Background Generalist physician care is associated with improved patient outcomes. Despite initiatives to promote generalism in educational settings, recruitment to generalist disciplines remains less than required to serve societal needs. Increasingly this impacts not just general practice but also generalist specialties such as internal medicine, surgery, and paediatrics. One potential factor for this deficit is a lack of explicit attention to generalism as a praxis, including clarifying key aspects of generalist expertise.\r\n\r\nAim To examine empirical clinical literature on generalism, and characterise how generalism is described and delivered by physicians in primary and secondary care.\r\n\r\nDesign & setting A systematic mixed studies review (SMSR) including quantitative, qualitative, mixed-methods studies, and systematic reviews of physician generalist practice.\r\n\r\nMethod MEDLINE, Psycinfo, SocINDEX, Embase, Ovid HealthSTAR, Scopus, and Web of Science will be searched for English language studies from 1999 to present, using a structured search. Given study heterogeneity, quality appraisal will not be performed. Two reviewers will perform study selection for each study. Data extraction will focus on how generalism is defined and characterised, including the clinical care provided by generalists and patient experiences of generalist care. Quantitative and qualitative data will be summarised in tabular and narrative form. Convergent synthesis design will then be used to synthesise quantitative and qualitative data.\r\n\r\nConclusion Findings will characterise generalism and generalist practice from a grassroots clinical perspective. By identifying similarities and differences across generalist disciplines, this work will inform more focused educational initiatives on generalism at undergraduate and postgraduate level, including collaborations between generalist disciplines.
\n \n\n \n \nCardiovascular disease (CVD) is a leading cause of mortality globally and in the UK, with significant efforts focused on early risk identification and prevention. Elevated low-density lipoprotein cholesterol (LDL-C) is a key modifiable risk factor for cardiovascular disease (CVD), yet the impact of LDL-C monitoring frequency on major adverse cardiovascular events (MACE) remains unclear. This study evaluated the relationship between LDL-C measurement frequency and the risk of MACE in a large, nationwide cohort. A retrospective cohort study using anonymised electronic health records from the Clinical Practice Research Datalink (CPRD) Aurum, linked to hospitalisation, social deprivation, and mortality data. The cohort included individuals registered for at least one year with at least one recorded low-density LDL-C measurement between 1 January 2000 and 31 December 2022. The primary outcome was MACE, defined as a composite of non-fatal coronary heart disease, non-fatal stroke, or cardiovascular death. Multivariable Cox proportional hazards models and Kaplan-Meier survival plot were used to estimate the incidence and hazard ratios (HRs) by LDL-C monitoring frequency. The study cohort comprised 5,133,574 individuals, with 2,733,144 (53.2%) being women. The median follow-up duration was 3.31 years (IQR: 7.39-12.11). Among the 5,133,574 individuals, the incidence of MACE declined with more frequent LDL-C monitoring, from 1937.0 (95% CI: 1928.2-1945.8) events per 100,000 person-years (one measurement) to 1615.4 (95% CI: 1605.8-1625.0), 1484.6 (95% CI: 1473.7-1495.6), and 1204.9 (95% CI: 1200.1-1209.6) for those with two, three, and four or more measurements, respectively. Compared to individuals with one LDL-C measurement, the adjusted HRs for MACE were 0.703 (95% CI: 0.698-0.709), for two measurements, 0.570 (95% CI: 0.565-0.575) for three, and 0.312 (95% CI: 0.310-0.314) for four or more. The Kaplan-Meier curve demonstrated improved event-free survival with increased LDL-C monitoring (log-rank p<0.0001). More frequent LDL-C monitoring was associated with a lower risk of MACE. These findings highlight the potential benefits of regular LDL-C monitoring as a potentially impactful strategy for CVD prevention and long-term risk management.
\n \n\n \n \nAbstract\r\nBackground: Social relationships are important for self-management and outcomes of multiple long-term conditions (MLTC). Previous research indicates MLTC negatively impacts social relationships and people living with MLTC do not feel adequately supported to manage their health. However, there is limited understanding of the processes and contextual factors that influence social relationships in the context of MLTC. This study explored experiences of social relationships for adults living with MLTC to improve understanding of their social relationship needs.\r\n\r\nMethods: Semi-structured telephone interviews were conducted with 22 people living with MLTC in Southern England. Participants were recruited through charity networks and GP practices. Eligibility criteria were: individuals aged \u2265 45 years living with MLTC within the community. Participants were purposively sampled to include diverse characteristics in terms of age, gender, and residential area deprivation. Transcribed interview data were analysed using reflexive thematic analysis.\r\n\r\nResults: Four themes were developed. 'There is no single route to meaningful social connection' reflected how participants achieved, valued, and maintained meaning in relationships in diverse ways. 'Change in sense of self' captured the mental load, nostalgia, low mood and depressive symptoms experienced because of MLTC, which was reported to negatively impact their relationships with others. 'A need to be seen and understood' described how participants valued social relationships that enabled them to talk about their conditions with others who have shared experiences. Participants experienced a sense of abandonment when they felt unable to share their needs and experiences with family and close friends. Some participants experienced distress around the need to self-manage their health, which was reinforced by limited health and care services. 'Altered interaction' reflected how MLTC required participants to find new ways to maintain social connection.\r\n\r\nConclusion: Meaningful connection may be achieved through diverse social relationships, including acquaintances and support groups. Further efforts to connect people to these forms of relationships could improve self-management of MLTC, though strategies may vary for adults with different characteristics and health needs. Interventions that target mental burden, nostalgia, low mood and depressive symptoms experienced because of MLTC could support appropriate and meaningful social connection. Further research is needed to test these relationships.\r\n\r\nPatient and public contribution: Three public contributors shaped the design of this study by sharing their experiences and views of key issues people who lack adequate social support may experience and how this might impact management of their health. They noted the importance of speaking to a range of people to understand social relationship needs of people living with MLTC, as experiences will vary. Two public contributors reviewed and helped refine the interview topic guide and commented on the importance of tone when conducting interviews, to encourage participants to share their experiences. One public contributor supported analysis of the transcripts through coding, discussion, and manuscript review. They highlighted the abandonment expressed by participants and how participants appeared to want to be seen as independent despite wanting and needing more support.
\n \n\n \n \nAbstract\r\nBackground\r\nPrevious longitudinal studies have linked multimorbidity to loneliness (feeling alienated) and social isolation (having reduced social contact). However, the nature of these associations over time is unclear.\r\nObjective\r\nTo examine bidirectional associations of multimorbidity with loneliness and social isolation over a 14-year follow-up in a nationally representative cohort of adults aged \u2265 50 years.\r\nMethods\r\nThis retrospective cohort study used seven waves of data (collected between 2004/2005 and 2018/2019) from adults in the English Longitudinal Study of Ageing. Multimorbidity was defined as the presence of \u22652 long-term conditions. Loneliness was measured using the 3-item University of California Los Angeles (UCLA) scale. Social isolation was derived based on cohabitation status, frequency of contact with children, relatives, and friends, and social organisation membership. We used Cox proportional hazards models adjusted for social isolation or loneliness, demographic and health behaviour variables.\r\nResults\r\nThe cohort consisted of 6031 adults with baseline and follow-up data on loneliness, social isolation, multimorbidity, and other covariates. Loneliness was associated with increased risk of incident multimorbidity [aHR (95 % CI): 1.38 (1.15\u20131.65)], whereas social isolation was not [aHR (95 % CI): 0.97 (0.81\u20131.16)]. Multimorbidity was associated with increased risk of incident loneliness [aHR (95 % CI): 1.55 (1.30\u20131.84)], but not significantly associated with subsequent risk of incident social isolation [aHR (95 % CI): 1.09 (0.92\u20131.28)].\r\nConclusions\r\nAn independent bidirectional association exists between loneliness and multimorbidity. Interventions targeting loneliness may prevent or delay multimorbidity and also improve wellbeing for people with multimorbidity.
\n \n\n \n \nAbstract\r\nChildren and adolescents with type 1 diabetes mellitus (T1D) are less active than recommended and than their peers without T1D. Several barriers to physical activity have been reported, including lack of confidence in the support received from those who facilitate physical activity such as sports coaches and PE teachers (physical activity providers). This study aims to explore the experiences and needs of physical activity providers in supporting children and adolescents with T1D to engage in structured physical activity. A mixed-methods study, including an online survey and semi-structured interviews, was conducted to provide a broad understanding of the current context along with more in-depth exploration of strategies implemented. Thirty-four participants completed the survey and nine participated in semi-structured interviews. Survey data were summarised descriptively. Qualitative data were analysed using a reflective thematic approach. Fewer than one-third of respondents had received T1D-related training, and only 12% were aware of relevant policies at their institution. Despite moderate confidence among half of the respondents in supporting children and adolescents with T1D, nearly all expressed a need for specific training. Two overarching themes emerged from the interviews: the existing context within which providers operate and effective strategies to support T1D-related physical activity.\r\n\r\nConclusion: Findings suggest improvements can be made to (1) training for physical activity providers to allow them to better support children and adolescents with T1D to participate in physical activity and (2) policies to help ensure a supportive and safe environment for children and adolescents with T1D.
\n \n\n \n \nABSTRACT\r\nIntroduction\r\nLong Covid, the patient-preferred term, describes symptoms persisting after an acute Covid-19 infection. Understanding the importance and meaning of a Long Covid diagnosis to children and young people (CYP), their families and professionals associated with their care can give insight into the way that these diagnoses are used across these groups to support care and needs of the patient. This study explores the meaning and importance of a Long Covid diagnosis from the perspectives of CYP with Long Covid, their parents and relevant professionals.\r\n\r\nMethods\r\nCYP and their parents or carers were invited to interview following participation in an initial cohort study. Professionals with experience working with CYP with Long Covid were invited to participate in a focus group. Interviews were carried out with four CYP with Long Covid (all female, aged 10\u201317 years); parents were present at three interviews. Seven professionals with experience in the care of CYP or Long Covid participated in one of two focus groups. Data were analysed thematically using constant comparison techniques.\r\n\r\nResults\r\nThe three main themes presented are as follows: the importance of receiving a diagnosis, diagnosis facilitates access to support and perspectives of discordance between family and professionals. The diagnosis of Long Covid has different meanings and significance for parents and professionals. Families described the diagnosis as a legitimisation of their experiences and a way to access support, but professionals questioned some of the ways families use the diagnosis, focusing instead on appropriate treatment according to CYP's needs.\r\n\r\nConclusion\r\nFor families, Long Covid diagnoses are important for validating and legitimising symptoms, removing uncertainty, and supporting access and participation, particularly in school. While these uses differ from those of professionals, understanding the importance of a Long Covid diagnosis to families may ensure effective communication, negotiation of an acceptable management plan, and ongoing support for this group.\r\n\r\nPatient or Public Contribution\r\nPatients and the public contributed throughout this project and had input on the study design, topic guides, and dissemination of findings.
\n \n\n \n \nAbstract\r\nObjectives\r\nMost adult patients in England now have access to their primary care electronic health record (EHR), including free-text consultation notes, via the NHS App or other online services. As EHRs were not designed for patient audiences, this study aimed to explore patients\u2019 and carers\u2019 perspectives and understanding of simulated consultation notes.\r\nMethods\r\nOne interview and five focus groups were conducted with 26 patients and carers from a purposive sample of underserved communities in England between April and May 2023. Participants\u2019 understanding and views were elicited regarding five vignettes about patient consultation scenarios and corresponding simulated primary care EHR entries. Verbatim transcripts were analysed inductively using thematic analysis.\r\nResults\r\nMost participants struggled to fully understand the simulated consultation notes, particularly medical acronyms, clinician shorthand and non-clinical abbreviations. Participants also identified issues which may cause unintended offence or anxiety, and made suggestions about how EHRs may be improved to meet the needs of patient audiences and maintain positive patient-clinician relationships.\r\nConclusions\r\nOpening up online record access to include patient audiences necessitates a significant cultural shift in the way that consultation notes are written and used. Participants proposed technological and documentation adaptations to enhance understanding, support diverse patient needs and maintain positive patient-clinician relationships.
\n \n\n \n \nOn 24 July 2025, Pulse reported the death of a Devonshire man who had been removed from mainstream general practice.1 Although no further details were given, the coroner\u2019s investigation has suggested that the man, diagnosed with autism spectrum disorder, had been receiving insufficient care through the \u2018Special Allocation Scheme\u2019 (SAS). Previously known as the \u2018violent patient service\u2019, the SAS is a national (England-wide) service for patients who have been removed from their regular GP provider after being reported for violence or aggression. It was developed in an attempt to maintain the safety of GP staff, while providing continued primary care to patients in a secure setting.2 Since the introduction of the scheme in 2004, levels of violence and aggression in general practice have been escalating and remain a pressing concern.3\r\n\r\nWhile the SAS has received little attention in the wider media and research, the patient\u2019s death has prompted calls for tighter protocols and safeguarding measures when general practices consider referring patients to the SAS. In July 2024, NHS England updated its guidance recommending that general practices consider disabilities, neurodiversity, and safeguarding before making such referrals.1,2 However, questions remain about when SAS registration is the appropriate course of action, if the service itself is unsuitable for many patients with complex needs.
\n \n\n \n \nPurpose: Prostate cancer (PCa) is the most common cancer among UK men, with Black men twice as likely to develop it and 2.5 times more likely to die from it than White men. This study identifies the barriers and facilitators to PCa healthcare in UK Black men and suggests ways to improve engagement and experiences across the care pathway.\r\n\r\nMethods: We conducted semi-structured interviews with: (i) 12 UK Black men living with and beyond PCa. (ii) 15 UK Black men aged 45 or above. (iii) 15 UK multi-disciplinary healthcare professionals (HCPs). Interview transcripts were coded and analysed thematically, using the socioecological model to map barriers and facilitators.\r\n\r\nResults: Barriers include mistrust of Western medicine, experiences of racism, fear and stigma around PCa, inadequate culturally sensitive information, underrepresentation of Black HCPs and Black men in healthcare spaces, limited culturally sensitive psychological support, and masculinity constructs affecting open discussions and preferences for minimally invasive treatments. Facilitators include racially concordant HCPs, culturally sensitive care, continuity of care and support from partners, peers, and local community groups.\r\n\r\nConclusion: Our findings underscore the need for tailored culturally sensitive information, community partnerships, and Black representation in both healthcare spaces and public health campaigns to improve healthcare engagement, foster trust and improve prostate cancer outcomes for Black men.
\n \n\n \n \nBackground Postural hypotension is associated with excess mortality, falls, and cognitive decline. Postural hypotension is poorly recorded in routine general practice records. Few studies have explored measurement and diagnosis of postural hypotension in general practice.\r\n\r\nAim To understand how postural hypotension is measured, diagnosed, and managed in general practice.\r\n\r\nDesign and setting This was an online survey of general practice staff in England.\r\n\r\nMethod Clinical research networks distributed the survey to practices, seeking individual responses from any clinical staff involved in routine blood pressure (BP) measurement. Responses were analysed according to role and demographic data using descriptive statistics. Multivariable modelling of checking for postural BP measurements was performed.\r\n\r\nResults There were 703 responses from 243 general practices (mean practice-level response rate 17%). Half (362; 51%) of responders were doctors, 196 (28%) nurses, and 77 (11%) healthcare assistants (HCAs). In total, 8% (58/703) did not routinely check for postural hypotension, usually citing time constraints. For the remaining 92%, postural symptoms were the predominant reason for checking (97% responders, 627/645); only 24% cited any other guideline indication for postural hypotension testing. The study found that 77% used sit-to-stand BP measurements; approximately one-quarter measured standing BP for >1 min. On regression modelling, other professionals tested less for postural hypotension than doctors (odds ratios: nurses 0.323, 95% confidence interval [CI] = 0.117 to 0.894, HCAs 0.102, 95% CI = 0.032 to 0.325, and pharmacists 0.099, 95% CI = 0.023 to 0.411).\r\n\r\nConclusion Awareness of reasons, besides symptoms, and adherence to guidelines for postural hypotension testing, are low. Time is the key barrier to improved testing for postural hypotension. Clarity on pragmatic methods of measuring postural hypotension in general practice would also facilitate measurement uptake.
\n \n\n \n \nAbstract\r\nThere is a place for the use of benzodiazepines/z-hypnotics on adult mental health wards, but they are often continued beyond a length of time where they are beneficial. This can result in dependence and withdrawal effects if stopped. Timely deprescribing of these medicines is encouraged, but there is limited evidence available as to what can be a facilitator or barrier to deprescribing benzodiazepines/z-hypnotics on these wards. Semi-structured interviews, with twenty-nine NHS healthcare professionals from eleven different NHS organisations, involved in the use of benzodiazepines/z-hypnotics on adult mental health wards, were conducted and recorded on Microsoft Teams and transcribed. Themes were generated via thematic analysis on NVIVO software, informed by a grounded, inductive approach, to identify similarities and differences in participants perceptions. The four main themes identified from participants\u2019 experiences were: Culture (shared values, beliefs and practices). Patient factors. Practical measures to facilitate deprescribing of benzodiazepines/z-hypnotics on adult mental health wards. Primary/secondary care interface. Deprescribing culture, rather than being led nationally, is more influenced by local factors. Some patient behaviour patterns can be a barrier to deprescribing but many of these can be overcome by promoting patient-centred care, allowing patients to feel involved and enabled to make informed decisions around their care. Access to non-pharmacological methods to de-escalate behaviour, promote wellbeing and improve sleep on adult mental health wards can support deprescribing. Cohesive multi-disciplinary team working aids deprescribing, but staff pressures can hinder this by reducing access to appropriately trained staff. Effective discharge planning is important but not always achieved. Good communication post discharge can facilitate continued deprescribing. Overcoming the barriers and developing the facilitators identified could improve benzodiazepine/z-hypnotic deprescribing on adult mental health wards. Changes to national NHS culture and priorities are required to influence local culture. Otherwise, deprescribing practices will remain greatly influenced by local factors on individual wards. Good practice exists but further research and funding is needed to disseminate this throughout the NHS.
\n \n\n \n \nBackground\r\nWomen benefit from reduced fracture risk while using menopausal hormone therapy. However, information on risks after stopping menopausal hormone therapy is scarce and inconsistent, with no information on longer-term fracture risk as women age. We aimed to produce robust estimates of fracture risk among past users for the longest possible period after discontinuing therapy.
\n \n\n \n \nPurpose: Chronic pain (pain >3 months) affects 35-50% of UK adults. People with chronic pain (for example, chronic back pain, fibromyalgia and osteoarthritis) commonly present to primary care to manage distressing symptoms of pain, depression, anxiety, reduced function and reduced quality of life.
\n \n\n \n \nBackground\r\nHealth and social care services increasingly recognise the value of involving people with lived experience in service design and delivery. For people who have experienced multiple disadvantage (combinations of homelessness, mental ill health, addiction, involvement with the criminal justice systems or domestic violence/abuse), participating in professional settings may be challenging and can risk re\u2010traumatisation and greater disillusionment. However, gaining confidence and competency to do this offers opportunities for personal and professional development, contributing to meaningful change. It is necessary that individuals with lived experience can engage safely and effectively in these settings. This study analyses how an organisation of people who have experienced multiple disadvantage, Independent Futures (IF), enabled co\u2010production within services and systems, to understand how people can be best supported and how involvement impacts them.\r\n\r\nMethods\r\nSixteen IF members and three IF staff participated in semi\u2010structured interviews. A staff survey, at two time points, investigated how employees from Changing Futures partner organisations perceived their ability to embed co\u2010production within services, with 147 responses. Internal documentation was analysed to illustrate the diversity of co\u2010production work that IF contributed to.\r\n\r\nResults\r\nPutting trauma\u2010informed principles into practice facilitated personal growth, improved confidence and some work skills for IF members, who contributed to 65 different workstreams. However, embedding co\u2010production into wider services and systems proved challenging. Staff survey comments highlighted obstacles related to resources, time and hierarchical cultures.\r\n\r\nConclusion\r\nLived experience organisations can model trauma\u2010informed practice and influence systems. Embedding trauma\u2010informed principles requires flexibility, openness and willingness that is sustainable only when everyone adopts and commits to these principles. Any evidence of tokenism destroys trust and undermines the endeavour.\r\n\r\nPublic Contribution Statement\r\nThis study was co\u2010produced with people with lived experience of multiple disadvantage and staff participants. Two lived experience IF members were involved in: developing the funding bid, designing the research including designing the staff survey, developing interview topic guides, commenting on information sheets and developing interview arrangements to ensure comfort and safety of IF members. Four lived experience IF members and three members of staff contributed to writing the paper, including reviewing key literature, refining the analysis and developing the discussion and conclusion.
\n \n\n \n \nBackground: Burnout is associated with career disengagement among general practitioners (GPs), but the underlying mechanisms of this association remain poorly understood.\r\n\r\nObjective: This study examined the pathways linking burnout to career disengagement factors among GPs.\r\n\r\nMethods: An 11-item online questionnaire, including validated abbreviated measures of burnout outcomes (single items on emotional exhaustion (EE) and depersonalisation), career disengagement factors (intention to quit patient care, work\u2013life balance, presenteeism and job satisfaction), and demographic information, was distributed to a random sample of GPs in England between December 2019 and April 2020. Correlations between burnout outcomes and disengagement factors were assessed, followed by a path analysis using a generalized structural equation model, to examine directional relationships between burnout outcomes and survey variables.\r\n\r\nResults: A total of 351 GPs from 57 different medical practices completed the questionnaire. Up to one in four GPs (22.5%) experienced emotional exhaustion, while up to one in three (27.4%) experienced depersonalisation on a weekly basis. In addition, one in three GPs (33.3%) expressed a moderate-to-high intention to quit patient care within the next 5\u202fyears. Moreover, one in five GPs (18.8%) reported job dissatisfaction, two in five GPs (40.7%) indicated poor work\u2013life balance, and up to one in two GPs (27.4%) reported presenteeism in the past year. In the path analysis, intention to quit patient care had significant direct associations with both job satisfaction and burnout and significant indirect associations (via burnout) with work\u2013life balance and presenteeism. GP demographics were excluded from the path analysis because they exhibited very weak correlations with dimensions of burnout and work engagement factors.\r\n\r\nConclusion: These findings highlight the urgent need for interventions and policies aimed at addressing burnout and improving job satisfaction to retain GPs. In addition, improving work\u2013life balance and reducing presenteeism could serve as effective early preventative measures to reduce burnout and job dissatisfaction and, in turn, retain GPs.
\n \n\n \n \nBackground\r\nHealth and social care services increasingly recognise the value of involving people with lived experience in service design and delivery. For people who have experienced multiple disadvantage (combinations of homelessness, mental ill health, addiction, involvement with the criminal justice systems or domestic violence/abuse), participating in professional settings may be challenging and can risk re-traumatisation and greater disillusionment. However, gaining confidence and competency to do this offers opportunities for personal and professional development, contributing to meaningful change. It is necessary that individuals with lived experience can engage safely and effectively in these settings. This study analyses how an organisation of people who have experienced multiple disadvantage, Independent Futures (IF), enabled co-production within services and systems, to understand how people can be best supported and how involvement impacts them.\r\n\r\nMethods\r\nSixteen IF members and three IF staff participated in semi-structured interviews. A staff survey, at two time points, investigated how employees from Changing Futures partner organisations perceived their ability to embed co-production within services, with 147 responses. Internal documentation was analysed to illustrate the diversity of co-production work that IF contributed to.\r\n\r\nResults\r\nPutting trauma-informed principles into practice facilitated personal growth, improved confidence and some work skills for IF members, who contributed to 65 different workstreams. However, embedding co-production into wider services and systems proved challenging. Staff survey comments highlighted obstacles related to resources, time and hierarchical cultures.\r\n\r\nConclusion\r\nLived experience organisations can model trauma-informed practice and influence systems. Embedding trauma-informed principles requires flexibility, openness and willingness that is sustainable only when everyone adopts and commits to these principles. Any evidence of tokenism destroys trust and undermines the endeavour.\r\n\r\nPublic Contribution Statement\r\nThis study was co-produced with people with lived experience of multiple disadvantage and staff participants. Two lived experience IF members were involved in: developing the funding bid, designing the research including designing the staff survey, developing interview topic guides, commenting on information sheets and developing interview arrangements to ensure comfort and safety of IF members. Four lived experience IF members and three members of staff contributed to writing the paper, including reviewing key literature, refining the analysis and developing the discussion and conclusion.
\n \n\n \n \nAbstract\r\nActivity pacing aims to manage symptoms of chronic pain and improve function by modifying pain-related behaviours: avoidance, overdoing and overdoing-underdoing cycling. Research regarding the effectiveness of activity pacing is unclear, and hindered by the absence of a validated scale. The previously developed 28-item Activity Pacing Questionnaire (APQ-28) comprises five domains: Activity adjustment, Activity planning, Activity consistency, Activity progression and Activity acceptance. This study aimed to shorten the APQ and provide evidence for its validity, reliability and responsiveness. Paper-based questionnaires collected data from patients with chronic pain attending healthcare services in England, UK, at baseline (n=347), and again at 2-weeks (n=130) and 12-weeks (n=121). Outcome measures included the APQ-28, and other measures of pacing, avoidance, overdoing, pain, self-efficacy, quality of life, physical/mental function, depression and anxiety. Statistical analyses explored validity, reliability, responsiveness and measurement error. Factor analysis (n=347) showed poor model fit for the previous five-factor model, leading to selecting a four-factor model (removing Activity acceptance) with three items per domain, forming the APQ-12 (CFI=0.995, TLI=0.992, RMSEA=0.052, SRMR=0.050). The four domains showed satisfactory internal consistency (Cronbach\u2019s alpha=0.70\u20130.84) and test-retest reliability (n=130, ICC=0.53\u20130.64). Only Activity consistency showed significant responsiveness (n=121, Rho=0.27, 95% CI=0.1\u20130.43). Measurement error of the APQ-12 domains included smallest detectable change (range=1.55\u20131.76), standard error of measurement (range=0.56\u20130.63) and minimally important change (range=-0.17\u20130.33). Confirmatory factor analysis on external data supported the four-domain structure (CFI=0.983, TLI=0.977, RMSEA=0.071, SRMR=0.106). The APQ-12 shows promise as a multi-domain measure of activity pacing for use in clinical practice and future research.
\n \n\n \n \nBackground\r\nGestational diabetes mellitus (GDM) is associated with increased risk of developing type 2 diabetes and cardiovascular disease (CVD). Here we explore whether the associations are mediated by development of type 2 diabetes and other CVD risk factors.\r\n\r\nMethods\r\nThe Exploring Long-term Outcomes following PrEgnancy affected by GDM (ELOPE-GDM) study is a population-based matched cohort study, containing 43\u2009572 records of women diagnosed with GDM matched with 174\u2009288 records of non-GDM women.\r\n\r\nWe used Cox proportional hazards models to assess the risk of GDM on CVD, ischemic heart disease (IHD) and stroke/TIA and quantified the proportions of these effects mediated by the progression to type 2 diabetes, hypertension or dyslipidaemia using causal mediation analysis.\r\n\r\nResults\r\nThere were significant associations between GDM and CVD; (adjusted HR 1.58 (95% CI 1.27\u20131.97)), IHD (1.83 (1.35\u20132.49)) and stroke/TIA (1.43 (1.06\u20131.95)). There were strong associations between GDM and developing type 2 diabetes (OR 13.90 (95% CI 13.19\u201314.51)), hypertension (1.87 (1.781\u20131.92)), dyslipidaemia (1.80 (1.76\u20131.84)) or any of these postpartum mediators (1.67 (1.63\u20131.71)). However, most of the effect of GDM on CVD was not attributed to the overall mediating effects of type 2 diabetes (36% (95% CI 8%\u201364%)), hypertension (15% (5%\u201324%)), dyslipidaemia (37% (18%\u201355%)) or a combination of these conditions (32% (11%\u201353%)) which developed after pregnancy.\r\n\r\nConclusion\r\nThese findings emphasise the need for comprehensive cardio metabolic screening following a pregnancy affected by GDM.
\n \n\n \n \nAbstract\r\nBackground\r\nPeople living with MLTCs attending primary care often have unmet social care needs (SCNs), which can be challenging to identify and address. Artificial intelligence (AI) derived clusters could help to identify patients at risk of SCNs. Evidence is needed on views about the use of AI-derived clusters, to inform acceptable and meaningful implementation within interventions.\r\nMethod\r\nQualitative semi-structured interviews (online and telephone), including a description of AI-derived clusters and a tailored vignette, with 24 people living with MLTCs and 20 people involved in the care of MLTCs (carers and health care professionals). Interviews were analysed using Reflexive and Codebook Thematic Analysis.\r\nResults\r\nPrimary care was viewed as an appropriate place to have conversations about SCNs. However, participants felt health care professionals lack capacity to have these conversations and to identify support. AI was perceived as a tool that could potentially increase capacity but only when supplemented with effective, clinical conversations. Interventions harnessing AI should be brief, be easy to use and remain relevant over time, to ensure no additional burden on clinical capacity. Interventions must allow flexibility to be used by multidisciplinary teams within primary care, frame messages positively and facilitate conversations that remain patient centered.\r\nConclusion\r\nOur findings suggest that implementing AI-derived clusters to identify and support SCNs in primary care is perceived as valuable and can be used as a tool to inform and prioritse effective clinical conversations. But concerns must be addressed, including how AI-derived clusters can be used in a way that considers personal context.
\n \n\n \n \nAbstract\r\nBackground Despite growing concerns about young people\u2019s mental health, it remains unclear how rates of psychiatric diagnoses and psychotropic medication prescribing have changed.\r\n\r\nAim To investigate temporal trends in UK primary care-recorded incidence of (1) psychiatric diagnoses: attention deficit hyperactivity disorders (ADHD), autism spectrum conditions, anxiety disorders, depression, substance misuse, and personality disorders, and (2) psychotropic medication prescribing, in individuals aged 1\u201324 years.\r\n\r\nDesign and setting This was a population-based study using primary care data from the Clinical Practice Research Datalink.\r\n\r\nMethod The monthly incidence of each outcome from January 2010 to March 2022 were calculated. Negative binomial regression was used to predict expected incidence rates when the COVID-19 pandemic began in March 2020, based on antecedent trends. Observed and predicted (that is, expected) rates were compared.\r\n\r\nResults In the 2 years following March 2020, the incidence of ADHD diagnoses in females was 24.7% (95% confidence interval = 11.9 to 38.9%) greater than the expected incidence rate predicted from the trends before the pandemic. The increase in ADHD diagnoses occurred more commonly for females aged 20\u201324 years, followed by those aged 17\u201319 years, as well as among females from less deprived areas. Similar trends were observed for ADHD medications. Observed rates of other outcomes, including common mental illnesses, were below or close to the expected levels, with the differentials between observed and expected rates being greater for males than females.\r\n\r\nConclusion Increased ADHD awareness may partly explain the study's findings. However, the fall in other diagnoses may reflect barriers to accessing health services at the height of the pandemic. Early identification and timely treatment of mental health difficulties and neurodevelopmental conditions are crucial.
\n \n\n \n \n