Maternal Antibiotic Exposure and the Risk of Developing Antenatal Depressive Symptoms.

Background: Antenatal depression is common and has significant consequences. The literature suggests that antibiotic exposure may be associated with depression. Many individuals are exposed to antibiotics during pregnancy. Further investigation of the association between antenatal antibiotic use and the development of depression during pregnancy is needed. Methods: A national prospective observational cohort study of pregnant individuals was undertaken using an online survey, completed during the third trimester. Antenatal depressive symptoms (ADSs) were defined as having an Edinburgh Postnatal Depression Scale score of ≥13 and/or receiving a clinical diagnosis of depression. Results: One in six individuals (16.5%, n = 977) experienced ADSs during their pregnancy, of whom 37.9% received a depression diagnosis. There was no relationship between antibiotic use and the development of ADSs. Four factors were identified as significant independent predictors of ADSs: personal history of depression, severe nausea and vomiting causing an inability to eat, emotional abuse from an intimate partner within the prior 12 months, and not having a university degree. Conclusions: Antenatal antibiotic use was not associated with the development of ADSs. Given the high incidence of undiagnosed depression, new strategies and models of care that prioritise individuals with risk factors may be required to optimise antenatal care.

Maternal Antibiotic Exposure and the Risk of Developing Antenatal or Postpartum Depressive Symptoms: The Maternal Experience Study Protocol.

Limited epidemiological evidence suggests a link between antibiotic use and developing depression. This study seeks to investigate this association in depth, using a cohort of pregnant individuals. The primary aim is to explore any association between the use of antibiotics during pregnancy and the development of antenatal depressive symptoms up to the third trimester, as well as the use of antibiotics during pregnancy and within 12 months postpartum and the development of postpartum depressive symptoms. A national prospective, observational, longitudinal cohort study has been designed to examine these relationships. A sample size of 1500 pregnant individuals has been sought for this study, assuming 10 potential predictor variables (including antibiotic use) in the final multiple logistic regression model and allowing for a 30% drop-out rate. The development of depressive symptoms is considered either a diagnosis by a medical doctor and/or a scoring 13 or higher on the Edinburgh Postnatal Depression Scale. Data will be collected during the third trimester and at 6 weeks, 6 months, and 12 months postpartum. These surveys include variables previously identified as associated with antenatal and postpartum depression (e.g., level of social support, experience of intimate partner abuse, and obstetric complications), as well as antibiotic and probiotic use. This study will provide an update on the prevalence of the symptoms of depression during pregnancy and postpartum and its associated risk factors. It will also, for the first time, comprehensively explore the potential association between antibiotic use during pregnancy and up to 12 months postpartum and the development of depressive symptoms.

Ten-Year Trends in Psychotropic Prescribing and Polypharmacy in Australian General Practice Patients with and without Dementia.

OBJECTIVE: Little research has evaluated trends in psychotropic prescribing and polypharmacy in primary care patients, especially those with dementia. We sought to examine this in Australia from 2011 to 2020 using the primary care dataset, MedicineInsight. METHODS: Ten consecutive serial cross-sectional analyses were performed to evaluate the proportion of patients aged 65 years or more, with a recorded diagnosis of dementia, who were prescribed psychotropic medications within the first six months of each year from 2011 to 2020. This proportion was compared with propensity score-matched control patients without dementia. RESULTS: Before matching, 24,701 patients (59.2% females) with, and 72,105 patients (59.2% females) without, a recorded diagnosis of dementia were included. In 2011, 42% (95% confidence interval [CI] 40.5-43.5%) of patients in the dementia group had at least one recorded prescription of a psychotropic medication, which declined to 34.2% (95% CI 33.3-35.1%; p for trend < 0.001) by 2020. However, it remained unchanged for matched controls (36% [95% CI 34.6-37.5%] in 2011 and 36.7% [95% CI 35.7-37.6%] in 2020). The greatest decline in the dementia groups by medication class was for antipsychotics (from 15.9% [95% CI 14.8-17.0%] to 8.8% [95% CI 8.2-9.4%]; p for trend < 0.001). During this period, the prevalence of psychotropic polypharmacy (use of two or more individual psychotropics) also decreased from 21.7% (95% CI 20.5-22.9%) to 18.1% (95% CI 17.4-18.9%) in the dementia groups, and slightly increased from 15.2% (95% CI 14.1-16.3%) to 16.6% (95% CI 15.9-17.3%) in the matched controls. CONCLUSIONS: The decline in psychotropic prescribing, particularly antipsychotics, in Australian primary care patients with dementia is encouraging. However, psychotropic polypharmacy still occurred in almost one in five patients with dementia at the end of the study period. Programs focused on encouraging further reductions in the use of multiple psychotropic drugs in patients with dementia are recommended, particularly in rural and remote regions.

Risk of osteoporosis in patients with atrial fibrillation with and without oral anticoagulant therapy.

BACKGROUND: We aimed to compare the risk of developing osteoporosis in patients prescribed warfarin or direct-acting oral anticoagulants (DOACs) with those with no therapy. RESEARCH DESIGN AND METHODS: We included 37,632 patients aged between 18 and 111 years with a recorded diagnosis of AF between 1 January 2013 and 31 December 2017. Patients were followed until the diagnosis of osteoporosis, switch or discontinuation of the OAC, last clinical visit, or end of the study period, whichever occurred first. The incidences of new-onset osteoporosis were calculated using the Cox proportional hazards model. RESULTS: Of total, 16,995 (45.2%) had no recorded OAC prescription, and 20,637 had a recorded prescription of warfarin (6,609) or DOAC (14,028). Compared with those not prescribed an OAC, the risk of being diagnosed with new-onset osteoporosis increased in patients prescribed warfarin (HR 2.22, 95% CI 2.00-2.47, p < 0.001) and DOACs (HR 1.42, 95% CI 1.29-1.58, p < 0.001). However, the effect of DOACs was not statistically significant (HR 1.07, 95% CI 0.86-1.33, p < 0.535) after excluding patients with at least one recorded prescription of systemic corticosteroids, antiepileptics, or proton pump inhibitors. CONCLUSIONS: Use of warfarin or DOACs was associated with a significantly increased risk of developing osteoporosis compared with no OAC treatment.

Effects of a Mobile App Called Quittr, Which Utilizes Premium Currency and Games Features, on Improving Engagement With Smoking Cessation Intervention: Pilot Randomized Controlled Trial.

BACKGROUND: Numerous mobile health (mHealth) apps have been developed to support smokers attempting to quit smoking. Although these apps have been reported to be successful, only modest improvements in the quit rate have been measured. It has been proposed that efforts to improve user engagement and retention may improve the quit rate further. Owing to the high cost of smoking-related disease, it is considered worthwhile to pursue even small improvements. OBJECTIVE: The aim of this study was to test a novel smartphone app that leverages premium currency strategies developed by the mobile games industry in an attempt to improve engagement and retention with a smoking cessation intervention. METHODS: We designed and developed a smoking cessation app called "Quittr" in line with previously developed smoking cessation mHealth apps. In addition to this established framework, we added a stand-alone fully featured city-building clicker-style game called "Tappy Town," and a premium virtual currency called "QuitCoins." The user earns QuitCoins for using the app in a way that contributes positively toward their quit attempt, and they can redeem these coins in Tappy Town for bonuses. To establish whether these features improved engagement and retention, we ran a 5-month randomized controlled trial where the intervention group had the full app with the extra games features, while the control group had the standard app only. Recruitment was performed via web-based advertising. Participants (N=175) had no direct contact with the researchers or other support staff. RESULTS: No significant differences in terms of engagement, retention, or smoking outcomes were found between the control and intervention groups. However, survey data indicated that the majority of the participants valued Tappy Town (10/17, 59%) and the QuitCoins rewards system (13/17, 77%). Usage data also suggested that Tappy Town was widely played and was generally appealing to users (mean total time spent in app, control group: 797 seconds vs intervention group: 3502 seconds, P<.001). Analysis of the results suggests that users in the intervention group may have been negatively affected by the aspects of the chosen design, and some theories were explored to explain this unexpected outcome. CONCLUSIONS: Although the novel features of the Quittr app failed to improve the key outcomes measured in this study, there were enough positive indications to warrant further exploration of the concept. Additional research will be required to identify and correct any design flaws that may have adversely affected our participants before a follow-up study can be completed. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Register ACTRN12617000491369; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372661&isReview=true.

More action needed: Psychotropic prescribing in Australian residential aged care.

OBJECTIVE: For at least two decades, concerns have been raised about inappropriate psychotropic prescribing in Australian residential aged care facilities, due to their modest therapeutic benefit and increased risk of falls and mortality. To date, the majority of prevalence data has been collected in Sydney exclusively and it is not known if recent initiatives to promote appropriate psychotropic prescribing have impacted utilisation. Thus, we aimed to comprehensively analyse psychotropic use in a large national sample of residential aged care facility residents. METHOD: A cross-sectional, retrospective cohort study of residents from 150 residential aged care facilities distributed nationally during April 2014-October 2015. Antipsychotic, anxiolytic/hypnotic and antidepressant utilisation was assessed, along with anticonvulsant and anti-dementia drug use. Negative binomial regression analysis was used to examine variation in psychotropic use. RESULTS: Full psychotropic prescribing data was available from 11,368 residents. Nearly two-thirds (61%) were taking psychotropic agents regularly, with over 41% prescribed antidepressants, 22% antipsychotics and 22% of residents taking benzodiazepines. Over 30% and 11% were charted for 'prn' (as required) benzodiazepines and antipsychotics, respectively. More than 16% of the residents were taking sedating antidepressants, predominantly mirtazapine. South Australian residents were more likely to be taking benzodiazepines ( p < 0.05) and residents from New South Wales/Australian Capital Territory less likely to be taking them ( p < 0.01), after adjustment for rurality and size of residential aged care facility. Residents located in New South Wales/Australian Capital Territory were also significantly less likely to take antidepressants ( p < 0.01), as were residents from outer regional residential aged care facilities ( p < 0.01). Antipsychotic use was not associated with State, rurality or residential aged care facility size. CONCLUSION: Regular antipsychotic use appears to have decreased in residential aged care facilities but benzodiazepine prevalence is higher, particularly in South Australian residential aged care facilities. Sedating antidepressant and 'prn' psychotropic prescribing is widespread. Effective interventions to reduce the continued reliance on psychotropic management, in conjunction with active promotion of non-pharmacological strategies, are urgently required.

RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities.

OBJECTIVE: To assess the impact of a multi-strategic, interdisciplinary intervention on antipsychotic and benzodiazepine prescribing in residential aged care facilities (RACFs). Design, setting: Prospective, longitudinal intervention in Australian RACFs, April 2014 - March 2016. PARTICIPANTS: 150 RACFs (with 12 157 residents) comprised the main participant group; two further groups were consultant pharmacists (staff education) and community pharmacies (prescribing data). Data for all RACF residents, excluding residents receiving respite or end-stage palliative care, were included. INTERVENTION: A multi-strategic program comprising psychotropic medication audit and feedback, staff education, and interdisciplinary case review at baseline and 3 months; final audit at 6 months. MAIN OUTCOME MEASURE: Mean prevalence of regular antipsychotic and benzodiazepine prescribing at baseline, and at 3 and 6 months. Secondary measures: chlorpromazine and diazepam equivalent doses/day/resident; proportions of residents for whom drug was ceased or the dose reduced; prevalence of antidepressant and prn (as required) psychotropic prescribing (to detect any substitution practice). RESULTS: During the 6-month intervention, the proportion of residents prescribed antipsychotics declined by 13% (from 21.6% [95% CI, 20.4-22.9%] to 18.9% [95% CI, 17.7-20.1%]), and that of residents regularly prescribed benzodiazepines by 21% (from 22.2% [95% CI, 21.0-23.5%] to 17.6% [95% CI, 16.5-18.7]; each, P < 0.001). Mean chlorpromazine equivalent dose declined from 22.9 mg/resident/day (95% CI, 19.8-26.0) to 20.2 mg/resident/day (95% CI, 17.5-22.9; P < 0.001); mean diazepam equivalent dose declined from 1.4 mg/resident/day (95% CI, 1.3-1.5) to 1.1 mg/resident/day (95% CI, 0.9-1.2; P < 0.001). For 39% of residents prescribed antipsychotics and benzodiazepines at baseline, these agents had been ceased or their doses reduced by 6 months. There was no substitution by sedating antidepressants or prn prescribing of other psychotropic agents. CONCLUSIONS: The RedUSe program achieved significant reductions in the proportions of RACF residents prescribed antipsychotics and benzodiazepines. TRIAL REGISTRATION: Australian New Zealand Clinical Trials, ACTRN12617001257358.

Simulation and Feedback in Health Education: A Mixed Methods Study Comparing Three Simulation Modalities.

Background. There are numerous approaches to simulating a patient encounter in pharmacy education. However, little direct comparison between these approaches has been undertaken. Our objective was to investigate student experiences, satisfaction, and feedback preferences between three scenario simulation modalities (paper-, actor-, and computer-based). Methods. We conducted a mixed methods study with randomized cross-over of simulation modalities on final-year Australian graduate-entry Master of Pharmacy students. Participants completed case-based scenarios within each of three simulation modalities, with feedback provided at the completion of each scenario in a format corresponding to each simulation modality. A post-simulation questionnaire collected qualitative and quantitative responses pertaining to participant satisfaction, experiences, and feedback preferences. Results. Participants reported similar levels satisfaction across all three modalities. However, each modality resulted in unique positive and negative experiences, such as student disengagement with paper-based scenarios. Conclusion. Importantly, the themes of guidance and opportunity for peer discussion underlie the best forms of feedback for students. The provision of feedback following simulation should be carefully considered and delivered, with all three simulation modalities producing both positive and negative experiences in regard to their feedback format.

An Internet-Based Method for Extracting Nursing Home Resident Sedative Medication Data From Pharmacy Packing Systems: Descriptive Evaluation.

BACKGROUND: Inappropriate use of sedating medication has been reported in nursing homes for several decades. The Reducing Use of Sedatives (RedUSe) project was designed to address this issue through a combination of audit, feedback, staff education, and medication review. The project significantly reduced sedative use in a controlled trial of 25 Tasmanian nursing homes. To expand the project to 150 nursing homes across Australia, an improved and scalable method of data collection was required. This paper describes and evaluates a method for remotely extracting, transforming, and validating electronic resident and medication data from community pharmacies supplying medications to nursing homes. OBJECTIVE: The aim of this study was to develop and evaluate an electronic method for extracting and enriching data on psychotropic medication use in nursing homes, on a national scale. METHODS: An application uploaded resident details and medication data from computerized medication packing systems in the pharmacies supplying participating nursing homes. The server converted medication codes used by the packing systems to Australian Medicines Terminology coding and subsequently to Anatomical Therapeutic Chemical (ATC) codes for grouping. Medications of interest, in this case antipsychotics and benzodiazepines, were automatically identified and quantified during the upload. This data was then validated on the Web by project staff and a "champion nurse" at the participating home. RESULTS: Of participating nursing homes, 94.6% (142/150) had resident and medication records uploaded. Facilitating an upload for one pharmacy took an average of 15 min. A total of 17,722 resident profiles were extracted, representing 95.6% (17,722/18,537) of the homes' residents. For these, 546,535 medication records were extracted, of which, 28,053 were identified as antipsychotics or benzodiazepines. Of these, 8.17% (2291/28,053) were modified during validation and verification stages, and 4.75% (1398/29,451) were added. The champion nurse required a mean of 33 min website interaction to verify data, compared with 60 min for manual data entry. CONCLUSIONS: The results show that the electronic data collection process is accurate: 95.25% (28,053/29,451) of sedative medications being taken by residents were identified and, of those, 91.83% (25,762/28,053) were correct without any manual intervention. The process worked effectively for nearly all homes. Although the pharmacy packing systems contain some invalid patient records, and data is sometimes incorrectly recorded, validation steps can overcome these problems and provide sufficiently accurate data for the purposes of reporting medication use in individual nursing homes.

Quittr: The Design of a Video Game to Support Smoking Cessation.

BACKGROUND: Smoking is recognized as the largest, single, preventable cause of death and disease in the developed world. While the majority of smokers report wanting to quit, and many try each year, smokers find it difficult to maintain long-term abstinence. Behavioral support, such as education, advice, goal-setting, and encouragement, is known to be beneficial in improving the likelihood of succeeding in a quit attempt, but it remains difficult to effectively deliver this behavioral support and keep the patient engaged with the process for a sufficient duration. In an attempt to solve this, there have been numerous mobile apps developed, yet engagement and retention have remained key challenges that limit the potential effectiveness of these interventions. Video games have been clearly linked with the effective delivery of health interventions, due to their capacity to increase motivation and engagement of players. OBJECTIVE: The objective of this study is to describe the design and development of a smartphone app that is theory-driven, and which incorporates gaming characteristics in order to promote engagement with content, and thereby help smokers to quit. METHODS: Game design and development was informed by a taxonomy of motivational affordances for meaningful gamified and persuasive technologies. This taxonomy describes a set of design components that is grounded in well-established psychological theories on motivation. RESULTS: This paper reports on the design and development process of Quittr, a mobile app, describing how game design principles, game mechanics, and game elements can be used to embed education and support content, such that the app actually requires the user to access and engage with relevant educational content. The next stage of this research is to conduct a randomized controlled trial to determine whether the additional incentivization game features offer any value in terms of the key metrics of engagement-how much content users are consuming, how many days users are persisting with using the app, and what proportion of users successfully abstain from smoking for 28 days, based on user-reported data and verified against a biochemical baseline using cotinine tests. CONCLUSIONS: We describe a novel, and theoretically-informed mobile app design approach that has a broad range of potential applications. By using the virtual currency approach, we remove the need for the game to comprehensively integrate the healthy activity as part of its actual play mechanics. This opens up the potential for a wide variety of health problems to be tackled through games where no obvious play mechanic presents itself. The implications of this app are that similar approaches may be of benefit in areas such as managing chronic conditions (diabetes, heart disease, etc), treating substance abuse (alcohol, illicit drugs, etc), diet and exercise, eating disorders (anorexia, bulimia, and binge eating), and various phobias.

Development of a Flexible and Extensible Computer-based Simulation Platform for Healthcare Students.

Accessing appropriate clinical placement positions for all health profession students can be expensive and challenging. Increasingly simulation, in a range of modes, is being used to enhance student learning and prepare them for clinical placement. Commonly these simulations are focused on the use of simulated patient mannequins which typically presented as single-event scenarios, difficult to organise, and usually scenarios include only a single healthcare profession. Computer based simulation is relatively under-researched and under-utilised but is beginning to demonstrate potential benefits. This paper describes the development and trialling of an entirely virtual 3D simulated environment for inter-professional student education.

A Computer Simulation of Community Pharmacy Practice for Educational Use.

OBJECTIVE: To provide a computer-based learning method for pharmacy practice that is as effective as paper-based scenarios, but more engaging and less labor-intensive. DESIGN: We developed a flexible and customizable computer simulation of community pharmacy. Using it, the students would be able to work through scenarios which encapsulate the entirety of a patient presentation. We compared the traditional paper-based teaching method to our computer-based approach using equivalent scenarios. The paper-based group had 2 tutors while the computer group had none. Both groups were given a prescenario and postscenario clinical knowledge quiz and survey. ASSESSMENT: Students in the computer-based group had generally greater improvements in their clinical knowledge score, and third-year students using the computer-based method also showed more improvements in history taking and counseling competencies. Third-year students also found the simulation fun and engaging. CONCLUSION: Our simulation of community pharmacy provided an educational experience as effective as the paper-based alternative, despite the lack of a human tutor.

Respiratory knowledge discovery utilising expertise.

BACKGROUND: Significant amounts of medical data are being archived, in the hope that they can be analysed and provide insight. A critical problem with analysing such data is the amount of existing knowledge required to produce effective results. AIMS: This study tests a method that seeks to overcome these problems with analysis, by testing it over a large set of archived lung function test results. A knowledge base of lung function interpretation expertise has been compiled and serves as a base for analysis. METHOD: A user examines the dataset with the assistance of the knowledge discovery tool. Two pertinent respiratory research questions are analysed (the relative correlation between diffusing capacity and FEV(1) or FVC bronchodilator response, and the effects of BMI on various parameters of lung function), and the results compared and contrasted with relevant literature. RESULTS: The method finds interesting results from the lung function data supporting and questioning other published studies, while also finding correlations that suggest further areas of research. CONCLUSION: While the analysis does not necessarily reveal groundbreaking information, it shows that the method can successfully discover new knowledge and is useful in a research context.