Management of hypertensive disorders of pregnancy in two Australian tertiary care maternity hospitals.

Background: Hypertensive disorders of pregnancy (HDP) are common obstetric medical problems. Compliance with clinical guidelines and evidence from major trials has the potential to translate to significantly improve maternal and perinatal outcomes. The aims of this study were to prospectively review management of HDP in an Australian cohort in the context of the Society of Obstetric Medicine of Australian and New Zealand (SOMANZ) guidelines and current evidence in published literature regarding management controversies. Methods: The management of 100 pregnant women with HDP and prescription for antihypertensive medication at two tertiary obstetric centres was prospectively reviewed in 2013. Compliance with SOMANZ guidelines, uptake of findings from the HYPITAT trial and the Control of Hypertension In Pregnancy Study (CHIPS) trial were assessed. Results: Sixty-eight women had chronic hypertension, while 32 had gestational hypertension. Management of HDP was mostly consistent with current SOMANZ guidelines and evidence from CHIPS and HYPITAT. Conclusion: Clinicians were practising according to the current SOMANZ guidelines, indicating vigilance on behalf of the treating team.

Smoking, respiratory symptoms, lung function and life expectancy: A longitudinal study of ageing.

BACKGROUND AND OBJECTIVE: Prognostic indices have been developed to predict various outcomes, including mortality. These indices and hazard ratios may be difficult for patients to understand. We investigated the association between smoking, respiratory symptoms and lung function with remaining life expectancy (LE) in older adults. METHODS: Data were from the 2004/05 English Longitudinal Study of Ageing (ELSA) (n = 8930), participants aged ≥50-years, with mortality data until 2012. Respiratory symptoms included were chronic phlegm and shortness of breath (SOB). The association between smoking, respiratory symptoms and FEV1 /FVC, and remaining LE was estimated using a parametric survival function and adjusted for covariates including age at baseline and sex. RESULTS: The extent to which symptoms and FEV1 /FVC predicted differences in remaining LE varied by smoking. Compared to asymptomatic never smokers with normal lung function (the reference group), in never smokers, only those with SOB had a significant reduction in remaining LE. In former and current smokers, those with respiratory symptoms had significantly lower remaining LE compared to the reference group if they had FEV1 /FVC <0.70 compared to those with FEV1 /FVC ≥0.70. Males aged 50-years, current smokers with SOB and FEV1 /FVC <0.70, had a remaining LE of 19.2 (95%CI: 16.5-22.2) years, a decrease of 8.1 (5.3-10.8) years, compared to the reference group. CONCLUSION: Smoking, respiratory symptoms and FEV1 /FVC are strongly associated with remaining LE in older people. The use of remaining LE to communicate mortality risk to patients needs further investigation.

Case-Finding and Treatment Effects in COPD: Secondary Analysis of an Interdisciplinary Intervention Trial.

Background: US Preventive Services Taskforce recommends against screening for COPD in asymptomatic adults due to limited evidence on the efficacy of treatments for this population. However, global and Australian guidelines recommend a case-finding approach where those with symptoms and/or risk factors, including smoking, are screened. This study aims to explore patient characteristics by time of COPD diagnosis and the effectiveness of early treatment in those with or without symptoms. Methods: Secondary analysis of a randomised controlled trial that included those with a pre-existing (n=130) or new diagnosis (n=142) of COPD. Those randomised to the intervention arm received an interdisciplinary intervention of smoking cessation support, home medicines review and home-based pulmonary rehabilitation, while controls received usual care. The primary outcome was health-related quality of life (HR-QoL) measured using St George's Respiratory Questionnaire. To estimate the impact of early treatment, we compared the effectiveness of treatment versus control at 6- and 12-months for the new versus pre-existing diagnosis groups, and those symptomatic versus asymptomatic or minimally symptomatic based on COPD Assessment Test score. Results: Approximately half of those newly diagnosed with COPD were already symptomatic. Early treatment in those diagnosed via case-finding had a positive non-significant impact on HR-QoL. The size of the treatment effects generally favoured the pre-existing diagnosis group when compared to case-finding and favoured those symptomatic when compared to those asymptomatic. Conclusion: Despite useful insights into the impacts of case-finding and early treatments, this study, like most others, was not sufficiently powered. Further larger studies or combining sub-groups across studies are required.

Cough in Children and Adults: Diagnosis, Assessment and Management (CICADA). Summary of an updated position statement on chronic cough in Australia.

INTRODUCTION: Cough is the most common symptom leading to medical consultation. Chronic cough results in significant health care costs, impairs quality of life, and may indicate the presence of a serious underlying condition. Here, we present a summary of an updated position statement on cough management in the clinical consultation. MAIN RECOMMENDATIONS: Assessment of children and adults requires a focused history of chronic cough to identify any red flag cough pointers that may indicate an underlying disease. Further assessment with examination should include a chest x-ray and spirometry (when age > 6 years). Separate paediatric and adult diagnostic management algorithms should be followed. Management of the underlying condition(s) should follow specific disease guidelines, as well as address adverse environmental exposures and patient/carer concerns. First Nations adults and children should be considered a high risk group. The full statement from the Thoracic Society of Australia and New Zealand and Lung Foundation Australia for managing chronic cough is available at https://lungfoundation.com.au/resources/cicada-full-position-statement. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: Algorithms for assessment and diagnosis of adult and paediatric chronic cough are recommended. High quality evidence supports the use of child-specific chronic cough management algorithms to improve clinical outcomes, but none exist in adults. Red flags that indicate serious underlying conditions requiring investigation or referral should be identified. Early and effective treatment of chronic wet/productive cough in children is critical. Culturally specific strategies for facilitating the management of chronic cough in First Nations populations should be adopted. If the chronic cough does not resolve or is unexplained, the patient should be referred to a respiratory specialist or cough clinic.

A novel, multidomain, primary care nurse-led and mHealth-assisted intervention for dementia risk reduction in middle-aged adults (HAPPI MIND): study protocol for a cluster randomised controlled trial.

INTRODUCTION: Middle-aged multidomain risk reduction interventions targeting modifiable risk factors for dementia may delay or prevent a third of dementia cases in later life. We describe the protocol of a cluster randomised controlled trial (cRCT), HAPPI MIND (Holistic Approach in Primary care for PreventIng Memory Impairment aNd Dementia). HAPPI MIND will evaluate the efficacy of a multidomain, nurse-led, mHealth supported intervention for assessing dementia risk and reducing associated risk factors in middle-aged adults in the Australian primary care setting. METHODS AND ANALYSIS: General practice clinics (n≥26) across Victoria and New South Wales, Australia, will be recruited and randomised. Practice nurses will be trained to implement the HAPPI MIND intervention or a brief intervention. Patients of participating practices aged 45-65 years with ≥2 potential dementia risk factors will be identified and recruited (approximately 15 patients/clinic). Brief intervention participants receive a personalised report outlining their risk factors for dementia based on Australian National University Alzheimer's Disease Risk Index (ANU-ADRI) scores, education booklet and referral to their general practitioner as appropriate. HAPPI MIND participants receive the brief intervention as well as six individualised dementia risk reduction sessions with a nurse trained in motivational interviewing and principles of behaviour change, a personalised risk reduction action plan and access to the purpose-built HAPPI MIND smartphone app for risk factor self-management. Follow-up data collection will occur at 12, 24 and 36 months. Primary outcome is ANU-ADRI score change at 12 months from baseline. Secondary outcomes include change in cognition, quality of life and individual risk factors of dementia. ETHICS AND DISSEMINATION: Project approved by Monash University Human Research Ethics Committee (ID: 28273). Results will be disseminated in peer-reviewed journals and at healthcare conferences. If effective in reducing dementia risk, the HAPPI MIND intervention could be integrated into primary care, scaled up nationally and sustained over time. TRIAL REGISTRATION NUMBER: ACTRN12621001168842.

Trend over time on knowledge of the health effects of cigarette smoking and smokeless tobacco use in Bangladesh: Findings from the International Tobacco Control Policy Evaluation Bangladesh Surveys.

INTRODUCTION: Cigarette smoking and smokeless tobacco (ST) use are prevalent in Bangladesh. This longitudinal study examined how knowledge of the health effects of smoking and ST use in Bangladesh has changed overtime with the country's acceleration of tobacco control efforts. METHODS: Data were analysed from the International Tobacco Control Survey, a nationally representative longitudinal study of users and non-users of tobacco (aged 15 and older) in Bangladesh, across four waves conducted in 2009 (n = 4378), 2010 (n = 4359), 2012 (n = 4223) and 2015 (n = 4242). Generalised estimating equations assessed the level of knowledge about harms of tobacco use across four waves. Multivariable logistic regressions assessed whether knowledge of health effects from cigarette smoking and ST use in 2015 differed by user group. RESULTS: In 2015 survey, most tobacco users were aware that cigarette smoking causes stroke (92%), lung cancer (97%), pulmonary tuberculosis (97%) and ST use causes mouth cancer (97%) and difficulty in opening mouth (80%). There were significant increases in the total knowledge score of smoking related health harm from 2010 to 2012 (mean difference = 0.640; 95% confidence interval [CI] 0.537, 0.742) and 2012 to 2015 (mean difference = 0.555; 95% CI 0.465, 0.645). Participants had greater odds of awareness for ST health effects from 2010 to 2015. DISCUSSION AND CONCLUSIONS: The results suggest that increasing efforts of awareness policy interventions is having a positive effect on tobacco-related knowledge in Bangladesh. These policy initiatives should be continued to identify optimal methods to facilitate behaviour change and improve cessation of smoking and ST use.

Different Case Finding Approaches to Optimise COPD Diagnosis: Evidence from the RADICALS Trial.

Aim: Diagnosis of COPD in primary care is hindered by underuse of spirometry. Case finding using validated symptom and health status questionnaires, and simple handheld devices in high-risk populations may improve diagnosis. This study aimed to determine the best combination of measures to optimise COPD diagnosis in the primary care setting. Methods: We recruited 335 current or ex-smokers, including those with an established diagnosis of COPD from general practices. Participants' FEV1 and FEV6 were measured using a handheld spirometry device (COPD-6®). Each completed the COPD assessment test (CAT), a modified Medical Research Council (mMRC) dyspnoea scale, St George's Respiratory Questionnaire (SGRQ) and smoking history questionnaire. From these data we calculated the predictive validity for spirometry-confirmed diagnosis of COPD. Area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated for each. Kappa coefficient was used to measure the agreement between the Fixed-Ratio (FR) and Lower Limit of Normal (LLN) spirometric criteria in diagnosing COPD. Results: FEV1/FEV6 <0.70 alone showed significant association (p<0.0001) with COPD diagnosis and good predictive accuracy (AUROC=0.725). However, no further improvement was found after combining SGRQ, CAT and mMRC with FEV1/FEV6. FEV1/FEV6 <0.70 using the COPD-6® handheld device had moderate sensitivity (65.7%) and high PPV (90.1%), high specificity (79.3%) and NPV (44.8%). There was good agreement between FR and LLN definitions (κ=0.70). Conclusion: Handheld micro-spirometers can facilitate case finding of COPD in smokers and ex-smokers attending general practice. The fixed ratio criterion currently recommended by COPD-X guidelines offers the simplest method for diagnosing COPD in Australian primary care.

Diabetes treatment deintensification in Australians with dementia compared to the general population: A national cohort study.

BACKGROUND: Diagnosis of dementia may change peoples' goals of care. In people with diabetes, this may lead to relaxing treatment targets and reducing the use of diabetes medications. The aim of this study was to examine changes in diabetes medication use before and after initiating medication for dementia. METHODS: A national cohort of people aged 65-97 years, living with dementia and diabetes, and a general population cohort with diabetes matched for age, sex, and index date were extracted from the Australian national medication claims database. Trajectories of diabetes medication use, expressed as mean defined daily dose (DDD) each month for each individual from 24 months before to 24 months after the index date, were estimated using group-based trajectory modeling (GBTM). Cohorts were analyzed separately. RESULTS: People with dementia (N = 1884) and the matched general population (N = 7067) had a median age of 80 years (interquartile range 76-84) and 55% were female. In both models, people exhibited one of five diabetes medication trajectories, with 16.5% of people with dementia and 24.0% of the general population assigned to trajectories that represented deintensification. In the general population model, those on deintensifying trajectories were older than those on stable trajectories (median 83 vs. 79 years). In the dementia cohort model, those on high or low deintensifying trajectories were slightly older (median age 81 or 82, respectively, vs. 80 years) and had at least 1 more comorbidity (median 8 or 7, respectively, vs. 6) than those on stable trajectories. CONCLUSIONS: Initiating medication for dementia does not appear to be a trigger for deintensification of diabetes treatment regimens. Deintensification was more common in the general population; people living with dementia are potentially overtreated for diabetes.

Multi-domain prognostic models used in middle-aged adults without known cognitive impairment for predicting subsequent dementia.

BACKGROUND: Dementia, a global health priority, has no current cure. Around 50 million people worldwide currently live with dementia, and this number is expected to treble by 2050. Some health conditions and lifestyle behaviours can increase or decrease the risk of dementia and are known as 'predictors'. Prognostic models combine such predictors to measure the risk of future dementia. Models that can accurately predict future dementia would help clinicians select high-risk adults in middle age and implement targeted risk reduction. OBJECTIVES: Our primary objective was to identify multi-domain prognostic models used in middle-aged adults (aged 45 to 65 years) for predicting dementia or cognitive impairment. Eligible multi-domain prognostic models involved two or more of the modifiable dementia predictors identified in a 2020 Lancet Commission report and a 2019 World Health Organization (WHO) report (less education, hearing loss, traumatic brain injury, hypertension, excessive alcohol intake, obesity, smoking, depression, social isolation, physical inactivity, diabetes mellitus, air pollution, poor diet, and cognitive inactivity). Our secondary objectives were to summarise the prognostic models, to appraise their predictive accuracy (discrimination and calibration) as reported in the development and validation studies, and to identify the implications of using dementia prognostic models for the management of people at a higher risk for future dementia. SEARCH METHODS: We searched MEDLINE, Embase, PsycINFO, CINAHL, and ISI Web of Science Core Collection from inception until 6 June 2022. We performed forwards and backwards citation tracking of included studies using the Web of Science platform.  SELECTION CRITERIA: We included development and validation studies of multi-domain prognostic models. The minimum eligible follow-up was five years. Our primary outcome was an incident clinical diagnosis of dementia based on validated diagnostic criteria, and our secondary outcome was dementia or cognitive impairment determined by any other method. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the references, extracted data using a template based on the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS), and assessed risk of bias and applicability of included studies using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). We synthesised the C-statistics of models that had been externally validated in at least three comparable studies.  MAIN RESULTS: We identified 20 eligible studies; eight were development studies and 12 were validation studies. There were 14 unique prognostic models: seven models with validation studies and seven models with development-only studies. The models included a median of nine predictors (range 6 to 34); the median number of modifiable predictors was five (range 2 to 11). The most common modifiable predictors in externally validated models were diabetes, hypertension, smoking, physical activity, and obesity. In development-only models, the most common modifiable predictors were obesity, diabetes, hypertension, and smoking. No models included hearing loss or air pollution as predictors. Nineteen studies had a high risk of bias according to the PROBAST assessment, mainly because of inappropriate analysis methods, particularly lack of reported calibration measures. Applicability concerns were low for 12 studies, as their population, predictors, and outcomes were consistent with those of interest for this review. Applicability concerns were high for nine studies, as they lacked baseline cognitive screening or excluded an age group within the range of 45 to 65 years. Only one model, Cardiovascular Risk Factors, Ageing, and Dementia (CAIDE), had been externally validated in multiple studies, allowing for meta-analysis. The CAIDE model included eight predictors (four modifiable predictors): age, education, sex, systolic blood pressure, body mass index (BMI), total cholesterol, physical activity and APOEƐ4 status. Overall, our confidence in the prediction accuracy of CAIDE was very low; our main reasons for downgrading the certainty of the evidence were high risk of bias across all the studies, high concern of applicability, non-overlapping confidence intervals (CIs), and a high degree of heterogeneity. The summary C-statistic was 0.71 (95% CI 0.66 to 0.76; 3 studies; very low-certainty evidence) for the incident clinical diagnosis of dementia, and 0.67 (95% CI 0.61 to 0.73; 3 studies; very low-certainty evidence) for dementia or cognitive impairment based on cognitive scores. Meta-analysis of calibration measures was not possible, as few studies provided these data. AUTHORS' CONCLUSIONS: We identified 14 unique multi-domain prognostic models used in middle-aged adults for predicting subsequent dementia. Diabetes, hypertension, obesity, and smoking were the most common modifiable risk factors used as predictors in the models. We performed meta-analyses of C-statistics for one model (CAIDE), but the summary values were unreliable. Owing to lack of data, we were unable to meta-analyse the calibration measures of CAIDE. This review highlights the need for further robust external validations of multi-domain prognostic models for predicting future risk of dementia in middle-aged adults.

Experiences of hospitalized smokers initiated on varenicline as part of a pragmatic smoking cessation trial.

Varenicline is an effective monotherapy for smoking cessation, but adherence is often suboptimal. This qualitative study explored the experiences of varenicline treatment among participants enrolled in a randomized controlled trial, who self-reported being adherent or nonadherent to varenicline treatment (n = 15). Individual interviews were conducted using a semi-structured interview guide. Data were analyzed using thematic framework approach. An environment of forced abstinence played a key role in motivating quit attempts. The main barriers to varenicline adherence were medicine-related side effects, relapse to smoking, and a belief that the medication was not working if abstinence was not achieved by the target quit date. Participants adherent to treatment adopted a reduce-to-quit approach and noticed a gradual reduction in cigarette cravings. When asked about their preferences for support while on varenicline treatment, participants expressed the need for proactive follow-up by health professionals and more active behavioral support to assist them in adhering to treatment. Prescribers should encourage varenicline users to persist with treatment, even if abstinence is not achieved by the target quit date. Further research is needed to explore the awareness and acceptability of the reduce-to-quit method among prescribers and patients and its impact on varenicline adherence and in term long-term abstinence.

Which smokers enroll in a hospital based smoking cessation trial? Survey of smoking related behaviors, quit attempts, and motivation to quit.

BACKGROUND: Understanding smoking behaviors in hospital patients who smoke may improve inpatient cessation treatments. This study aimed to describe smoking-related behaviors, past-quit attempts, and self-reported difficulties experienced in quitting among those who enrolled in a smoking cessation trial of varenicline. METHODS: Baseline data were obtained from adult hospitalized smokers (average ≥ 10 cigarettes/day in 4-weeks prior to hospitalization) who enrolled in a randomized, placebo-controlled trial of varenicline ± nicotine lozenges at five Australian public hospitals. A logistic regression model tested the association between participant characteristics and quitting in the previous 12 months. RESULTS: Participants' (n = 320; 57% male, 52.5 ± 12.1 years old) motivation and confidence in quitting were high. A total of 120 participants (37.5%) had attempted quitting in the previous 12-months. Prior hospitalization (P = .008) and employment status (P = .015) were significantly associated with past quit attempts. No statistically significant differences were noted in the reason for hospitalization or the level of nicotine dependence between participants who attempted quitting in the previous 12 months and their counterparts. Smoking cessation pharmacotherapy was used by 55% of those attempting to quit; nicotine replacement therapy (65.2%) and varenicline (16.7%) most common. Stress or anxiety, urges to smoke and a lack of motivation were the difficulties experienced in past quit attempts. CONCLUSIONS: Those who had a prior hospitalization and were unemployed had significantly greater odds of reporting past quit attempts. Further research is needed to investigate the degree of adherence among inpatient smokers with the smoke-free hospital policies and the frequency of NRT provision and uptake on admission.

Validity of three risk prediction models for dementia or cognitive impairment in Australia.

BACKGROUND: no studies have compared the predictive validity of different dementia risk prediction models in Australia. OBJECTIVES: (i) to investigate the predictive validity of the Australian National University-Alzheimer's Disease Risk Index (ANU-ADRI), LIfestyle for BRAin Health (LIBRA) Index and cardiovascular risk factors, ageing and dementia study (CAIDE) models for predicting probable dementia/cognitive impairment in an Australian cohort. (ii) To develop and assess the predictive validity of a new hybrid model combining variables from the three models. METHODS: the Hunter Community Study (HCS) included 3,306 adults aged 55-85 years with a median follow-up of 7.1 years. Probable dementia/cognitive impairment was defined using Admitted Patient Data Collection, dispensing of cholinesterase inhibitors or memantine, or a cognitive test. Model validity was assessed by calibration and discrimination. A hybrid model was developed using deep neural network analysis, a machine learning method. RESULTS: 120 (3.6%) participants developed probable dementia/cognitive impairment. Mean calibration by ANU-ADRI, LIBRA, CAIDE and the hybrid model was 19, 0.5, 4.7 and 3.4%, respectively. The discrimination of the models was 0.65 (95% CI 0.60-0.70), 0.65 (95% CI 0.60-0.71), 0.54 (95% CI 0.49-0.58) and 0.80 (95% CI 0.78-0.83), respectively. CONCLUSION: ANU-ADRI and LIBRA were better dementia prediction tools than CAIDE for identification of high-risk individuals in this cohort. ANU-ADRI overestimated and LIBRA underestimated the risk. The new hybrid model had a higher predictive performance than the other models but it needs to be validated independently in longitudinal studies.

COPD-X Australian guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2022 update.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a treatable and preventable disease characterised by persistent respiratory symptoms and chronic airflow limitation on spirometry. COPD is highly prevalent and is associated with exacerbations and comorbid conditions. "COPD-X" provides quarterly updates in COPD care and is published by the Lung Foundation Australia and the Thoracic Society of Australia and New Zealand. MAIN RECOMMENDATIONS: The COPD-X guidelines (version 2.65) encompass 26 recommendations addressing: case finding and confirming diagnosis; optimising function; preventing deterioration; developing a plan of care; and managing an exacerbation. CHANGES IN MANAGEMENT AS A RESULT OF THESE GUIDELINES: Both non-pharmacological and pharmacological strategies are included within these recommendations, reflecting the importance of a holistic approach to clinical care for people living with COPD to delay disease progression, optimise quality of life and ensure best practice care in the community and hospital settings when managing exacerbations. Several of the new recommendations, if put into practice in the appropriate circumstances, and notwithstanding known variations in the social determinants of health, could improve quality of life and reduce exacerbations, hospitalisations and mortality for people living with COPD.

Effectiveness of Interventions Targeting Treatable Traits for the Management of Obstructive Airway Diseases: A Systematic Review and Meta-Analysis.

BACKGROUND: The management of obstructive airway diseases (OADs) is complex. The treatable traits (TTs) approach may be an effective strategy for managing OADs. OBJECTIVE: To determine the effectiveness of interventions targeting TTs for managing OADs. METHODS: Ovid Embase, Medline, CENTRAL, and CINAHL Plus were searched from inception to March 9, 2022. Studies of interventions targeting at least 1 TT from pulmonary, extrapulmonary, and behavioral/lifestyle domains were included. Two reviewers independently extracted relevant data and performed risk-of-bias assessments. Meta-analyses were performed using random-effects models. Subgroup and sensitivity analyses were carried out to explore heterogeneity and to determine the effects of outlying studies. RESULTS: Eleven studies that used the TTs approach for OAD management were identified. Traits targeted within each study ranged from 13 to 36. Seven controlled trials were included in meta-analyses. TT interventions were effective at improving health-related quality of life (mean difference [MD] = -6.96, 95% CI: -9.92 to -4.01), hospitalizations (odds ratio [OR] = 0.52, 95% CI: 0.39 to 0.69), all-cause-1-year mortality (OR = 0.65, 95% CI: 0.45 to 0.95), dyspnea score (MD = -0.29, 95% CI: -0.46 to -0.12), anxiety (MD = -1.61, 95% CI: -2.92 to -0.30), and depression (MD = -2.00, 95% CI: -3.53 to -0.47). CONCLUSION: Characterizing TTs and targeted interventions can improve outcomes in OADs, which offer a promising model of care for OADs.

Characterising the use of varenicline: an analysis of the Australian dispensing claims data.

BACKGROUND AND AIMS: In Australia, patterns of use of smoking cessation medications and factors associated with their dispensing are currently not known. This study aimed to measure the demographic and clinical factors associated with varenicline dispensing compared with nicotine replacement therapy (NRT) and bupropion among first-time users of Pharmaceutical Benefits Scheme (PBS) subsidised smoking cessation medicines in Australia and to characterise those who discontinued varenicline treatment prematurely. DESIGN: Retrospective, population-based study. Logistic regression was used to identify factors associated with varenicline dispensing compared with NRT and bupropion. Sensitivity analyses estimated the proportion of individuals who completed the recommended 12 weeks of varenicline treatment. SETTING AND PARTICIPANTS: First-time users of PBS subsidised smoking cessation medicines in Australia. Individuals first dispensed a smoking cessation medicine between 2011 and 2019 were identified from a 10% random sample of the national dispensing claims data. MEASUREMENTS: The outcome for the regression analysis was the dispensing of varenicline compared with NRT and bupropion. The dispensing of a smoking cessation medicine was identified using the World Health Organization Anatomical Therapeutic Chemical Classification System and PBS item codes. Independent variables included demographic and clinical characteristics such as sex, age, concessional status, year of treatment initiation and comorbidities identified using the Rx-Risk index. The proportion of people who discontinued varenicline treatment after the initiation pack was determined using prescription refill data. FINDINGS: A total of 94 532 people had their first PBS subsidised smoking cessation medicine. Of these, 62 367 (66.0%) were dispensed varenicline, 29 949 (31.7%) NRT and 2216 (2.3%) bupropion. The odds of varenicline dispensing were higher in males (OR, 1.18; 95% CI, 1.14-1.21), but lower in older adults (0.86 [0.82-0.90] in above 30 years to 0.49 [0.47-0.52] in 61 years and above), among concession beneficiaries (0.44; 0.43-0.46), and those with congestive heart failure (0.60; 0.53-0.68), depression (0.61; 0.54-0.69), anxiety (0.70; 0.66-0.73), psychotic illness (0.39; 0.37-0.42), and chronic obstructive pulmonary disease (0.87; 0.82-0.92). The majority (37 670; 60.4%) of those dispensed varenicline discontinued treatment after the initiation pack. Anxiety and psychotic illnesses were significantly more prevalent in those who discontinued treatment. Only 2804 (4.5%) of those dispensed varenicline completed 12 weeks of treatment. CONCLUSION: Individuals dispensed varenicline in Australia appear to be healthier compared with those who are dispensed nicotine replacement therapy or bupropion.

Educational interventions for health professionals managing chronic obstructive pulmonary disease in primary care.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable health condition. COPD is associated with substantial burden on morbidity, mortality and healthcare resources. OBJECTIVES: To review existing evidence for educational interventions delivered to health professionals managing COPD in the primary care setting. SEARCH METHODS: We searched the Cochrane Airways Trials Register from inception to May 2021. The Register includes records from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and PsycINFO. We also searched online trial registries and reference lists of included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and cluster-RCTs. Eligible studies tested educational interventions aimed at any health professionals involved in the management of COPD in primary care. Educational interventions were defined as interventions aimed at upskilling, improving or refreshing existing knowledge of health professionals in the diagnosis and management of COPD. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data and assessed the risk of bias of included studies. We conducted meta-analyses where possible and used random-effects models to yield summary estimates of effect (mean differences (MDs) with 95% confidence intervals (CIs)). We performed narrative synthesis when meta-analysis was not possible. We assessed the overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were: 1) proportion of COPD diagnoses confirmed with spirometry; 2) proportion of patients with COPD referred to, participating in or completing pulmonary rehabilitation; and 3) proportion of patients with COPD prescribed respiratory medication consistent with guideline recommendations. MAIN RESULTS: We identified 38 studies(22 cluster-RCTs and 16 RCTs) involving 4936 health professionals (reported in 19/38 studies) and 71,085 patient participants (reported in 25/38 studies). Thirty-six included studies evaluated interventions versus usual care; seven studies also reported a comparison between two or more interventions as part of a three- to five-arm RCT design. A range of simple to complex interventions were used across the studies, with common intervention features including education provided to health professionals via training sessions, workshops or online modules (31 studies), provision of practice support tools, tool kits and/or algorithms (10 studies), provision of guidelines (nine studies) and training on spirometry (five studies). Health professionals targeted by the interventions were most commonly general practitioners alone (20 studies) or in combination with nurses or allied health professionals (eight studies), and the majority of studies were conducted in general practice clinics. We identified performance bias as high risk for 33 studies. We also noted risk of selection, detection, attrition and reporting biases, although to a varying extent across studies. The evidence of efficacy was equivocal for all the three primary endpoints evaluated: 1) proportion of COPD diagnoses confirmed with spirometry (of the four studies that reported this outcome, two supported the intervention); 2) proportion of patients with COPD who are referred to, participate in or complete pulmonary rehabilitation (of the four studies that reported this outcome, two supported the intervention); and 3) proportion of patients with COPD prescribed respiratory medications consistent with guideline recommendations (12 studies reported this outcome, the majority evaluated multiple drug classes and reported a mixed effect). Additionally, the low quality of evidence and potential risk of bias make the interpretation more difficult. Moderate-quality evidence (downgraded due to risk of bias concerns) suggests that educational interventions for health professionals probably improve the proportion of patients with COPD vaccinated against influenza (three studies) and probably have little impact on the proportion of patients vaccinated against pneumococcal infection (two studies). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on the frequency of COPD exacerbations (10 studies). There was a high degree of heterogeneity in the reporting of health-related quality of life (HRQoL). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on HRQoL overall, and when using the COPD-specific HRQoL instrument, the St George's Respiratory Questionnaire (at six months MD 0.87, 95% CI -2.51 to 4.26; 2 studies, 406 participants, and at 12 months MD -0.43, 95% CI -1.52 to 0.67, 4 studies, 1646 participants; reduction in score indicates better health). Moderate-quality evidence suggests that educational interventions for health professionals may improve patient satisfaction with care (one study). We identified no studies that reported adverse outcomes. AUTHORS' CONCLUSIONS: The evidence of efficacy was equivocal for educational interventions for health professionals in primary care on the proportion of COPD diagnoses confirmed with spirometry, the proportion of patients with COPD who participate in pulmonary rehabilitation, and the proportion of patients prescribed guideline-recommended COPD respiratory medications. Educational interventions for health professionals may improve influenza vaccination rates among patients with COPD and patient satisfaction with care. The quality of evidence for most outcomes was low or very low due to heterogeneity and methodological limitations of the studies included in the review, which means that there is uncertainty about the benefits of any currently published educational interventions for healthcare professionals to improve COPD management in primary care. Further well-designed RCTs are needed to investigate the effects of educational interventions delivered to health professionals managing COPD in the primary care setting.

Dataset of De Novo hybrid berry transcriptome profiling and characterization of Piper species (Piper nigrum and Piper longum) using Illumina and Nanopore sequencing.

Piper nigrum and Piper longum are the most popular and economically essential spice crops globally valued for their aromatic alkaloids, especially Piperine. However, Piperine synthesis pathway mechanisms are not yet well known. This work was aimed to generate the full-length comparative berry transcriptome analysis dataset of P. nigrum and P. longum by Illumina and Nanopore sequencing platforms. While short-read sequencing technology is widely using to capture transcriptome profiles, there are still some limitations due to the read length. We used Oxford Nanopore technology for long reads and the Illumina sequencing platform for short reads to generate a hybrid transcriptome assembly from half matured and fully matured berries of P. nigrum and P. longum. From P. nigrum and P. longum 37.3 million and 38.1 million raw reads were generated respectively. A total of 308369 contigs from P. nigrum and 267715 contigs from P. longum were obtained and successfully annotated. The transcriptome data revealed gene families involved in piperine and other secondary metabolite biosynthetic pathways. The raw data were uploaded to NCBI database. This dataset shed light on the further exploration of the piperine biosynthetic pathway, its transcriptomic changes, and evolution. Data generated has been submitted to SRA of NCBI with Bio samples accession: (SAMN13981803, SAMN22826456).

Pregnant women's experiences with the management of hypertensive disorders of pregnancy: a qualitative study.

BACKGROUND: Hypertensive disorders are a leading cause of mortality and morbidity during pregnancy. Despite multiple national and international clinical guidelines and a plethora of research in the field of optimising management, there has been limited research describing the perspectives and experiences of pregnant women with the management of hypertensive disorders of pregnancy (HDP). Understanding these perceptions and experiences is imperative to the optimisation of HDP management. METHODS: A qualitative study involving face-to-face, in-depth interviews were undertaken with 27 pregnant women diagnosed with and being treated for HDP to explore their perspectives of and experiences with clinical management. Written consent was obtained individually from each participant, and the interviews ranged from 16 to 54 min. Inductive codes were generated systematically for the entire data set. Line-by-line analysis was then performed and nodes were created within NVivo, a qualitative data management software. Data collection was continued until thematic saturation was reached. Thematic analysis was employed to interpret the data. RESULTS: Three major descriptive themes were discerned regarding the women's perspectives on and experiences with the management of HDP: attitudes towards monitoring of HDP, attitudes and perceptions towards development and management of complications, and perceptions of pregnant women with chronic hypertension. Trust in the hospital system, positive attitudes towards close blood pressure monitoring as well as self-monitoring of blood pressure, and a realistic approach to emergency antenatal hospital admissions contributed to a positive attitude towards monitoring of HDP. Women with prior experiences of HDP complications, including pre-eclampsia, were more confident in their clinical management and knew what to expect. Those without prior experience were often in shock when they developed pre-eclampsia. Some women with chronic hypertension displayed limited understanding of the potential risks that they may experience during pregnancy and thus lacked comprehension of the seriousness of the condition. CONCLUSIONS: The clinical management experiences of pregnant women with HDP were varied. Many women did not feel that they were well informed of management decisions and had a desire to be more informed and involved in decision-making. Clear, concise information about various facets of HDP management including blood pressure monitoring, prescription of the appropriate antihypertensive agent, and planning for potential early delivery are required.

'I wish my body was stronger': A qualitative study of attitudes and behaviours regarding treatment of hypertensive disorders of pregnancy.

OBJECTIVES: To investigate pregnant women's attitudes and behaviours towards hypertensive disorders of pregnancy and their treatment. METHODS: Face-to-face, in-depth interviews were undertaken with 27 pregnant women diagnosed with and being treated for hypertensive disorders of pregnancy to investigate attitudes and behaviours regarding the conditions and their treatment. Written consent was obtained individually from each participant, and the interviews ranged from 16 to 54 minutes. Data collection was continued until thematic saturation was reached. Thematic analysis was employed to interpret the data. RESULTS: Four major themes emerged around beliefs and behaviours of pregnant women regarding treatment of their hypertension: understanding of hypertensive disorders of pregnancy and their implications, risks versus benefits of antihypertensive medication during pregnancy, trust in medical professionals and adherence to medication. The women's level of understanding of hypertensive disorders of pregnancy and their implications determined whether they were able to make informed decisions about their treatment. Prior experiences and concern for preservation of the pregnancy played major roles in the perception of the risk/benefit balance of using antihypertensive medication during pregnancy. The degree of trust in the treating medical professionals varied according to the perception of their confidence and knowledge. CONCLUSIONS: Sound understanding of the condition, a positive risk/benefit balance regarding antihypertensive medication use during pregnancy, and trust in medical professionals contributed to adherence to medication. Good communication with healthcare professionals is important to achieve optimal treatment.

Adherence to anti-hypertensive medication in pregnancy.

OBJECTIVES: To assess adherence to anti-hypertensive medication by pregnant women and to identify the factors associated with adherence or lack thereof. STUDY DESIGN: Observational study in 100 pregnant women with either chronic hypertension or gestational hypertension who were being treated with at least one anti-hypertensive medication and attending antenatal clinics at one of two maternity hospitals. In-depth interviews were conducted with a subset of 27 women from the same group. Quotes from interview transcripts were used to illustrate the quantitative results. MAIN OUTCOME MEASURES: BP control, self-reported adherence, complexity of medication regimen. RESULTS: Participants (mean age 33 [±4.9] years; mean gestation 29 (±7) weeks) had a median blood pressure (BP) of 130/80 mmHg (IQR: 16/15). Sixty-five women had chronic hypertension, of whom 13 were diagnosed during pregnancy, before 20 weeks gestation. Thirty-five women had gestational hypertension. Ninety-two per cent of participants had sub-optimal adherence. There were no significant differences in adherence scores between participants with chronic hypertension and their counterparts. The main contributors to sub-optimal adherence were intentionally putting up with medical problems before taking any action, confusion about the medication, and making changes to the recommended medication regimen to suit lifestyle. CONCLUSIONS: Nine out of ten pregnant women using anti-hypertensives self-reported some degree of suboptimal adherence, intentionally and/or unintentionally. Health professionals, including pharmacists, general practitioners and obstetricians, have a role in promoting optimal medication adherence.