To assess the risk factors for symptomatic gallstones, 88,837 women in the Nurses' Health Study cohort (age range, 34 to 59 years) were followed for four years after completing a detailed questionnaire about food and alcohol intake in 1980. A total of 433 cholecystectomies and 179 cases of newly symptomatic, unremoved gallstones, diagnosed by ultrasonographic examination or x-ray films, were reported during the four-year follow-up. The age-adjusted relative risk for very obese women, who had a Quetelet index of relative weight (weight in kilograms divided by the square of the height in meters) of more than 32 kg per square meter, was 6.0 (95 percent confidence interval, 4.0 to 9.0), as compared with women whose relative weight was less than 20 kg per square meter. For slightly overweight women (relative weight, 24 to 24.9 kg per square meter), the relative risk was 1.7 (95 percent confidence interval, 1.1 to 2.7). Overall, we observed a roughly linear relation between relative weight and the risk of gallstones. Among the 59,306 women whose relative weight was less than 25 kg per square meter, a high energy intake (greater than 8200 J per day), as compared with a low energy intake (less than 4730 J per day), was associated with an increased incidence of symptomatic gallstones (relative risk, 2.1; 95 percent confidence interval, 1.4 to 3.3), and an alcohol intake of at least 5 g per day was associated with a decreased incidence as compared with abstention (relative risk, 0.6; 95 percent confidence interval, 0.4 to 0.8). Parity did not appear to be an important risk factor after an adjustment was made for relative weight. These data support a strong association between obesity and symptomatic gallstones and suggest that even moderate overweight may increase the risk.

Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. [Review]. Cochrane database of systematic reviews [online], Issue 11, article number CS011227.

Although obesity is a well-recognized risk factor for gallstones, the excess risks associated with higher levels of obesity and recent weight change are poorly quantified. We evaluated these issues in the Nurses' Health Study. Among 90,302 women aged 34-59 y at baseline followed from 1980 to 1988, 2122 cases of newly diagnosed symptomatic gallstones occurred during 607,104 person-years of follow-up. From 1980 to 1986, 488 cases of newly diagnosed unremoved gallstones were documented. We observed a striking monotonic increase in gallstone disease risk with obesity; women with a body mass index (BMI) greater than 45 kg/m2 had a sevenfold excess risk compared with those whose BMI was less than 24 kg/m2. Women with a BMI greater than 30 kg/m2 had a yearly gallstone incidence of greater than 1% and those with a BMI greater than or equal to 45 kg/m2 had a rate of approximately 2%/y. Recent weight loss was associated with a modestly increased risk after adjustment for BMI before weight loss. Current smoking was an independent risk factor; women smoking greater than or equal to 35 cigarettes/d had a relative risk of 1.5 (95% CI 1.2-1.9).

There is an accumulation of global evidence of the positive views and experiences of diverse stakeholder groups and their perceptions of facilitators and barriers to pharmacist prescribing. There are, however, organizational issues to be tackled which may otherwise impede the implementation and sustainability of pharmacist prescribing.

Many countries have implemented nonmedical prescribing (NMP) and many others are scoping prescribing practices with a view to developing NMP. This paper provides a future perspective on NMP in light of findings of an umbrella review of aspects of NMP. This is followed by coverage of the Scottish Government strategy of pharmacist prescribing and finally, consideration of two key challenges. The review identified seven systematic reviews of influences on prescribing decision-making, processes of prescribing, and barriers and facilitators to implementation. Decision making was reported as complex with many, and often conflicting, influences. Facilitators of NMP included perceived improved patient care and professional autonomy, while barriers included lack of defined roles and resource pressures. Three systematic reviews explored patient outcomes that were noted to be equivalent or better to physician prescribing. In particular, a Cochrane review of 46 studies of clinical, patientreported, and resource-use outcomes of NMP compared with medical prescribing showed positive intervention-group effects. Despite positive findings, authors highlighted high bias, poor definition and description of 'prescribing' and the 'prescribing process' and difficulty in separating NMP effects from the contributions of other healthcare team members. While evidence of benefit and safety is essential to inform practice, for NMP to be implemented and sustained on a large scale, there needs to be clear commitment at the highest level. The approach being taken by the Scottish Government to pharmacist prescribing implementation may inform developments in other professions and countries. The vision is that by 2023, all pharmacists providing pharmaceutical care will be pharmacist-independent prescribers. There are, however, challenges to implementing NMP into working practice; two key challenges are the need for sustainable models of care and evaluation research. These challenges could be met by considering the theoretical basis for implementation, and robust and rigorous evaluation.

BackgroundInappropriate use of multiple medicines (inappropriate polypharmacy) is a major challenge in older people with consequences of increased prevalence and severity of adverse drug reactions and interactions, and reduced medicines adherence. The aim of this study was to determine the levels of consensus amongst key stakeholders in the European Union (EU) in relation to aspects of the management of polypharmacy in older people.MethodsForty-six statements were developed on aspects of healthcare structures, processes and desired outcomes, with consensus defined at ≥ 80% agreement. Panel members were strategists (e.g. directors, leading clinicians and commissioners) from each of the 28 EU member states, with a target recruitment of five per member state. Three Delphi rounds were conducted via email, with panel members being provided with summative results and collated, anonymised comments at the commencement of Rounds 2 and 3.ResultsNinety panel members were recruited (64.3% of target), with high participation levels throughout the three Delphi rounds (91.1%, 83.3%, 72.2%). During Round 1, consensus was obtained for 27/46 statements (58.7%), with an additional two statements in Round 2 and none in Round 3. Consensus was obtained for statements relating to: potential gain arising from polypharmacy management (3/4 statements); strategic development (7/7); change management (5/7) indicator measures (4/6); legislation (0/3); awareness raising (5/5); polypharmacy reviews (5/7); and EU vision (0/7). Analysis of free text comments indicated that the vision statements were too ambitious and not achievable by the specified timeframe of 2025.ConclusionConsensus was obtained amongst key EU strategists around many aspects of polypharmacy management in older people. Notably, no consensus was achieved in relation to statements relating to the need to alter legislation in areas of healthcare delivery, remuneration and practitioner scope of practice. While the vision for the EU by 2025 was considered rather ambitious, there is great potential and clear opportunity to advance polypharmacy management throughout the EU and beyond.

Background: eHealth is defined as "the use of information and communication technology for health". Adoption and acceptance are key concepts to measure the level of eHealth impact. The aim of this systematic review was to critically appraise, synthesise and present evidence of the status of eHealth adoption and acceptance in Saudi Arabia from the perspectives of multiple stakeholders.Methods: Based on a Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guided protocol published with the international prospective register of systematic reviews (Prospero), five databases were searched for articles published between 1993 and 2017. Inclusion and exclusion criteria of studies were applied in which only peer-reviewed, full-text primary research articles in English language were included. One reviewer performed the searches; two reviewers independently screened the titles then abstracts followed by full articles.Studies excluded were recorded with reasons. Critical appraisal tools appropriate to study design were applied. Eleven items from every study were extracted for further synthesis.Results: After duplicates were removed, 110 papers were screened, and 15 studies met the inclusion criteria. Studies were generally of good quality. Thirty-nine factors were identified as influences affecting the adoption and acceptance of eHealth in Saudi Arabia. Lack of eHealth studies from the perspective of health managers and the limitation of studies to few geographical areas were identified as knowledge gaps.Conclusion: eHealth field in Saudi Arabia showed evidence of continual growth in both publications and awareness of significance. Therefore, findings from this review may help key professionals to address the current challenges and barriers and prioritise the main areas for improvement.

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