psychosocial care for cancer survivors: A systematic literature review on the role of general practitioners.

OBJECTIVE: To explore the general practitioners (GP's) role in providing psychosocial care for cancer survivors through a systematic literature review. METHODS: We searched MEDLINE, EMBASE, PsycINFO, and CINAHL and included the studies that complied with the predefined inclusion and exclusion criteria. At least two independent reviewers performed the quality appraisal and data extraction. RESULTS: We included 33 (five qualitative, 19 observational, and nine intervention) studies; the majority of these studies focused on care for depression and anxiety (21/33). Cancer survivors were more likely to contact their GP for psychosocial problems compared with noncancer controls. Survivors were more likely to use antidepressants compared with controls, although 71% of survivors preferred depression treatment to be "talking therapy only." Overall, GPs and patients mostly agreed that GPs are the preferred healthcare provider to manage psychosocial problems. The major exception is a survivor's fear of recurrence-here, the oncologist was the preferred healthcare provider. Only two interventions effectively decreased depression or anxiety; these studies included patients who had a clinical indication for psychosocial care, were specifically designed for decreasing depression/anxiety, and consisted of a multidisciplinary team approach. The other interventions evaluated GP-led follow-up for cancer survivors and found that this did not impact the patients' levels of anxiety, depression, or distress neither negatively nor positively. CONCLUSIONS: Cancer survivors often prefer psychosocial care by their GP, and GPs generally consider they are well placed to provide this care. Although evidence on the effectiveness of psychosocial care by GPs is limited, an active multidisciplinary team approach seems key.

General practitioners' considerations when deciding whether to initiate end-of-life conversations: a qualitative study.

BACKGROUND: End-of-life discussions often are not initiated until close to death, even in the presence of life-limiting illness or frailty. Previous research shows that doctors may not explicitly verbalize approaching end-of-life in the foreseeable future, despite shifting their focus to comfort care. This may limit patients' opportunity to receive information and plan for the future. General Practitioners (GPs) have a key role in caring for increasing numbers of patients approaching end-of-life. OBJECTIVE: To explore GPs' thought processes when deciding whether to initiate end-of-life discussions. METHODS: A qualitative approach was used. We purposively recruited 15 GPs or GP trainees from South-East Queensland, Australia, and each participated in a semi-structured interview. Transcripts were analyzed using inductive thematic analysis. RESULTS: Australian GPs believe they have a responsibility to initiate end-of-life conversations, and identify several triggers to do so. Some also describe caution in raising this sensitive topic, related to patient, family, cultural and personal factors. CONCLUSIONS: These findings enable the development of approaches to support GPs to initiate end-of-life discussions that are cognizant both of GPs' sense of responsibility for these discussions, and factors that may contribute to caution initiating them, such as anticipated patient response, cultural considerations, societal taboos, family dynamics and personal challenges to doctors.

General practitioners' practical approach to initiating end-of-life conversations: a qualitative study.

BACKGROUND: As doctors who provide care across the life-course, general practitioners (GPs) play a key role in initiating timely end-of-life discussions. Nonetheless, these discussions are often not initiated until close to death. Given the ageing of the population, GPs will be confronted with end-of-life care more often, and this needs to become a core skill for all GPs. OBJECTIVE: To describe GPs' approach to initiating end-of-life discussions. METHODS: Fifteen GPs or GP trainees from South-East Queensland, Australia, were purposively recruited to participate in a semi-structured interview. We analysed transcripts using a thematic analysis. RESULTS: GPs' approach to initiating end-of-life discussions was summarized by four themes: (1) Preparing the ground; (2) finding an entry point; (3) tailoring communication and (4) involving the family. CONCLUSIONS: Emphasis on the doctor-patient relationship; assessing patient readiness for end-of-life discussions; and sensitive information delivery is consistent with factors previously reported to be important to both GPs and patients in this context. Our findings provide a framework for GPs initiating end-of-life discussions, which must be tailored to patient and GP personality factors. Further research is required to evaluate its outcomes.

Long-term distress in older patients with cancer: a longitudinal cohort study.

BACKGROUND: Receiving a cancer diagnosis can be a major life event which causes distress even years after primary treatment. AIM: To examine the prevalence of distress in older patients with cancer (OPCs) up until 5 years post-diagnosis, and identify predictors present at time of diagnosis. Results are compared with reference groups of middle-aged patients with cancer (MPCs) and older patients without a cancer diagnosis (OPs). DESIGN & SETTING: OPCs, MPCs, and OPs participated in a longitudinal cohort study in Belgium and the Netherlands by filling in questionnaires at designated time points from 2010-2019. METHOD: Data from 541 patients were analysed using multivariable logistic regression analyses. RESULTS: At baseline, 40% of OPCs, 37% of MPCs, and 17% of OPs reported distress. After 5 years, 35% of OPCs, 23% of MPCs, and 25% of OPs reported distress. No significant predictors for long-term distress in OPCs and OPs were found. For MPCs, it was found that baseline distress (odds ratio [OR] 2.94; 95% confidence intervals [CI] = 1.40 to 6.19) and baseline fatigue (OR 4.71; 95% CI = 1.81 to 12.31) predicted long-term distress. CONCLUSION: Distress is an important problem for people with cancer, with peaks at different moments after diagnosis. Feelings of distress are present shortly after diagnosis but they decrease quickly for the majority of patients. In the long term, however, OPCs in particular appear to be most at risk for distress. This warrants extra attention from primary healthcare professionals, such as GPs who are often patients' first medical contact point. More research into risk factors occurring later in an illness trajectory might shed more light on predictors for development of long-term distress.

General practitioners' engagement in end-of-life care: a semi-structured interview study.

BACKGROUND: Early identification of approaching end-of-life and care planning improve outcomes at the end of life. Nevertheless, the majority of people who die are not identified in time to enable appropriate care planning. We aimed to describe the challenges general practitioners (GPs) found in providing end-of-life care; what prompted GPs to identify and discuss approaching end of life with their patient and how their practice changed. METHODS: We conducted a qualitative study of 15 Australian GPs using semi-structured interviews, examining end-of-life care of one of their randomly selected, deceased patients. Interviews were analysed using a general inductive approach. RESULTS: When a life-limiting prognosis was articulated, GPs integrated end-of-life care into their clinical care directly. Care often included a care plan developed in consultation with the patient. Even when death was not articulated, GPs were aware of approaching end of life and changed their focus to comfort of the patient. GPs generally had an informal care plan in mind, but this developed gradually and without discussing these plans with the patient. How GPs provided end-of-life care depended primarily on patient traits (eg, willingness to discuss physical decline) and the GP's characteristics (eg, experience, training and consulting style). CONCLUSIONS: GPs were aware of their patients' approaching end of life and care was adjusted accordingly. However, under certain circumstances this was not explicitly articulated and discussed. It is not clear if implicit but unarticulated end-of-life care is sufficient to meet patients' needs. Future studies should investigate this.

Breastfeeding questions to medicines call centres from the Australian public and health professionals.

There is considerable uncertainty regarding medication use during breastfeeding. This study compared lactation-related questions about medicines from consumers and health professionals to identify knowledge gaps. A retrospective, mixed-methods study of lactation-related call data extracted from two Australian medicines call centre databases: National Prescribing Service (NPS) Medicines Line (ML) for the general public and Therapeutic Advice and Information Service (TAIS) for health professionals, was conducted. Of the 5662 lactation-related calls by consumers to ML, most were from women enquiring about themselves (95%). The 2219 lactation-related calls from health professionals to TAIS were largely from GPs (46%), community pharmacists (35%) and nurses (12%). Consumers commonly enquired about medicines freely accessible or over-the-counter, including non-steroidal anti-inflammatory products (9.3%), paracetamol (6.9%), ibuprofen (4.8%) and codeine (4.2%). Health professionals' questions involved prescription medicines such as antidepressants (16.9%), with queries on sertraline (3.7%), levonorgestrel (2.7%) and domperidone (2.4%) most common. Question themes were similar for both cohorts, focusing mainly around medication safety, risk minimisation and milk supply. Understanding the compelling and common themes driving medicines help-seeking related to breastfeeding is key to addressing information gaps and improving overall medication use during breastfeeding.

A systematic literature review on the association between loneliness and coping strategies.

Loneliness is an emerging and important public health concern associated with increased risk for health disorders and even mortality. Interventions targeting coping strategies might be effective in alleviating feelings of loneliness. However, the relationship between loneliness and coping strategies is not well understood. We systematically reviewed quantitative studies addressing the association between loneliness and coping. Studies were included if loneliness and coping styles were measured with a validated scale and the association between both was assessed quantitatively. We searched Medline, Embase, PsycINFO, Cochrane Library, and CINAHL databases in compliance with the predefined in- and exclusion criteria. Two independent reviewers performed the search, quality appraisal, and data extraction. Coping styles were subdivided according to problem-focused and emotion-focused coping strategies. We included twelve studies that measured the association between loneliness and coping. Half of the studies had low risk of bias (n = 6), in the remaining six the risk of bias was moderate (n = 1) or high (n = 5). All studies that showed a significant association between loneliness and coping consistently showed that problem-focused coping styles were associated with lower levels of loneliness, and emotion-focused coping styles with higher levels of loneliness. Our findings suggest that learning how to use problem-focused coping strategies could be an important aspect of interventions targeting loneliness. This should be further explored in randomized clinical trials. Trials should report changes is coping and changes in loneliness and also include multivariate models that investigate if changes in coping contributed to changes in loneliness. Furthermore, further research should explore the role of different subgroups (e.g. older people), and the role of different types of loneliness as these can affect the effectiveness of loneliness interventions.

The influence of coping strategies on subsequent well-being in older patients with cancer: A comparison with 2 control groups.

OBJECTIVE: To evaluate dispositional coping strategies as predictors for changes in well-being after 1 year in older patients with cancer (OCP) and 2 control groups. METHODS: OCP were compared with 2 control groups: middle-aged patients with cancer (MCP) (aging effect) and older patients without cancer (ONC) (cancer effect). Patients were interviewed shortly after a cancer diagnosis and 1 year later. Dispositional coping was measured with the Short Utrecht Coping List. For well-being, we considered psychological well-being (depression, loneliness, distress) and physical health (fatigue, ADL, IADL). Logistic regression analyses were performed to study baseline coping as predictor for subsequent well-being while controlling for important baseline covariates. RESULTS: A total of 1245 patients were included in the analysis at baseline: 263 OCP, 590 ONC, and 392 MCP. Overall, active tackling was employed most often. With the exception of palliative reacting, OCP utilized each coping strategy less frequently than MCP. At 1-year follow-up, 833 patients (66.9%) were interviewed. Active coping strategies (active tackling and seeking social support) predicted subsequent well-being only in MCP. Avoidance coping strategies did not predict well-being in any of the patient groups. Palliative reacting predicted distress in OCP; depression and dependency for ADL in MCP. CONCLUSIONS: Coping strategies influence subsequent well-being in patients with cancer, but the impact is different in the age groups. Palliative reacting was the only coping strategy that predicted well-being (ie, distress) in OCP and is therefore, especially in this population, a target for coping skill interventions.

Focus on early-career GPs: qualitative evaluation of a multi-faceted educational intervention to improve antibiotic prescribing.

Background: We conducted an educational intervention emphasizing rational antibiotic prescribing in early-career General Practitioners (GP) in vocational training (trainees). The intervention consisted of an online introduction module, an online communication training module, face-to-face workshops, and cases to be discussed one-on-one by the trainee-supervisor dyad during regular scheduled education sessions. Objectives: To explore the participants' experiences with the intervention. Methods: A qualitative study of 14 GP trainees and supervisors. Interviews followed a semi-structured interview guide, were transcribed and analysed using concurrent thematic analysis. Results: Overall, the intervention was well received. Resources were not often used in practice, but GP trainees used the information in communicating with patients. The intervention improved trainees' confidence and provided new communication strategies, e.g. explicitly asking about patients' expectations and talking patients through the examination to form an overall clinical picture. Trainees seemed eager to learn and adapt their practice, whereas GP supervisors rather commented that the intervention was reinforcing. None of the participants reported prescribing conflicts between trainee and supervisor. However, most participants identified conflicts within the GP practice or with specialists: other doctors who prescribe more antibiotics perpetuate patients' ideas that antibiotics will fix everything, which in turn causes conflict with the patient and undermines attempts to improve antibiotic prescribing. Conclusion: The educational intervention was received positively. Early-career GPs thought it influenced their prescribing behaviour and improved their confidence in non-prescribing. Interventions that target teams (e.g. entire practice) could minimize conflict, ensure consistency of messages and support overall antibiotic stewardship in primary care.

Methylphenidate for children and adolescents with autism spectrum disorder.

BACKGROUND: Children with autistic spectrum disorder (ASD) frequently present with inattention, impulsivity and hyperactivity, which are the cardinal symptoms of attention deficit hyperactivity disorder (ADHD). The effectiveness of methylphenidate, a commonly used ADHD treatment, is therefore of interest in these children. OBJECTIVES: To assess the effects of methylphenidate for symptoms of ADHD (inattention, impulsivity and hyperactivity) and ASD (impairments in social interaction and communication, and repetitive, restricted or stereotypical behaviours) in children and adolescents aged 6 to 18 years with ASD. SEARCH METHODS: In November 2016, we searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, 11 other databases and two trials registers. We also checked reference lists and contacted study authors and pharmaceutical companies. SELECTION CRITERIA: Randomised controlled trials (RCTs) that investigated the effect of methylphenidate versus placebo on the core symptoms of ASD or ADHD-like symptoms, or both, in children aged 6 to 18 years who were diagnosed with ASD or pervasive developmental disorder. The primary outcome was clinical efficacy, defined as an improvement in ADHD-like symptoms (inattention, impulsivity and hyperactivity) and in the core symptoms of ASD (impaired social interaction, impaired communication, and stereotypical behaviours), and overall ASD. Secondary outcomes examined were: rate of adverse events; caregiver well-being; need for institutionalisation, special schooling or therapy to achieve learning outcomes; and overall quality of life. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. We combined outcome measures that used different psychometric scales, where clinically appropriate. We used a coefficient of 0.6 to calculate standard deviations and adjust for the studies' cross-over design. We considered a standardised mean difference (SMD) of 0.52 as the minimum clinically relevant inter-treatment difference. We applied the GRADE rating for strength of evidence for each outcome. MAIN RESULTS: The studies: we included four cross-over studies, with a total of 113 children aged 5 to 13 years, most of whom (83%) were boys. We included two studies with five-year-old children since we were unable to obtain the disaggregated data for those aged six years and above, and all other participants were in our target age range. All participants resided in the USA. The duration of treatment in the cross-over phase was one week for each dose of methylphenidate. Studies used a range of outcome scales, rated by parents, teachers or both; clinicians; or programme staff. We report parent-rated outcomes separately. Risk of bias: we considered three trials to be at high risk of bias due to selective reporting and all trials to be at unclear risk of bias for blinding of participants and assessors, due to the potential for recognising the side effects of methylphenidate. We judged all trials to be at low or unclear risk of bias for other items. Primary outcomes: the meta-analysis suggested that high-dose methylphenidate (0.43 mg/kg/dose to 0.60 mg/kg/dose) had a significant and clinically relevant benefit on hyperactivity, as rated by teachers (SMD -0.78, 95% confidence interval (CI) -1.13 to -0.43; 4 studies, 73 participants; P < 0.001; low-quality evidence) and parents (mean difference (MD) -6.61 points, 95% CI -12.19 to -1.03, rated on the hyperactivity subscale of the Aberrant Behviour Checklist, range 0 to 48; 2 studies, 71 participants; P = 0.02; low-quality evidence). Meta-analysis also showed a significant but not clinically relevant benefit on teacher-rated inattention (MD -2.72 points, 95% CI -5.37 to -0.06, rated on the inattention subscale of the Swanson, Nolan and Pelham, Fourth Version questionnaire, range 0 to 27; 2 studies, 51 participants; P = 0.04; low-quality evidence). There were inadequate data to conduct a meta-analysis on the symptom of impulsivity. There was no evidence that methylphenidate worsens the core symptoms of ASD or benefits social interaction (SMD -0.51, 95% CI -1.07 to 0.05; 3 studies, 63 participants; P = 0.07; very low-quality evidence), stereotypical behaviours (SMD -0.34, 95% CI -0.84 to 0.17; 3 studies, 69 participants; P = 0.19; low-quality evidence), or overall ASD (SMD -0.53, 95% CI -1.26 to 0.19; 2 studies, 36 participants; P = 0.15; low-quality evidence), as rated by teachers. There were inadequate data to conduct a meta-analysis on the symptom of impaired communication. SECONDARY OUTCOMES: no data were available for the secondary outcomes of caregiver well-being; need for institutionalisation, special schooling options or therapy to achieve learning outcomes; or overall quality of life. No trials reported serious adverse events. The only adverse effect that was significantly more likely with treatment was reduced appetite as rated by parents (risk ratio 8.28, 95% CI 2.57 to 26.73; 2 studies, 74 participants; P < 0.001; very low-quality evidence). Subgroup analysis by dose did not identify any significant differences in effect on our primary outcomes between low-, medium- or high-dose ranges. AUTHORS' CONCLUSIONS: We found that short-term use of methylphenidate might improve symptoms of hyperactivity and possibly inattention in children with ASD who are tolerant of the medication, although the low quality of evidence means that we cannot be certain of the true magnitude of any effect. There was no evidence that methylphenidate has a negative impact on the core symptoms of ASD, or that it improves social interaction, stereotypical behaviours, or overall ASD. The evidence for adverse events is of very low quality because trials were short and excluded children intolerant of methylphenidate in the test-dose phase. Future RCTs should consider extending the duration of treatment and follow-up. The minimum clinically important difference also needs to be confirmed in children with ASD using outcome scales validated for this population.

Growing and retaining general practice research leaders in Australia: How can we do better?

BACKGROUND: The aim of this study was to explore the experiences of Australian general practitioners (GPs) with a Doctor of Philosophy (PhD) about their choice to abandon or pursue an academic career. METHODS: A qualitative study of 18 GPs (PhD obtained between 2006 and 2016) was conducted. Semi-structured telephone interviews were transcribed and analysed using concurrent thematic analysis. RESULTS: General practice researchers faced insecure career pathways. They often work in isolation, there is a lack of critical mass, and research was often described as a hobby (ie unfunded, done from home). Solutions included expanding academic general practice registrar positions to include advanced research training, building professional networks, mentoring, and better marketing of general practice research. DISCUSSION: Focused investment in developing clear and sustainable career pathways is essential to nurture and retain general practice researchers and research leaders. The research culture and professional standing of general practice researchers also need to improve. Support from professional bodies and colleagues, and enabling research collaborations, are key.

The utilization of formal and informal home care by older patients with cancer: a Belgian cohort study with two control groups.

BACKGROUND: The purpose of this paper is to analyse the utilization of formal and informal home care among older patients with cancer (OCP) and to compare this with middle-aged patients with cancer (MCP) and older patients without cancer (ONC). Additionally, we examined predictors of transitions towards formal care one year after a cancer diagnosis. METHODS: OCP and MCP had to be recruited within three months after a cancer diagnosis and have an estimated life expectancy over six months. ONC consisted of patients without known cancer, seen by the general practitioner. Formal and informal care were compared between the patient groups at baseline, i.e. shortly after a cancer diagnosis and changes in care were studied after one year. RESULTS: A total of 844 patients were evaluable for formal care at baseline and 469 patients (56%) at follow-up. At baseline, about half of older adults and 18% of MCP used formal care, while about 85% of cancer patients and 57% ONC used informal care. Formal care increased for all groups after one year though not significantly in OCP. The amount of informal care only changed in MCP which decreased after one year. Cancer-related factors and changes in need factors predict a transition towards formal care after a cancer diagnosis. CONCLUSIONS: A cancer diagnosis has a different impact on the use of formal and informal care than ageing as such. The first year after a cancer diagnosis is an important time to follow-up on the patients' needs for home care.

Chewing the fat over statins: Consumer concerns about lipid-lowering medication.

BACKGROUND: The objective of this article was to explore the information needs of consumers using statins. METHODS: Calls made to a national medicines call centre in Australia were analysed. Where question narratives were available electronically (n = 1486), the main concerns were identified using a coding scheme. Subsequently, we evaluated whether these concerns were addressed in the medication leaflet. RESULTS: The most common concerns were about side effects (36%) and interactions (28%). Concerns about side effects related to musculoskeletal (27%), gastrointestinal (12%) and skin problems (5%). Concerns about interactions included other medicines (49%), complementary and alternative medicines (CAMs; 39%) and grapefruit (6%). Additional questions related to differences between treatments (12%) and dosage (8%). Most topics were mentioned in the medication leaflet, but strategies to manage these concerns were lacking. DISCUSSION: When prescribing statins, information about common side effects, when symptoms require action, and interactions with other medicines, especially CAMs, should be addressed and tailored to the patient.

Functional status decline in older patients with breast and colorectal cancer after cancer treatment: A prospective cohort study.

OBJECTIVES: The aim of the present study was to disentangle the impact of age and that of cancer diagnosis and treatment on functional status (FS) decline in older patients with cancer. MATERIALS AND METHODS: Patients with breast and colorectal cancer aged 50-69years and aged ≥70years who had undergone surgery, and older patients without cancer aged ≥70years were included. FS was assessed at baseline and after 12months follow-up, using the Katz index for activities of daily living (ADL) and the Lawton scale for instrumental activities of daily living (IADL). FS decline was defined as ≥1 point decrease on the ADL or IADL scale from baseline to 12months follow-up. RESULTS: In total, 179 older patients with cancer (≥ 70years), 341 younger patients with cancer (50-69years) and 317 older patients without cancer (≥ 70years) were included. FS decline was found in 43.6%, 24.6% and 28.1% of the groups, respectively. FS decline was significantly worse in older compared to younger patients with cancer receiving no chemotherapy (44.5% versus 17.6%, p<0.001), but not for those who did receive chemotherapy (39.4% versus 30.8%, p=0.33). Among the patients with cancer, FS decline was significantly associated with older age (OR 2.63), female sex (OR 3.72), colorectal cancer (OR 2.81), polypharmacy (OR 2.10) and, inversely, with baseline ADL dependency (OR 0.44). CONCLUSION: Cancer treatment, and older age are important predictors of FS decline. The relation of baseline ADL dependency and chemotherapy with FS decline suggest that the fittest of the older patients with cancer were selected for chemotherapy.