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Progression of stroke risk in patients aged <65 years diagnosed with atrial fibrillation: a cohort study in general practice
Background As a result of new technologies, atrial fibrillation (AF) is more likely to be diagnosed in people aged <65 years. Aim To investigate the risk of someone diagnosed with AF aged <65 years developing an indication for anticoagulation before they reach 65 years. Design and setting Population-based cohort study of patients from English practices using the Clinical Practice Research Datalink, a primary care database of electronic medical records. Method The study included patients aged <65 years newly diagnosed with AF. The CHA2DS2-VASc score was derived at time of diagnosis based on patients’ medical records. Patients not eligible for anticoagulation were followed up until they became eligible or turned 65 years old. The primary outcome of interest was development of a risk factor for stroke in AF. Results Among 18 178 patients aged <65 years diagnosed with AF, 9188 (50.5%) were eligible for anticoagulation at the time of diagnosis. Among the 8990 patients not eligible for anticoagulation, 1688 (18.8%) developed a risk factor during follow-up before reaching 65 years of age or leaving the cohort for other reasons, at a rate of 6.1 per 100 patient-years. Hypertension and heart failure were the most common risk factors to occur, with rates of 2.65 (95% CI = 2.47 to 2.84) and 1.58 (95% CI = 1.45 to 1.72) per 100 patient-years, respectively. The rate of new diabetes was 0.95 (95% CI = 0.85 to 1.06) per 100 patient-years. Conclusion People aged <65 years with AF are at higher risk of developing hypertension, heart failure, and diabetes than the general population, so may warrant regular review to identify new occurrence of such risk factors.
Why do people choose not to take part in screening? Qualitative interview study of atrial fibrillation screening nonparticipation
Introduction While screening uptake is variable, many individuals feel they ‘ought’ to participate in screening programmes to aid the detection of conditions amenable to early treatment. Those not taking part in screening are often presented as either hindered by practical or social barriers or personally at fault. Why some people choose not to participate receives less consideration. Methods We explored screening nonparticipation by examining the accounts of participants who chose not to participate in screening offered by a national research trial of atrial fibrillation (AF) screening in England (SAFER: Screening for Atrial Fibrillation with ECG to Reduce stroke). AF is a heart arrhythmia that increases in prevalence with age and increases the risk of stroke. Systematic screening for AF is not a nationally adopted programme within the United Kingdom; it provides a unique opportunity to explore screening nonparticipation outside of the norms and values attached to existing population-based screening programmes. We interviewed people aged over 65 (n = 50) who declined an invitation from SAFER and analysed their accounts thematically. Results Beyond practical reasons for nonparticipation, interviewees challenged the utility of identifying and managing AF earlier. Many questioned the benefits of screening at their age. The trial's presentation of the screening as research made it feel voluntary—something they could legitimately decline. Conclusion Nonparticipants were not resistant to engaging in health-promoting behaviours, uninformed about screening or unsupportive of its potential benefits. Instead, their consideration of the perceived necessity, legitimacy and utility of this screening shaped their decision not to take part. Patient or Public Contribution The SAFER programme is guided by four patient and carer representatives. The representatives are embedded within the team (e.g., one is a co-applicant, another sits on the programme steering committee) and by participating in regular meetings advise on all aspects of the design, management and delivery of the programme, including engaging with interpreting and disseminating the findings. For the qualitative workstream, we established a supplementary patient and public involvement group with whom we regularly consult about research design questions.
Protocol for the mixed methods, Managing young people (aged 16–25) with Attention deficit hyperactivity disorder in Primary care (MAP) study: mapping current practice and co-producing guidance to improve healthcare in an underserved population
Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in children and adolescents, with an average worldwide prevalence of 5%. Up to 40% of young people continue to experience symptoms into adulthood. Young people with ADHD experience poorer outcomes than their peers across multiple domains, with treatment shown to reduce these risks. Primary care practitioners play an important role in healthcare provision for this group in the UK. However, many feel unsure about how best to provide support, reporting prescribing concerns and need for more evidence-based guidance. A lack of national data on primary care provision hinders efforts to improve access to care and optimise outcomes. This mixed-methods study aims to provide evidence that may be used to improve primary care services for young people aged 16–25 years with ADHD.
Temporal trends in eating disorder and self-harm incidence rates among adolescents and young adults in the UK in the 2 years since onset of the COVID-19 pandemic: a population-based study
Background Self-harm and eating disorders share multiple risk factors, with onset typically during adolescence or early adulthood. We aimed to examine the incidence rates of these psychopathologies among young people in the UK in the 2 years following onset of the COVID-19 pandemic. Methods We conducted a population-based study using the primary care electronic health records of patients aged 10–24 years in the UK Clinical Practice Research Datalink (CPRD). The observation period was from Jan 1, 2010, to March 31, 2022. We calculated the monthly incidence rates of eating disorders and self-harm according to the first record of each outcome. On the basis of antecedent trends between January, 2010, and February, 2020, negative binomial regression models were fitted to predict monthly incidence rates after the pandemic began in March, 2020. Percentage differences between observed and expected incidence were calculated to indicate changes since the onset of the pandemic, with stratification by sex, age, and deprivation quintile. Findings The primary care health records of 9 184 712 patients aged 10–24 years (4 836 226 [52·7%] female patients and 4 348 486 [47·3%] male patients; n=1881 general practices) were included for analysis. The incidence rates of eating disorders and self-harm among girls were higher than expected between March 1, 2020, and March 31, 2022. The observed incidence of eating disorders was 42·4% (95% CI 25·7–61·3) higher than expected for girls aged 13–16 years, and 32·0% (13·3–53·8) higher than expected for girls aged 17–19 years, whereas other age groups showed little difference between observed and expected incidence. Similarly, the increase in self-harm incidence was driven by girls aged 13–16 years, for whom the observed incidence was 38·4% (20·7–58·5) higher than expected. By contrast, among boys in all age groups, the incidence rates of eating disorders and self-harm were lower than, or close to, the expected rates. Among boys, the observed incidence of eating disorders was 22·8% (9·2–34·4) lower than expected, and the observed incidence of self-harm was 11·5% (3·6–18·7) lower than expected. The estimated increases in eating disorder and self-harm incidence among girls aged 13–16 years were largely attributable to increases within less deprived communities. Interpretation Although causes are uncertain, increased incidence of eating disorder diagnoses and self-harm among teenage girls in the UK during the first 2 years of the COVID-19 pandemic highlight an urgent need for intervention. Early identification of mental health difficulties by primary care clinicians is necessary. Timely access to treatments and sufficient support from general practitioners and mental health services needs to be available to manage presenting problems and to prevent exacerbations of conditions.
Management of asthma in primary care in the changing context of the COVID-19 pandemic: a qualitative longitudinal study with patients
Abstract Background: The COVID-19 pandemic dramatically affected asthma monitoring in primary care. Yet, patients’ views and experiences of managing their asthma and seeking help from primary care during the pandemic have not been explored. Aim: To investigate patients’ experiences of asthma management in the community during the COVID-19 pandemic. Design and setting: A qualitative longitudinal study using semi-structured interviews with asthma patients usually managed in primary care. Method: Interviews were audio recorded, transcribed and analysed using inductive temporal thematic analysis and trajectory approach. Results: Forty-six interviews were conducted with 18 asthma patients over eight months that covered contrasting stages of the pandemic. Patients felt less vulnerable as the pandemic subsided but the process of making sense of risk was dynamic and influenced by multiple factors. Patients relied on self-management strategies but felt that routine asthma reviews should still have been conducted during the COVID-19 pandemic and highlighted limited opportunities to discuss their asthma with health care professionals. Patients with well controlled symptoms felt that remote reviews were largely satisfactory but still felt that face to face reviews were necessary for certain aspects such as physical examination and patient-led discussion of sensitive or broader issues associated with asthma including mental health. Conclusions: The dynamic nature of patients’ perception of risk throughout the pandemic highlighted the need for a greater clarity regarding patients’ personal risk. Having opportunity to discuss their asthma is important to patients even during periods when access to face to face consultations in primary care is more restricted than usual.
Adherence to limiting weight-bearing activity in patients with diabetic foot ulcers: A qualitative study
Abstract Patients with diabetic foot ulcers are advised to limit weight-bearing activity for ulcers to heal. Patients often disregard this advice although the reasons are not yet fully understood. This study explored (1) patients' experiences of receiving the advice and (2) factors influencing adherence to the advice. Semi-structured interviews were conducted with 14 patients with diabetic foot ulcers. Interviews were transcribed and analysed using inductive thematic analysis. Advice regarding limiting weight-bearing activity was described by patients as directive, generic and conflicting with other priorities. Rapport, empathy and rationale supported receptivity to the advice. Barriers and facilitators to limiting weight-bearing activity included demands of daily living, enjoyment of exercise, sick/disabled identity and burden, depression, neuropathy/pain, health benefits, fear of negative consequences, positive feedback, practical support, weather and active/passive role in recovery. It is important that healthcare professionals pay attention to how limiting weight-bearing activity advice is communicated. We propose a more person-centred approach in which advice is tailored to individuals' specific needs with discussion around patient priorities and constraints.
Association of Recent Fatherhood With Antidepressant Treatment Initiation Among Men in the United Kingdom
Abstract Importance There is some evidence that men may be at higher risk of depression directly following the birth of their child and that approximately 1 in 10 men will experience depression in the year after birth, but less is known about men’s antidepressant treatment during this time. Likewise, few direct comparisons have been made with antidepressant treatment in men who have not recently become fathers. Objectives To determine whether recently having a child was associated with increased odds of antidepressant treatment in men. Design, Setting, and Participants This cohort study used UK primary care electronic health records from the IQVIA Medical Research Database. Participants included men aged 15 to 55 years who had had a child in the previous year, from January 2007 to December 2016, and compared with up to 5 men who did not have a child in the same calendar year. Data were analyzed from January 2022 to March 2023. Exposure A record of having a child in the previous year was identified through linked primary care records using a family identification number. Main Outcomes and Measures The main outcome was antidepressant initiation in the year after childbirth or in the year after this index date for men who did not have a child. Random-effects Poisson regression was used to determine associations of cohort, age group, social deprivation, history of antidepressant treatment, and calendar year with having an antidepressant prescription in the year after index date using prevalence risk rates (PPRs). Results Analysis included 90 736 men who had had a child in the previous year and 453 632 men in the comparison cohort. Most men in the study (463 879 men [85.2%]) were aged between 25 and 44 years, and there were more men living in the least deprived areas (130 277 men [23.9%]) than the most deprived areas (72 268 men [13.3%]). Overall, 4439 men (4.9%) had at least 1 antidepressant prescription in the year after they had a child, compared with 26 646 men (5.9%) who did not have a child in the same year. However, after adjustment there was no difference in antidepressant treatment between groups (adjusted PRR [aPRR], 1.01; 95% CI, 0.98-1.04). In fathers, those who had recently received antidepressant treatment were much more likely to receive antidepressant treatment after childbirth compared with fathers with no history of antidepressant treatment (aPRR, 32.31; 95% CI, 30.37-34.38). Fathers living in the most deprived areas were 18% more likely to have an antidepressant prescription compared with fathers living in the least deprived areas (aPRR, 1.18; 95% CI, 1.07-1.30). Conclusions and Relevance These findings suggest that recently having a child was not associated with an increase in antidepressant treatment among men, but previous antidepressant treatment in fathers was strongly associated with treatment after childbirth. Further research is needed to determine whether antidepressant treatment or experiencing depression can be a barrier to fatherhood and whether fatherhood is a barrier to receiving antidepressant treatment.
Unpromising Futures: Early-Career GPs’ Narrative Accounts of Meaningful Work during a Professional Workforce Crisis
Abstract Over the past few decades, the intensification and reorganisation of work have led to growing precarity, insecurity and uncertainty for employees, affecting even professionals tied to traditionally model employers. Doctors, in particular, have seen substantial changes to their work: having to work harder, longer and more intensely with reductions in expected autonomy, deference and respect. This article focuses on how early-career GPs make sense of and navigate meaningful work in the context of a current workforce crisis. Drawing on 15 narrative interviews and 10 focus groups with early-career GPs, the findings show that meaningful work during a crisis is understood temporally, with imagined futures perceived as increasingly impossible due to changes to the structure and orientation of medical work, leading to different career plans. Utilising Adam and Groves’ approach to futures as a conceptual lens, the article focuses on how multiple, often clashing, future orientations impact meaningful work.
Why should we prioritise smoking cessation for people with mental health conditions?
Smoking is the single largest cause of preventable death and responsible globally for 7.7 million deaths in 2019. This is due to increased risk of cardiovascular disease, chronic obstructive pulmonary disease, type 2 diabetes, cancer, and blindness. Smoking is also associated with increased risk of developing mental health conditions (MHCs). In England, smoking accounted for 74 600 deaths in 2019 and 506 100 hospital admissions in 2019–2020.5 People with different types of MHCs are several times more likely to smoke than the general population, and are responsible for a large proportion of overall tobacco consumption, with one- third of cigarettes smoked by people with an MHC.7 People with MHCs therefore experience disproportionate levels of tobacco- associated harm, which is the single largest contributor to their 7–25- year reduced life expectancy, and smoking has wider social and economic impacts on this population.
Parental experiences of eczema advice in online parenting forums: Qualitative interview study
Background Parents of children with eczema are increasingly turning to online parenting forums for advice about managing childhood eczema. Little is known about how parents make sense of advice about eczema treatments in online forums, and how it affects their management of childhood eczema. Aim The aim of this study was to explore how parents of children with eczema make sense of and act upon advice about eczema treatments exchanged in online parenting forums. Design & setting Qualitative interviews with parents of children with eczema from the United Kingdom. Method 15 parents were recruited through online advertisements and snowball sampling. Semi-structured interviews were carried out face-to-face or by telephone and analysed inductively using reflexive thematic analysis. Results When seeking advice from online parenting forums about eczema treatments, parents described appraising the credibility of advice and considering the potential suitability of treatments that were recommended in the forum. Parents proceeded to making sense of online advice through either reading advice and not engaging in online discussions, or actively engaging in online discussions to direct topics and seek most relevant advice. Parents discussed advice received online in subsequent consultations with their general practitioner and requested prescriptions of recommended treatments. Some parents described trying new treatments without consulting their general practitioner. Conclusion Understanding how parents appraise, make sense of and act upon online advice could support health care professionals to disseminate advice appropriately, ask additional questions and sign-post parents to reliable online resources.
Self-management of multiple long-term conditions: A systematic review of the barriers and facilitators amongst people experiencing socioeconomic deprivation
Abstract Background Multiple long-term conditions are rising across all groups but people experiencing socioeconomic deprivation are found to have a higher prevalence. Self-management strategies are a vital part of healthcare for people with long-term conditions and effective strategies are associated with improved health outcomes in a variety of health conditions. The management of multiple long-term conditions are, however, less effective in people experiencing socioeconomic deprivation, leaving them more at risk of health inequalities. The purpose of this review is to identify and synthesise qualitative evidence on the barriers and facilitators of self-management on long-term conditions in those experiencing socioeconomic deprivation. Methods MEDLINE, EMBASE, AMED, PsycINFO and CINAHL Plus were searched for qualitative studies concerning self-management of multiple long-term conditions among socioeconomically disadvantaged populations. Data were coded and thematically synthesised using NVivo. Findings From the search results, 79 relevant qualitative studies were identified after the full text screening and 11 studies were included in the final thematic synthesis. Three overarching analytical themes were identified alongside a set of sub-themes: (1) Challenges of having multiple long-term conditions; prioritisation of conditions, impact of multiple long-term conditions on mental health and wellbeing, polypharmacy, (2) Socioeconomic barriers to self-management; financial, health literacy, compounding impact of multiple long-term conditions and socioeconomic deprivation, (3) Facilitators of self-management in people experiencing socioeconomic deprivation; maintaining independence, ‘meaningful’ activities, support networks. Discussion Self-management of multiple long-term conditions is challenging for people experiencing socioeconomic deprivation due to barriers around financial constraints and health literacy, which can lead to poor mental health and wellbeing. To support targeted interventions, greater awareness is needed among health professionals of the barriers/challenges of self-management among these populations.
Demographic characteristics, long-term health conditions and healthcare experiences of 6333 trans and non-binary adults in England: nationally representative evidence from the 2021 GP Patient Survey
Objective In order to address the lack of data on the health and healthcare needs of trans and non-binary adults, NHS England includes questions asking about both gender and trans status in its surveys to support quality improvement programmes. We used self-reported data from the GP Patient Survey to answer the research question: what are the demographic characteristics, health conditions and healthcare experiences of trans and non-binary adults in England? Design/setting Nationally representative, population-based cross-sectional survey in England with survey data collection from January to March 2021. Participants 840 691 survey respondents including 6333 trans and non-binary adults. Outcomes We calculated weighted descriptive statistics, and using logistic regression explored 15 long-term physical and mental health conditions, and 18 patient experience items, covering overall experience, access, communication and continuity. Results Trans and non-binary adults were younger, more likely to be from Asian, black, mixed or other ethnic groups and more likely to live in more deprived parts of the country. Age-specific patterns of long-term conditions were broadly similar among trans and non-binary adults compared with all other survey respondents, with some variation by condition. Overall, inequalities in long-term health conditions were largest for autism: OR (95% CI), 5.8 (5.0 to 6.6), dementia: 3.1 (2.5 to 3.9), learning disabilities: 2.8 (2.4 to 3.2) and mental health: 2.0 (1.9 to 2.2), with variation by age. In healthcare experience, disparities are much greater for interpersonal communication (OR for reporting a positive experience, range 0.4 to 0.7 across items) than access (OR range 0.8 to 1.2). Additionally, trans and non-binary adults report much higher preference for continuity 1.7 (1.6 to 1.8), with no evidence of any differences in being able to see or speak to a preferred general practitioner. Conclusion This research adds up to date evidence about population demographics, health and healthcare needs to support healthcare improvement for trans and non-binary adults.
The functions of self-harm in young people and their perspectives about future general practitioner-led care: A qualitative study
Background Self-harm in young people is a serious concern but a deeper understanding of the functions of self-harm in young people can tailor care and inform new clinical interventions to reduce repeat self-harm and suicide risk. General practitioners (GPs), as frontline healthcare professionals, have an important role in managing self-harm in young people. This study aimed to explore the functions of self-harm in young people and their perspectives on future GP-led care. Methods A qualitative study using interviews with young people aged between 16 and 25 years with a personal history of self-harm was conducted. Interviews were transcribed and analysed using reflexive thematic analysis. Findings Four distinct functions were identified: (1) handling emotional states; (2) self-punishment; (3) coping with mental illness and trauma; and (4) positive thoughts and protection. Young people valued GP-led support and felt future GP interventions should include self-help and be personalised. Conclusions These findings support clinicians, including GPs, to explore the functions of self-harm in young people aged 16–25 in a personalised approach to self-harm care. It should be noted that self-harm may serve more than one function for a young person and thus interventions should recognise this. Patient and Public Contribution A group consisting of young people with lived experience of self-harm, carers, the public, and those who work with young people who harm themselves conceived this study idea, informed recruitment methods and the interview topic guide, and supported the interpretation of findings.
Mental health services in response to the COVID-19 pandemic in high-income countries: protocol for a rapid review
Introduction The COVID-19 pandemic has caused disruptions to mental health services, forcing the rapid implementation of alternative ways of delivering services alongside a greater immediate, and continuously growing, demand across those services. The care and level of mental health service provided are felt to be inadequate to respond to the increasing demand for mental health conditions in the time of the pandemic, leading to an urgent need to learn from service change and consequences to inform solutions and plans to support the NHS post pandemic plan in the UK. This rapid review aims to understand the changes in mental health services during the pandemic and summarise the impact of these changes on the health outcomes of people with mental health conditions. Methods and analysis Cochrane CENTRAL, MEDLINE, Embase and PsycInfo will be searched for eligible studies with key terms indicating mental health AND COVID-19 AND health services. Peer-reviewed empirical studies aiming to investigate or describe new models of care, services, initiatives or programmes developed or evolved for patients (aged 18 years or over) with mental health in response to COVID-19, published in the English language and undertaken in a high-income country defined by Organisation for Economic Co-operation and Development (OECD) member will be included. Studies reporting views of the general public, letters of opinion to peer-review journals, editorial or commentaries will be excluded. Study selection and data extraction will be undertaken independently by two reviewers. Evidence will be summarised narratively and in a logic model. Ethics and dissemination Ethics approval is not required for this review. A list of interventions/services/models of care delivered to people with mental health conditions will be grouped as ‘Do’, ‘Don’t’ and ‘Don’t know’ based on the evidence on effectiveness and acceptability. The results will be written for publication in an open-access peer-reviewed journal and disseminated to the public and patients, clinicians, commissioners, funders and academic conferences.
Maternal and perinatal death surveillance and response: a systematic review of qualitative studies
Objective To understand the experiences and perceptions of people implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries, and the mechanisms by which this process can achieve its intended outcomes. Methods In June 2022, we systematically searched seven databases for qualitative studies of stakeholders implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries. Two reviewers independently screened articles and assessed their quality. We used thematic synthesis to derive descriptive themes and a realist approach to understand the context–mechanism–outcome configurations. Findings Fifty-nine studies met the inclusion criteria. Good outcomes (improved quality of care or reduced mortality) were underpinned by a functional action cycle. Mechanisms for effective death surveillance and response included learning, vigilance and implementation of recommendations which motivated further engagement. The key context to enable effective death surveillance and response was a blame-free learning environment with good leadership. Inadequate outcomes (lack of improvement in care and mortality and discontinuation of death surveillance and response) resulted from a vicious cycle of under-reporting, inaccurate data, and inadequate review and recommendations, which led to demotivation and disengagement. Some harmful outcomes were reported, such as inappropriate referrals and worsened staff shortages, which resulted from a fear of negative consequences, including blame, disciplinary action or litigation. Conclusion Conditions needed for effective maternal and/or perinatal death surveillance and response include: separation of the process from litigation and disciplinary procedures; comprehensive guidelines and training; adequate resources to implement recommendations; and supportive supervision to enable safe learning.
Supportive care needs of men with prostate cancer: A systematic review update
Background Prostate cancer is highly prevalent and impacts profoundly on patients' quality of life, leading to a range of supportive care needs. Methods An updated systematic review and thematic synthesis of qualitative data using the Preferred Reporting Items for Systematic Reviews (PRISMA) reporting guidelines, to explore prostate cancer patients' experience of, and need for, supportive care. Five databases (Medline, Embase, PsycInfo, Emcare and ASSIA) were searched; extracted data were synthesised using Corbin and Strauss's ‘Three Lines of Work’ framework. Results Searches identified 2091 citations, of which 105 were included. Overarching themes emerged under the headings of illness, everyday life and biographical work. Illness work needs include consistency and continuity of information, tailored to ethnicity, age and sexual orientation. Biographical work focused on a desire to preserve identity in the context of damaging sexual side effects. Everyday life needs centred around exercise and diet support and supportive relationships with partners and peers. Work-related issues were highlighted specifically by younger patients, whereas gay and bisexual men emphasised a lack of specialised support. Conclusion While demonstrating some overarching needs common to most patients with prostate cancer, this review offers novel insight into the unique experiences and needs of men of different demographic backgrounds, which will enable clinicians to deliver individually tailored supportive care.
Blood eosinophils to guide inhaled maintenance therapy in a primary care COPD population
Abstract Blood eosinophils are a potentially useful biomarker for guiding inhaled corticosteroid (ICS) treatment decisions in COPD. We investigated whether existing blood eosinophil counts predict benefit from initiation of ICS compared to bronchodilator therapy. We used routinely collected data from UK primary care in the Clinical Practice Research Datalink. Participants were aged ≥40 years with COPD, were ICS-naïve and starting a new inhaled maintenance medication (intervention group: ICS; comparator group: long-acting bronchodilator, non-ICS). Primary outcome was time to first exacerbation, compared between ICS and non-ICS groups, stratified by blood eosinophils (“high” ≥150 cells·µL−1 and “low” <150 cells·µL−1). Out of 9475 eligible patients, 53.9% initiated ICS and 46.1% non-ICS treatment with no difference in eosinophils between treatment groups (p=0.71). Exacerbation risk was higher in patients prescribed ICS than those prescribed non-ICS treatment, but with a lower risk in those with high eosinophils (hazard ratio (HR) 1.04, 95% CI 0.98–1.10) than low eosinophils (HR 1.19, 95% CI 1.09–1.31) (p-value for interaction 0.01). Risk of pneumonia hospitalisation with ICS was greatest in those with low eosinophils (HR 1.26, 95% CI 1.05–1.50; p-value for interaction 0.04). Results were similar whether the most recent blood eosinophil count or the mean of blood eosinophil counts was used. In a primary care population, the most recent blood eosinophil count could be used to guide initiation of ICS in COPD patients. We suggest that ICS should be considered in those with higher eosinophils and avoided in those with lower eosinophils (<150 cells·µL−1).
A descriptive cohort study of withdrawal from inhaled corticosteroids in COPD patients
Abstract Inhaled corticosteroid (ICS) therapy is widely prescribed without a history of exacerbations and consensus guidelines suggest withdrawal of ICS in these patients would reduce the risk of side effects and promote cost-effective prescribing. The study describes the prescribing behaviour in the United Kingdom (UK) in relation to ICS withdrawal and identifies clinical outcomes following withdrawal using primary and secondary care electronic health records between January 2012 and December 2017. Patients with a history ≥12 months’ exposure who withdrew ICS for ≥6 months were identified into two cohorts; those prescribed a long-acting bronchodilator maintenance therapy and those that were not prescribed any maintenance therapy. The duration of withdrawal, predictors of restarting ICS, and clinical outcomes were compared between both patient cohorts. Among 76,808 patients that had ≥1 prescription of ICS in the study period, 11,093 patients (14%) withdrew ICS therapy at least once during the study period. The median time without ICS was 9 months (IQR 7–14), with the majority (71%) receiving subsequent ICS prescriptions after withdrawal. Patients receiving maintenance therapy with a COPD review at withdrawal were 28% less likely to restart ICS (HR: 0.72, 95% CI 0.61, 0.85). Overall, 69% and 89% of patients that withdrew ICS had no recorded exacerbation event or COPD hospitalisation, respectively, during the withdrawal. This study provides evidence that most patients withdrawing from ICS do not experience COPD exacerbations and withdrawal success can be achieved by carefully planning routine COPD reviews whilst optimising the use of available maintenance therapies.
Clinical relevance of double-arm blood pressure measurement and prevalence of clinically important inter-arm blood pressure differences in Indian primary care
Abstract Hypertension guidelines recommend measuring blood pressure (BP) in both arms at least once. However, this is seldom done due to uncertainties regarding measurement procedure and the implications of finding a clinically important inter-arm BP difference (IAD). This study aimed to provide insight into the prevalence of clinically important IADs in a large Indian primary care cohort. A number of 134 678 (37% female) unselected Indian primary care participants, mean age 45.2 (SD 11.9) years, had BP measured in both arms using a standardized, triplicate, automated simultaneous measurement method (Microlife WatchBP Office Afib). On average, there were clinically minor differences in right and left arm BP values: systolic BP 134.4 vs 134.2 mmHg (p < .01) and diastolic BP 82.7 vs 82.6 mmHg (p < .01), respectively. Prevalence of significant mean systolic IAD between 10 and 15 mmHg was 7,813 (5.8%). Systolic IAD ≥ 15 mmHg 2,980 (2.2%) and diastolic IAD ≥ 10 mmHg 7,151 (5.3%). In total, there were 7,595 (5.6%) and 8,548 (6.3%) participants with BP above the 140/90 mmHg threshold in only the left or right arm, respectively. Prevalence of participants with elevated BP on one arm only was highest in patients with a systolic IAD ≥ 15 mmHg; 19.1% and 13.7%, for left and right arm, respectively. This study shows that a substantial prevalence of IAD exists in Indian primary care patients. BP is above the diagnostic threshold for hypertension in one arm only for 6% of participants. These findings emphasize the importance of undertaking bilateral BP measurement in routine clinical practice.
Performance of the imPulse device for the detection of atrial fibrillation in hospital settings
Background Atrial fibrillation (AF) increases thromboembolism and stroke risk; this can be reduced by oral anticoagulation, but only if AF is detected. A portable, point-of-care device, capable of accurately detecting and identifying AF, could reduce workload and diagnostic delay by minimizing need for follow-up 12-lead electrocardiogram (ECGs). Objective To assess the diagnostic performance of the Plessey imPulse lead I ECG device compared with a 12-lead ECG in detecting AF. Methods Cross-sectional diagnostic accuracy study. Participants underwent simultaneous 12-lead ECG and imPulse device recordings. The imPulse device reports AF to be “probable,” “possible,” “unlikely,” or “uncontrolled AF unlikely.” imPulse and ECG reference results were cross-tabulated; sensitivity, specificity, positive/negative predictive values, and positive/negative likelihood ratios with 95% confidence interval (CI) were estimated based on different imPulse device report categorizations and heart rate subgroups. Results A total of 217 participants were recruited (mean age 70.2 [standard deviation 12.7]), 56% male, 57% outpatients, 43% inpatients) and 199 were included in analyses. AF was diagnosed on ECG for 41 of 199 (20.6%) participants and reported by imPulse as possible, probable, or uncontrolled AF unlikely present for 49 of 199 (24.6%). Sensitivity and specificity for imPulse detection of possible, probable, or uncontrolled AF unlikely vs unlikely, compared with ECG, were 80.5% (95% CI, 65.1%–91.2%) and 89.9% (84.1%–94.1%), respectively. When probable or uncontrolled AF unlikely were compared vs possible or unlikely AF, sensitivity and specificity were 63.4% (46.9%–77.9%) and 98.1% (94.6%–99.6%), respectively. Conclusion The imPulse device has moderate sensitivity and good specificity compared with ECG AF detection in a hospital setting.
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