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This study explores dissatisfaction and neutrality metrics from 12 years of a national-level undergraduate student survey. The notion of dissatisfaction is much less prevalent in the narratives surrounding student survey outcomes, and the underpinning metrics are seldom considered. This is despite an increasingly vociferous debate about "value for money" of higher education and the positioning of students as consumers in a marketised sector. We used machine learning methods to explore over 2.7 million national survey outcomes from 154 institutions to describe year-on-year stability in the survey items that best predicted dissatisfaction and neutrality, together with their similarity to known metric predictors of satisfaction. The widely publicised annual increases in student 'satisfaction' are shown to be the result of complex reductions in the proportions of disagreement and neutrality across different survey dimensions. Due to the widespread use of survey metrics in university league tables, we create an anonymised, illustrative table to demonstrate how UK institutional rankings would have differed if dissatisfaction metrics had been the preferred focus for reporting. We conclude by debating the tensions of balancing the provision of valuable information about dissatisfaction, with perpetuating negative impacts that derive from this important subset of the survey population.

The purpose of this study is to use machine learning and exploratory data analysis to interrogate patterns of metrics from a national-level student survey. Analysis of over 1.8 million returns detected long-term stability of the predictors of student satisfaction, with survey items relating to course management and teaching being consistently most influential. All metric outputs increased over the survey period; however, the rates of increase of several dimensions including Overall Satisfaction decreased markedly in the most recent years to a point of levelling off. There was also a growing similarity in an institution of outcomes at a national level. This study contributes new insights into the influential survey instrument, through rigorous determination of the most influential survey items, descriptions of the changes in variability between institutions, and exploration of the importance of patterns of outliers at the extremes of the metric outputs. We also identify a rapidly growing spike in total satisfaction at a broad course level and highlight how this is inconsistent with a customer satisfaction model. We conclude by considering the challenges of the use of national-level student surveys for the management of student satisfaction in higher education.

Many countries use national-level surveys to capture student opinions about their university experiences. It is necessary to interpret survey results in an appropriate context to inform decision-making at many levels. To provide context to national survey outcomes, we describe patterns in the ratings of science and engineering subjects from the UK's National Student Survey (NSS). New, robust statistical models describe relationships between the Overall Satisfaction' rating and the preceding 21 core survey questions. Subjects exhibited consistent differences and ratings of "Teaching", "Organisation" and "Support" were thematic predictors of "Overall Satisfaction" and the best single predictor was "The course was well designed and running smoothly". General levels of satisfaction with feedback were low, but questions about feedback were ultimately the weakest predictors of "Overall Satisfaction". The UK's universities affiliated groupings revealed that more traditional "1994" and "Russell" groups over-performed in a model using the core 21 survey questions to predict "Overall Satisfaction", in contrast to the under-performing newer universities in the Million+ and Alliance groups. Findings contribute to the debate about "level playing fields" for the interpretation of survey outcomes worldwide in terms of differences between subjects, institutional types and the questionnaire items.

Background: Two online behavioural interventions (one website for parents/carers of children with eczema; and one for young people with eczema) have been shown in randomised controlled trials to facilitate a sustained improvement in eczema severity. Aim: To describe intervention use and examine potential mediators of intervention outcomes and contextual factors that may influence intervention delivery and outcomes. Design and setting: Quantitative process evaluation in UK primary care. Method: Parents/carers and young people were recruited through primary care. Intervention use was recorded and summarised descriptively. Logistic regression explored sociodemographic and other factors associated with intervention engagement. Mediation analysis investigated whether patient enablement (ability to understand and cope with health issues), treatment use, and barriers to adherence were mediators of intervention effect. Subgroup analysis compared intervention effects among pre-specified participant subsets. Results: A total of 340 parents/carers and 337 young people were recruited. Most parents/carers (87%, n = 148/171) and young people (91%, n = 153/168) in the intervention group viewed the core introduction by 24 weeks. At 24 weeks, users had spent approximately 20 minutes on average on the interventions. Among parents/carers, greater intervention engagement was associated with higher education levels, uncertainty about carrying out treatments, and doubts about treatment efficacy at baseline. Among young people, higher intervention use was associated with higher baseline eczema severity. Patient enablement (the ability to understand and cope with health issues) accounted for approximately 30% of the intervention effect among parents/carers and 50% among young people. Conclusion: This study demonstrated that positive intervention outcomes depended on a modest time commitment from users. This provides further support that the wider implementation of Eczema Care Online is justified. [ABSTRACT FROM AUTHOR]

There is an increasing requirement in higher education (HE) worldwide to deliver excellence. Benchmarking is widely used for this purpose, but methodological approaches to the creation of benchmark metrics vary greatly. Approaches require selection of factors for inclusion and subsequent calculation of benchmarks for comparison. We describe an approach using machine learning to select input factors based on their value to predict completion rates of nursing courses. Data from over 36,000 students, from nine institutions over three years were included and weighted averages provided a dynamic baseline for year on year and within year comparisons between institutions. Anonymised outcomes highlight the variation in benchmarked performances between institutions and we demonstrate the value of accompanying sensitivity analyses. Our methods are appropriate worldwide, for many forms of data and at multiple scales of enquiry. We discuss our results in the context of HE management, highlighting the value of scrutinising benchmark calculations.

Institutions are understandably interested in the profile of their own reputations based upon publicly available data about student experiences. The UK's National Student Survey (NSS) metrics are integrated into several "Good University" calculations, whereas teaching teams most often use the survey's text comments to change practices, rather than the metrics directly. There is little information about how messages from the national survey's text comments relate to the accompanying numerical ratings, partly because text comments are confidential to the institution and unavailable for wide-scale research. We categorised institutional NSS text comments into themes that mirrored those of the original questionnaire. Comparisons were made between frequencies of thematic comments and the national ratings of satisfaction for several subject areas. For the first time, we demonstrate broad agreement between comments about measures of teaching staff and course organisation with the performance of the subject areas (compared to metrics of their national counterparts). These findings are consistent with previous quantitative models predicting the most important factors that most influence overall satisfaction ratings. We intend this study to be a catalyst for other institutions to explore their non-publicly available, textual returns in a similar way. The outcomes of this type of work are pertinent to all countries that use large-scale surveys. However, institutions will need to release findings to a public audience if we are to gain a national/international perspective on this key linkage between publicly available metrics and the associated text comments.

Background: Evidence demonstrates that individuals with atopic eczema (eczema) have increased depression and anxiety; however, the role of ethnicity in these associations is poorly understood. We aimed to investigate whether associations between eczema and depression or anxiety differed between adults from white and minority ethnic groups in the UK. Methods: We used UK Clinical Practice Research Datalink GOLD to conduct matched cohort studies of adults (≥18 years) with ethnicity recorded in primary care electronic health records (April 2006‐January 2020). We matched (age, sex, practice) adults with eczema to up to five adults without. We used stratified Cox regression with an interaction between eczema and ethnicity, to estimate hazard ratios (HRs) for associations between eczema and incident depression and anxiety in individuals from white ethnic groups and a pooled minority ethnic group (adults from Black, South Asian, Mixed and Other groups). Results: We identified separate cohorts for depression (215,073 with eczema matched to 646,539 without) and anxiety (242,598 with eczema matched to 774,113 without). After adjusting for matching variables and potential confounders (age, sex, practice, deprivation, calendar period), we found strong evidence (p < 0.01) of ethnic differences in associations between eczema and depression (minority ethnic groups: HR = 1.33, 95% CI = 1.22,1.45; white ethnic groups: HR = 1.15, 95% CI = 1.12,1.17) and anxiety (minority ethnic groups: HR = 1.41, 95% CI = 1.28,1.55; white ethnic groups: HR = 1.17, 95% CI = 1.14,1.19). Conclusions: Adults with eczema from minority ethnic groups appear to be at increased depression and anxiety risk compared with their white counterparts. Culturally adapted mental health promotion and prevention strategies should be considered in individuals with eczema from minority ethnic groups. [ABSTRACT FROM AUTHOR]

Background: Psoriasis and atopic eczema are common inflammatory skin diseases. Existing research has identified increased risks of common mental disorders (anxiety, depression) in people with eczema and psoriasis; however, explanations for the associations remain unclear. We aimed to establish the risk factors for mental illness in those with eczema or psoriasis and identify the population groups most at risk. Methods: We used routinely collected data from the UK Clinical Practice Research Datalink (CPRD) GOLD. Adults registered with a general practice in CPRD (1997–2019) were eligible for inclusion. Individuals with eczema/psoriasis were matched (age, sex, practice) to up to five adults without eczema/psoriasis. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for hazards of anxiety or depression in people with eczema/psoriasis compared to people without. We adjusted for known confounders (deprivation, asthma [eczema], psoriatic arthritis [psoriasis], Charlson comorbidity index, calendar period) and potential mediators (harmful alcohol use, body mass index [BMI], smoking status, and, in eczema only, sleep quality [insomnia diagnoses, specific sleep problem medications] and high-dose oral glucocorticoids). Results: We identified two cohorts with and without eczema (1,032,782, matched to 4,990,125 without), and with and without psoriasis (366,884, matched to 1,834,330 without). Sleep quality was imbalanced in the eczema cohorts, twice as many people with eczema had evidence of poor sleep at baseline than those without eczema, including over 20% of those with severe eczema. After adjusting for potential confounders and mediators, eczema and psoriasis were associated with anxiety (adjusted HR [95% CI]: eczema 1.14 [1.13–1.16], psoriasis 1.17 [1.15–1.19]) and depression (adjusted HR [95% CI]: eczema 1.11 [1.1–1.12], psoriasis 1.21 [1.19–1.22]). However, we found evidence that these increased hazards are unlikely to be constant over time and were especially high 1-year after study entry. Conclusions: Atopic eczema and psoriasis are associated with increased incidence of anxiety and depression in adults. These associations may be mediated through known modifiable risk factors, especially sleep quality in people with eczema. Our findings highlight potential opportunities for the prevention of anxiety and depression in people with eczema/psoriasis through treatment of modifiable risk factors and enhanced eczema/psoriasis management. [ABSTRACT FROM AUTHOR]

Introduction: Previous research has shown associations between eczema and psoriasis and anxiety and depression. We investigated whether associations are consistent across different settings of ascertainment for depression and anxiety, including interview and survey responses from UK Biobank (a large longitudinal cohort recruiting individuals aged 40– 69 years between 2006– 2010), and linked primary care data, with the aim of drawing more reliable conclusions through triangulation.Methods: In cross-sectional studies, we estimated associations between eczema or psoriasis and anxiety or depression, defining anxiety or depression as 1) self-reported previous diagnosis at UK Biobank recruitment interview; 2) PHQ-9/GAD-7 score indicating depression or anxiety from a UK Biobank mental health follow-up survey in 2016; and 3) diagnosis in linked primary care electronic health record data.Results: We analysed 230,047 people with linked Biobank and primary care data. We found poor agreement between the data sources for eczema, psoriasis, anxiety, and depression. Eg, 9474 had a previous eczema diagnosis in primary care data, 4069 self-reported previous eczema diagnosis at the UK biobank interview, and 1536 had eczema in both data sources (for depression 40,455; 13,320; and 9588 respectively). Having eczema or psoriasis (recorded in primary care or baseline interview) was associated with higher odds of anxiety and depression. Eg, the adjusted odds ratio for depression comparing those with eczema to those without was greater than 1 when defining the outcome from 1) the recruitment interview (1.36, 95% confidence interval 1.27– 1.45); 2) the follow-up survey (1.24, 1.09– 1.39), and 3) primary care records (1.56, 1.50– 1.62).Discussion: Our findings support increased prevalence of mental illness in people with psoriasis and eczema across multiple data sources, which should be considered in planning of mental health services. However, we found poor agreement in disease ascertainment between settings, with implications for data interpretation in electronic health records. [ABSTRACT FROM AUTHOR]

Universities capture and use student feedback to improve the student experience, but how should information from national scale surveys be used at local and institutional levels? The authors explored the UK's National Student (Satisfaction) Survey (NSS) data relevant to science and engineering programmes using percentages of students who were satisfied or very satisfied. For brevity, one NSS national dataset was explored, but the patterns found were consistent for the following year. Simple exploratory data analysis techniques underlined the care that is needed when interpreting NSS outputs, corroborating previous research into its international precursors. Factor analysis supported claims of a high internal consistency of the survey. Subject groupings showed consistent differences in responses, with some subjects consistently recording higher satisfaction. This reduces the usefulness of the NSS for comparing different subject groupings within a university. Universities provide different subject compositions, so direct comparisons between institutions are not straightforward. Subject groupings should be compared only against similar subjects, and then with due care to understand the complexity of satisfaction. Further analysis of national questionnaires like this is required to contextualise its outputs. For example, there is a national trend of low satisfaction with assessment feedback in all subjects, but the relationship between feedback satisfaction and overall satisfaction is complex. There are marked differences between subjects which may, in science subjects, be associated with mathematical content. There is scope for future elucidations of the "overall satisfaction" value and for use of the measures of dissatisfaction. (Contains 4 tables and 5 figures.)

This article describes learner and tutor reports of a learning network that formed during the completion of investigative projects on a residential field course. Staff and students recorded project-related interactions, who they were with and how long they lasted over four phases during the field course. An enquiry based learning format challenged individuals to complete investigative bioscience projects utilising peers (n = 20) and tutors (n = 14) as resources. The residential nature of the course ensured full participation of tutors and learners at all stages of the study. Overall, students interacted for "academic purposes" with about 40% of their peers and over 50% of the tutors in their potential network, although there were some differences between students and tutors in their perceptions of the interactions. In addition, patterns of networking activity differed between project stages. Tutors and learners were most interactive at the start of the course, although the data collection/analysis stages were also busy in terms of tutor support. Learners reported that they valued their interactions, but larger networks did not lead to higher marks as high attainment students were found to have worked in smaller networks. The findings provide insights into how individuals are used as resources in learning networks and the dynamics of learning networks during a residential case study. (Contains 3 tables and 1 figure.)

Background: Lymphocyte skin homing in atopic eczema (AE) may induce lymphopenia. Objective: To determine if AE is associated with lymphopenia. Methods: We used UK primary care electronic health records (Clinical Practice Research Datalink GOLD) for a matched cohort study in adults (18 years+) (1997–2015) with at least one recorded lymphocyte count. We matched people with AE to up to five people without. We used multivariable logistic regression to estimate the association between AE and lymphopenia (two low lymphocyte counts within 3 months) and linear mixed effects regression to estimate the association with absolute lymphocyte counts using all available counts. Cox proportional hazard models were used to investigate the effect of lymphopenia on common infections. We replicated the study using US survey data (National Health and Nutrition Examination Survey [NHANES]). Results: Among 71,731 adults with AE and 126,349 adults without AE, we found an adjusted odds ratio (OR) for lymphopenia of 1.16 (95% CI: 1.09–1.23); the strength of association increased with increasing eczema severity. When comparing all recorded lymphocyte counts from adults with AE (n = 1,497,306) to those of people without AE (n = 4,035,870) we saw a lower mean lymphocyte (adjusted mean difference −0.047 × 109/L [95% CI: −0.051 to −0.043]) in those with AE. The difference was larger for men, with increasing age, and with increasing AE severity and was present among people with AE not treated with immunosuppressive drugs. In NHANES (n = 22,624), the adjusted OR for lymphopenia in adults with AE was 1.30 (95% CI: 0.80–2.11), and the adjusted mean lymphocyte count difference was −0.03 × 109/L (95% CI: −0.07 to 0.02). Despite having a lower lymphocyte count, adjusting for time with lymphopenia, did not alter risk estimates of infections. Conclusion: Atopic eczema, including increasing AE severity, is associated with a decreased lymphocyte count, regardless of immunosuppressive drug use. Whether the lower lymphocyte count has wider health implications for people with severe eczema warrants further investigation. [ABSTRACT FROM AUTHOR]

Introduction: Studies show that the COVID-19 pandemic disproportionately affected people with diabetes and those from disadvantaged backgrounds. During the first 6 months of the UK lockdown, > 6.6 M glycated haemoglobin (HbA1c) tests were missed. We now report variability in the recovery of HbA1c testing, and its association with diabetes control and demographic characteristics. Methods: In a service evaluation, we examined HbA1c testing across ten UK sites (representing 9.9% of England's population) from January 2019 to December 2021. We compared monthly requests from April 2020 to those in the equivalent 2019 months. We examined effects of (i) HbA1c level, (ii) between-practice variability, and (iii) practice demographics. Results: In April 2020, monthly requests dropped to 7.9–18.1% of 2019 volumes. By July 2020, testing had recovered to 61.7–86.9% of 2019 levels. During April–June 2020, we observed a 5.1-fold variation in the reduction of HbA1c testing between general practices (12.4–63.8% of 2019 levels). There was evidence of limited prioritization of testing for patients with HbA1c > 86 mmol/mol during April–June 2020 (4.6% of total tests vs. 2.6% during 2019). Testing in areas with the highest social disadvantage was lower during the first lockdown (April–June 2020; trend test p < 0.001) and two subsequent periods (July–September and October–December 2020; both p < 0.001). By February 2021, testing in the highest deprivation group had a cumulative fall in testing of 34.9% of 2019 levels versus 24.6% in those in the lowest group. Conclusion: Our findings highlight that the pandemic response had a major impact on diabetes monitoring and screening. Despite limited test prioritization in the > 86 mmol/mol group, this failed to acknowledge that those in the 59–86 mmol/mol group require consistent monitoring to achieve the best outcomes. Our findings provide additional evidence that those from poorer backgrounds were disproportionately disadvantaged. Healthcare services should redress this health inequality. [ABSTRACT FROM AUTHOR]

Background: Existing research exploring associations between atopic eczema (AE) or psoriasis, and severe mental illness (SMI – ie, schizophrenia, bipolar disorder, other psychoses) is limited, with longitudinal evidence particularly scarce. Therefore, temporal directions of associations are unclear. We aimed to investigate associations between AE or psoriasis and incident SMI among adults. Methods: We conducted matched cohort studies using primary care electronic health records (January 1997 to January 2020) from the UK Clinical Practice Research Datalink GOLD. We identified two cohorts: 1) adults (≥ 18 years) with and without AE and 2) adults with and without psoriasis. We matched (on age, sex, general practice) adults with AE or psoriasis with up to five adults without. We used Cox regression, stratified by matched set, to estimate hazard ratios (HRs) comparing incident SMI among adults with and without AE or psoriasis. Results: We identified 1,023,232 adults with AE and 4,908,059 without, and 363,210 with psoriasis and 1,801,875 without. After adjusting for matching variables (age, sex, general practice) and potential confounders (deprivation, calendar period) both AE and psoriasis were associated with at least a 17% increased hazard of SMI (AE: HR=1.17,95% CI=1.12– 1.22; psoriasis: HR=1.26,95% CI=1.18– 1.35). After additionally adjusting for potential mediators (comorbidity burden, harmful alcohol use, smoking status, body mass index, and, in AE only, sleep problems and high-dose glucocorticoids), associations with SMI did not persist for AE (HR=0.98,95% CI=0.93– 1.04), and were attenuated for psoriasis (HR=1.14,95% CI=1.05– 1.23). Conclusion: Our findings suggest adults with AE or psoriasis are at increased risk of SMI compared to matched comparators. After adjusting for potential mediators, associations with SMI did not persist for AE, and were attenuated for psoriasis, suggesting that the increased risk may be explained by mediating factors (eg, sleep problems). Our research highlights the importance of monitoring mental health in adults with AE or psoriasis. [ABSTRACT FROM AUTHOR]

Background The inappropriate use of antibiotics is understood to contribute to antimicrobial resistance. Oral antibiotics are regularly used to treat moderate-to-severe acne vulgaris. In practice, we do not know the typical length of oral antibiotic treatment courses for acne in routine primary care and what proportion of people receive more than one course of treatment following a new acne diagnosis. Objectives To describe how oral antibiotics are prescribed for acne over time in UK primary care. Methods We conducted a descriptive longitudinal drug utilization study using routinely collected primary care data from the Clinical Practice Research Datalink GOLD (2004–2019). We included individuals (8–50 years) with a new acne diagnosis recorded between 1 January 2004 and 31 July 2019. Results We identified 217 410 people with a new acne diagnosis. The median age was 17 years [interquartile range (IQR) 15–25] and median follow-up was 4.3 years (IQR 1.9–7.6). Among people with a new acne diagnosis, 96 703 (44.5%) received 248 560 prescriptions for long-term oral antibiotics during a median follow-up of 5.3 years (IQR 2.8–8.5). The median number of continuous courses of antibiotic therapy (≥ 28 days) per person was four (IQR 2–6). The majority (n = 59 010, 61.0%) of first oral antibiotic prescriptions in those with a recorded acne diagnosis were between the ages of 12 and 18. Most (n = 71 544, 74.0%) first courses for oral antibiotics were for between 28 and 90 days. The median duration of the first course of treatment was 56 days (IQR 50–93 days) and 18 127 (18.7%) of prescriptions of ≥ 28 days were for < 6 weeks. Among people who received a first course of oral antibiotic for ≥ 28 days, 56 261 (58.2%) received a second course after a treatment gap of ≥ 28 days. The median time between first and second courses was 135 days (IQR 67–302). The cumulative duration of exposure to oral antibiotics during follow-up was 255 days (8.5 months). Conclusions Further work is needed to understand the consequences of using antibiotics for shorter periods than recommended. Suboptimal treatment duration may result in reduced clinical effectiveness or repeated exposures, potentially contributing to antimicrobial resistance. [ABSTRACT FROM AUTHOR]

Background: Vitamin D has immunomodulatory effects, but any association with herpes zoster (HZ) is unclear. Aim: To explore the association between vitamin D status and risk of incident HZ in adults in the UK. Design and setting: A cohort study involving participants of UK Biobank (a database containing the health information from half a million individuals) across England, Wales, and Scotland, who had at least one vitamin D testing result with linked primary care electronic health records. Method: The primary exposure was vitamin D status, categorised as deficient (<25 nmol/L), insufficient (25–49 nmol/L), or sufficient (≥50 nmol/L). The secondary exposures were self-reported vitamin D supplementation at baseline assessment and vitamin D prescription records. The outcome was diagnosed incident HZ, identified from linked primary care or hospital inpatient records. Weibull regression was used, adjusting for potential confounders, including demographic factors, comorbidities, and immunosuppression. Results: In total, 177 572 eligible participants were included in the analysis, with a mean follow-up time of 10.1 years (standard deviation 1.9 years). No evidence showed that low vitamin D was associated with a higher incidence of HZ, compared with people with sufficient vitamin D (deficient: adjusted hazard ratio [HR] 0.99, 95% confidence interval [CI] = 0.90 to 1.10; insufficient: HR 1.03, 95% CI = 0.96 to 1.10). No evidence was found that supplementing vitamin D or receiving vitamin D prescription was associated with HZ incidence (supplementation: HR 0.88, 95% CI = 0.67 to 1.16; prescription: HR 1.11, 95% CI = 0.91 to 1.34). Conclusion: No association of vitamin D status, supplementation, or prescription with incident HZ was observed. No evidence supported vitamin D supplementation as a strategy to prevent HZ. [ABSTRACT FROM AUTHOR]

Background: Recent studies indicate that vitamin D supplementation may decrease respiratory tract infections, but the association between vitamin D and COVID-19 is still unclear. Objective: To explore the association between vitamin D status and infections, hospitalisation, and mortality due to COVID-19. Methods: We used UK Biobank, a nationwide cohort of 500,000 individuals aged between 40 and 69 years at recruitment between 2006 and 2010. We included people with at least one serum vitamin D test, living in England with linked primary care and inpatient records. The primary exposure was serum vitamin D status measured at recruitment, defined as deficiency at <25 nmol/L, insufficiency at 25–49 nmol/L and sufficiency at ≥ 50 nmol/L. Secondary exposures were self-reported or prescribed vitamin D supplements. The primary outcome was laboratory-confirmed or clinically diagnosed SARS-CoV-2 infections. The secondary outcomes included hospitalisation and mortality due to COVID-19. We used multivariable Cox regression models stratified by summertime months and non-summertime months, adjusting for demographic factors and underlying comorbidities. Results: We included 307,512 participants (54.9% female, 55.9% over 70 years old) in our analysis. During summertime months, weak evidence existed that the vitamin D deficiency group had a lower hazard of being diagnosed with COVID-19 (hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.77–0.95). During non-summertime, the vitamin D deficiency group had a higher hazard of COVID-19 compared with the vitamin D sufficient group (HR = 1.14, 95% CI = 1.01–1.30). No evidence was found that vitamin D deficiency or insufficiency was associated with either hospitalisation or mortality due to COVID-19 in any time strata. Conclusion: We found no evidence of an association between historical vitamin D status and hospitalisation or mortality due to COVID-19, along with inconsistent results for any association between vitamin D and diagnosis of COVID-19. However, studies using more recent vitamin D measurements and systematic COVID-19 testing are needed. [ABSTRACT FROM AUTHOR]

Background: Oral prednisolone is the mainstay treatment for bullous pemphigoid, an autoimmune blistering skin disorder affecting older people. Treatment with moderate-to-high doses is often initiated in secondary care, but then continued in primary care. Aim: To describe long-term oral prednisolone prescribing in UK primary care for adults with bullous pemphigoid from 1998 to 2017. Design and setting: A prospective cohort study using routinely collected data from the Clinical Practice Research Datalink, a primary care database containing the healthcare records for over 17 million people in the UK. Method: Oral prednisolone exposure was characterised in terms of the proportion of individuals with incident bullous pemphigoid prescribed oral prednisolone following their diagnosis, and the duration and dose of prednisolone. Results: In total, 2312 (69.6%) of 3322 people with bullous pemphigoid were prescribed oral prednisolone in primary care. The median duration of exposure was 10.6 months (interquartile range [IQR] 3.4–24.0). Of prednisolone users, 71.5% were continuously exposed for >3 months, 39.7% for >1 year, 14.7% for >3 years, 5.0% for >5 years, and 1.7% for >10 years. The median cumulative dose was 2974 mg (IQR 1059–6456). Maximum daily doses were ≥10 mg/day in 74.4% of prednisolone users, ≥20 mg/day in 40.7%, ≥30 mg/day in 18.2%, ≥40 mg/day in 6.6%, ≥50 mg/day in 3.8%, and ≥60 mg/day in 1.9%. Conclusion: A high proportion of people with incident bullous pemphigoid are treated with oral prednisolone in UK primary care. Action is required by primary and second care services to encourage use of steroid-sparing alternatives and, where switching is not possible, ensure prophylactic treatments and proactive monitoring of potential side effects are in place. [ABSTRACT FROM AUTHOR]

Background: Atopic dermatitis is known to be common among children, but there are few studies examining the epidemiology across the life course. In particular, there is a paucity of data on atopic dermatitis among older adults. Objective: To evaluate participant characteristics, patterns of disease activity and severity, and calendar trends in older adult atopic dermatitis in comparison to other age groups in a large population-based cohort. Methods: This was a cohort study of 9,154,936 individuals aged 0–99 years registered in The Health Improvement Network, a database comprised of electronic health records from general practices in the United Kingdom between 1994 and 2013. Atopic dermatitis was defined by a previously validated algorithm using a combination of at least one recorded atopic dermatitis diagnostic code in primary care and two atopic dermatitis therapies recorded on separate days. Cross-sectional analyses of disease prevalence were conducted at each age. Logistic mixed effect regression models were used to identify predictors of prevalent disease over time among children (0–17 years), adults (18–74 years), and older adults (75–99 years). Results: Physician-diagnosed atopic dermatitis was identified in 894,454 individuals with the following proportions in each age group: 18.3% of children, 7.7% of adults, and 11.6% of older adults. Additionally, atopic dermatitis prevalence increased across the 2-decade period (beta from linear regression test for trend in the change in proportion per year = 0.005, p = 0.044). In older adults, atopic dermatitis was 27% less common among females (adjusted OR 0.73, 95% CI 0.70–0.76) and was more likely to be active (59.7%, 95% CI 59.5–59.9%) and of higher severity (mean annual percentage with moderate and severe disease: 31.8% and 3.0%, respectively) than in other age groups. Conclusion: In a large population-based cohort, the prevalence of physician-diagnosed atopic dermatitis has increased throughout adulthood and was most common among males age 75 years and above. Compared to children ages 0–17 and adults ages 18–74, older adult atopic dermatitis was more active and severe. Because the prevalence of atopic dermatitis among older adults has increased over time, additional characterization of disease triggers and mechanisms and targeted treatment recommendations are needed for this population. [ABSTRACT FROM AUTHOR]

Summary: Background: Emerging evidence suggests an association between common inflammatory skin diseases and chronic kidney disease (CKD). Objectives: To explore the association between CKD stages 3–5 (CKD3–5) and atopic eczema, psoriasis, rosacea and hidradenitis suppurativa. Methods: We undertook two complementary analyses; a prevalent case–control study and a cohort study using routinely collected primary care data [UK Clinical Practice Research Datalink (CPRD)]. We matched individuals with CKD3–5 in CPRD in March 2018 with up to five individuals without CKD for general practitioner practice, age and sex. We compared the prevalence of CKD3–5 among individuals with and without each inflammatory skin disease. We included individuals in CPRD with diabetes mellitus (2004–2018) in a cohort analysis to compare the incidence of CKD3–5 among people with and without atopic eczema and psoriasis. Results: Our study included 56 602 cases with CKD3–5 and 268 305 controls. Cases were more likely than controls to have a history of atopic eczema [odds ratio (OR) 1·14, 99% confidence interval (CI) 1·11–1·17], psoriasis (OR 1·13, 99% CI 1·08–1·19) or hidradenitis suppurativa (OR 1·49, 99% CI 1·19–1·85), but were slightly less likely to have been diagnosed with rosacea (OR 0·92, 99% CI 0·87–0·97), after adjusting for age, sex, practice (matching factors), index of multiple deprivation, diabetes, smoking, harmful alcohol use and obesity. Results remained similar after adjusting for hypertension and cardiovascular disease. In the cohort with diabetes (N = 335 827), there was no evidence that CKD3–5 incidence was associated with atopic eczema or psoriasis. Conclusions: Atopic eczema, psoriasis and hidradenitis suppurativa are weakly associated with CKD3–5. Future research is needed to elucidate potential mechanisms and the clinical significance of our findings. What is already known about this topic?Emerging evidence supports an association between more common inflammatory skin diseases and chronic kidney disease (CKD), but the size and nature of this association remain unclear. What does this study add?People with CKD were more likely to have atopic eczema (14%), psoriasis (13%) and hidradenitis suppurativa (49%), compared with those without CKD.The link between inflammatory skin diseases and CKD did not appear to be mediated through cardiovascular comorbidity, hypertension or nephrotoxic drugs.A stronger association with CKD among those with severe atopic eczema and psoriasis was consistent with a dose–response association.There was no evidence of CKD incidence being associated with atopic eczema or psoriasis in the cohort of people with diabetes. Linked Comment: J. Wan and K. Abuabara. Br J Dermatol 2021; 185:693–694. Plain language summary available online [ABSTRACT FROM AUTHOR]

Summary: Background: Atopic dermatitis (AD) disease activity and severity is highly variable during childhood. Early attempts to identify subtypes based on disease trajectory have assessed AD presence over time without incorporating severity. Objectives: To identify childhood AD subtypes from symptom severity and trajectories, and determine associations with genetic risk factors, comorbidities and demographic and environmental variables. Methods: We split data from children in the Avon Longitudinal Study of Parents and Children birth cohort into development and validation sets. To identify subtypes, we ran latent class analyses in the development set on AD symptom reports up to age 14 years. We regressed identified subtypes on nongenetic variables in mutually adjusted, multiply imputed (genetic: unadjusted, complete case) multinomial regression analyses. We repeated analyses in the validation set and report confirmed results. Results: There were 11 866 children who contributed to analyses. We identified one Unaffected/Rare class (66% of children) and four AD subtypes: Severe–Frequent (4%), Moderate–Frequent (7%), Moderate–Declining (11%) and Mild–Intermittent (12%). Symptom patterns within the first two subtypes appeared more homogeneous than the last two. Filaggrin (FLG) null mutations, an AD polygenic risk score (PRS), being female, parental AD and comorbid asthma were associated with higher risk for some or all subtypes; FLG, AD‐PRS and asthma associations were stronger along a subtype gradient arranged by increasing severity and frequency; FLG and AD‐PRS further differentiated some phenotypes from each other. Conclusions: Considering severity and AD trajectories leads to four well‐defined and recognizable subtypes. The differential associations of risk factors among and between subtypes is novel and requires further research. What's already known about this topic? Atopic dermatitis (AD) is a heterogeneous condition in terms of both disease activity and severity.Childhood AD phenotypes in previous studies have focused only on disease activity. What does this study add? We incorporate disease severity over time to derive four clinically recognizable AD phenotypes using data‐driven methods.Disease severity improved over time in all phenotypes (even in those with high probability of activity in late childhood and adolescence).Several established risk factors, including genetic associates, were associated with our proposed phenotypes, with most factors more strongly associated with phenotypes reporting the worst symptoms. Fewer factors differentiated between more Frequent and Declining/Intermittent phenotypes. Linked Comment: C. Vestergaard. Br J Dermatol 2021; 185:477. [ABSTRACT FROM AUTHOR]

Summary: Background: Registry data suggest that people with immune‐mediated inflammatory diseases (IMIDs) receiving targeted systemic therapies have fewer adverse coronavirus disease 2019 (COVID‐19) outcomes compared with patients receiving no systemic treatments. Objectives: We used international patient survey data to explore the hypothesis that greater risk‐mitigating behaviour in those receiving targeted therapies may account, at least in part, for this observation. Methods: Online surveys were completed by individuals with psoriasis (globally) or rheumatic and musculoskeletal diseases (RMDs) (UK only) between 4 May and 7 September 2020. We used multiple logistic regression to assess the association between treatment type and risk‐mitigating behaviour, adjusting for clinical and demographic characteristics. We characterized international variation in a mixed‐effects model. Results: Of 3720 participants (2869 psoriasis, 851 RMDs) from 74 countries, 2262 (60·8%) reported the most stringent risk‐mitigating behaviour (classified here under the umbrella term 'shielding'). A greater proportion of those receiving targeted therapies (biologics and Janus Kinase inhibitors) reported shielding compared with those receiving no systemic therapy [adjusted odds ratio (OR) 1·63, 95% confidence interval (CI) 1·35–1·97]. The association between targeted therapy and shielding was preserved when standard systemic therapy was used as the reference group (OR 1·39, 95% CI 1·23–1·56). Shielding was associated with established risk factors for severe COVID‐19 [male sex (OR 1·14, 95% CI 1·05–1·24), obesity (OR 1·37, 95% CI 1·23–1·54), comorbidity burden (OR 1·43, 95% CI 1·15–1·78)], a primary indication of RMDs (OR 1·37, 95% CI 1·27–1·48) and a positive anxiety or depression screen (OR 1·57, 95% CI 1·36–1·80). Modest differences in the proportion shielding were observed across nations. Conclusions: Greater risk‐mitigating behaviour among people with IMIDs receiving targeted therapies may contribute to the reported lower risk of adverse COVID‐19 outcomes. The behaviour variation across treatment groups, IMIDs and nations reinforces the need for clear evidence‐based patient communication on risk‐mitigation strategies and may help inform updated public health guidelines as the pandemic continues. What is already known about this topic? At the beginning of the coronavirus disease 2019 (COVID‐19) pandemic, patients with immune‐mediated inflammatory diseases (IMIDs) on targeted systemic therapies were considered to be at higher risk of severe COVID‐19.Subsequent clinician‐reported registry data suggest that targeted systemic therapy use is associated with fewer adverse COVID‐19 outcomes compared with no systemic therapy. What does this study add? We characterize shielding behaviour in 3720 patients with IMIDs from a global self‐report survey.Use of targeted systemic therapy associates with increased shielding behaviour, compared with standard systemics or no therapy, as do demographic risk factors for severe COVID‐19 including male sex and obesity.Greater risk‐mitigating behaviour among people with IMIDs receiving targeted therapies may contribute to the reported lower risk of adverse COVID‐19 outcomes.Behaviour variation across treatment groups reinforces the need for clear, evidence‐based patient communication on risk‐mitigation strategies.These data may help to inform updated public health guidelines as the pandemic continues. Linked Comment: G. Becher and A.D. Burden. Br J Dermatol 2021; 185:7–8. [ABSTRACT FROM AUTHOR]

Summary: Background: Herpes zoster can cause rare but serious complications; the frequency of these complications has not been well described. Objectives: To quantify the risks of acute non‐postherpetic neuralgia (PHN) zoster complications, to inform vaccination policy. Methods: We conducted a cohort study among unvaccinated immunocompetent adults with incident zoster, and age‐, sex‐ and practice‐matched control adults without zoster, using routinely collected health data from the UK Clinical Practice Research Datalink (years 2001 to 2018). Crude attributable risks of complications were estimated as the difference between Kaplan–Meier‐estimated 3‐month cumulative incidences in patients with zoster vs. controls. We used Cox models to obtain hazard ratios for our primary outcomes in patients with and without zoster. Primary outcomes were ocular, neurological, cutaneous, visceral and zoster‐specific complications. We also assessed whether antivirals during acute zoster protected against the complications. Results: In total 178 964 incident cases of zoster and 1 799 380 controls were included. The absolute risks of zoster‐specific complications within 3 months of zoster diagnosis were 0·37% [95% confidence interval (CI) 0·34–0·39] for Ramsay Hunt syndrome, 0·01% (95% CI 0·0–0·01) for disseminated zoster, 0·04% (95% CI 0·03–0·05) for zoster death and 0·97% (95% CI 0·92–1·00) for zoster hospitalization. For other complications, attributable risks were 0·48% (95% CI 0·44–0·51) for neurological complications, 1·33% (95% CI 1·28–1·39) for ocular complications, 0·29% (95% CI 0·26–0·32) for cutaneous complications and 0·78% (95% CI 0·73–0·84) for visceral complications. Attributable risks were higher among patients > 50 years old. Patients with zoster had raised risks of all primary outcomes relative to controls. Antiviral prescription was associated with reduced risk of neurological complications (hazard ratio 0·61, 95% CI 0·53–0·70). Conclusions: Non‐PHN complications of zoster were relatively common, which may affect cost‐effectiveness calculations for zoster vaccination. Clinicians should be aware that zoster can lead to various complications, besides PHN. What is already known about this topic?Herpes zoster is typically mild and self‐limiting; however, it can cause serious cutaneous, visceral, neurological and ocular complications.Some complications lead to severe illness, high healthcare costs and mortality, while others can seriously affect quality of life.Better knowledge of the frequency of, and risk factors for, such zoster complications would be helpful to inform zoster vaccination policy. What does this study add?In this large cohort study among UK adults with zoster, we found raised risks of neurological, ocular, cutaneous, visceral and zoster‐specific complications in the 3 months after zoster diagnosis.Estimated absolute risks attributable to zoster were 0·48% [95% confidence interval (CI) 0·44–0·51] for neurological complications, 1·33% (95% CI 1·28–1·39) for ocular complications, 0·29% (95% CI 0·26–0·32) for cutaneous complications and 0·78% (95% CI 0·73–0·84) for visceral complications. Linked Comment: Kridin and Cohen. Br J Dermatol 2021; 184:994–995. [ABSTRACT FROM AUTHOR]

Deliberate self-harm (DSH) is a major global health problem and a significant risk factor for death by suicide. Despite this, those who suffer are often confronted with negative attitudes from healthcare professionals whilst seeking help, with detrimental consequences for treatment outcomes. While several factors may affect attitudes to DSH amongst healthcare professionals, there is now growing evidence to suggest an association with burnout. As current levels of burnout amongst junior doctors are estimated to be high, understanding the nature of this association is crucial. The over-arching aim of this project is therefore to explore junior doctors' attitudes toward DSH in comparison with other presenting conditions and to explore any possible relationship these may have with features of burnout. We conducted an online cross-sectional survey of junior doctors working within NHS Greater Glasgow and Clyde. After collecting sociodemographic information, participants were presented with both the abbreviated Maslach Burnout Inventory and the Medical Condition Regard Scale for patients presenting with; Chronic Obstructive Pulmonary Disease (COPD), Type I Diabetes Mellitus (T1DM), Schizophrenia and DSH. Significant differences in attitudes according to presenting complaints/conditions were identified. Participants reported the highest regard for TIDM and lowest regard for DSH, varying as a function of speciality and years of NHS service. 21% of participants were experiencing 'burnout' to a high degree, and scores also varied as a function of speciality and years of NHS service. No association between burnout and attitudes were observed for any of the investigated diagnoses. Our findings highlight the desperate need for evidence-based interventions to address burnout and negative attitudes toward DSH amongst junior doctors. Moreover, they may suggest that these attitudes worsen through the course of junior doctor training. We would therefore advocate for further research to assess the efficacy of interventions designed to address this. [ABSTRACT FROM AUTHOR]

Skin cancer referrals via the 2-week wait (urgent suspected cancer) pathway outnumber any other suspected malignancy.1,2 The most common skin cancers are keratinocyte cancers (KCs), which represents basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (cSCCs). Dear Editor, Skin cancer is the most common cancer in the UK. The EASR of first PPPA cSCC increased on average by 2-8 cancers per 100 000 PYs (95% CI 1-7-4-0), with first all-time cSCC increasing by 1-4 cancers per 100 000 PYs (95% CI 0-7-2-2). [Extracted from the article]

Summary: Background: Psoriasis is associated with risk factors for serious infections, but the independent relationship between psoriasis and serious infection is as yet unclear. Objectives: To determine whether people with psoriasis have a higher risk of hospitalization due to any infection, respiratory infections, soft‐tissue and skin infections, or a higher risk of death due to infection. Methods: We conducted a cohort study of people (≥ 18 years) with psoriasis using the UK Clinical Practice Research Datalink (CPRD GOLD) linked to Hospital Episode Statistics (HES) and Office for National Statistics (ONS) mortality records between 1 April 2003 and 31 December 2016, and matched with up to six comparators on age, sex and general practice. Hospitalization was ascertained from HES records; death was ascertained from ONS mortality records. Stratified Cox proportional hazard models were estimated, with stepwise adjustment in different models for potential confounders or mediators between psoriasis and serious infection. Results: There were 69 315 people with psoriasis and 338 620 comparators who were followed up for a median (interquartile range) of 4·9 (5·9) and 5·1 (6·3) years, respectively. People with psoriasis had a higher incidence rate of serious infection [20·5 per 1000 person‐years, 95% confidence interval (CI) 20·0–21·0, n = 7631] compared with those without psoriasis (16·1 per 1000 person‐years, 95% CI 15·9–16·3, n = 30 761). The fully adjusted hazard ratio for the association between psoriasis and serious infection was 1·36 (95% CI 1·31–1·40), with similar results across the other outcomes. Conclusions: Psoriasis is associated with a small increase in the risk of serious infection. Further research is needed to understand how psoriasis predisposes to a higher risk of infection. What is already known about this topic? Several studies have shown that people with psoriasis have a higher risk of hospitalization due to infection, but these studies are limited by residual confounding for lifestyle factors or underestimation of the true incidence of hospital admissions from primary care electronic health records. What does this study add? Using a large primary care database linked with secondary care Hospital Episode Statistics, we found that, after adjusting for potential confounders and mediators, the hazard ratio for the association between psoriasis and the development of serious infection was 1·36 (95% confidence interval 1·31–1·40).In summary, we show that having psoriasis is independently associated with a small but increased risk of serious infection. Linked Comment:Naldi. Br J Dermatol 2021; 184:6. Plain language summary available online [ABSTRACT FROM AUTHOR]

Summary: Background: A rising incidence and high mortality were found for bullous pemphigoid (BP) over a decade ago in the UK. Updated estimates of its epidemiology are required to understand the healthcare needs of an ageing population. Objectives: To determine the incidence, prevalence and mortality rates of BP in England from 1998 to 2017. Methods: We conducted a cohort study of longitudinal electronic health records using the Clinical Practice Research Datalink and linked Hospital Episode Statistics. Incidence was calculated per 100 000 person‐years and annual point prevalence per 100 000 people. Multivariate analysis was used to determine incidence rate ratios by sociodemographic factors. Mortality was examined in an age‐, sex‐ and practice‐matched cohort, using linked Office of National Statistics death records. Hazard ratios (HRs) were stratified by matched set. Results: The incidence was 7·63 [95% confidence interval (CI) 7·35–7·93] per 100 000 person‐years and rose with increasing age, particularly for elderly men. The annual increase in incidence was 0·9% (95% CI 0·2–1·7). The prevalence almost doubled over the observation period, reaching 47·99 (95% CI 43·09–53·46) per 100 000 people and 141·24 (95% CI 125·55–158·87) per 100 000 people over the age of 60 years. The risk of all‐cause mortality was highest in the 2 years after diagnosis (HR 2·96; 95% CI 2·68–3·26) and remained raised thereafter (HR 1·54; 95% CI 1·36–1·74). Conclusions: We report a modest increase in the incidence rate of BP, but show that the burden of disease in the elderly population is considerable. Mortality is high, particularly in the first 2 years after diagnosis. What is already known about this topic? Bullous pemphigoid (BP) is a blistering skin disorder which typically affects the elderly.BP poses a high burden on affected patients and has significant healthcare costs.The burden of disease in the UK was estimated over a decade ago and found to have a rising incidence and high mortality. What does this study add? The incidence of BP in England was 7·63 (95% CI 7·35–7·93) per 100 000 person‐years between 1998 and 2017.The burden of BP in the elderly population is substantial and it should not be considered a rare disease in these age groups.The risk of death was almost three times higher in the first 2 years after a diagnosis of BP compared with people without the disease and remained raised thereafter. Linked Comment:Bax and Werth. Br J Dermatol 2021; 184:5–6. Plain language summary available online [ABSTRACT FROM AUTHOR]

Summary: Background: Psychological stress is commonly cited as a risk factor for melanoma, but clinical evidence is limited. Objectives: This study aimed to evaluate the association between partner bereavement and (i) first‐time melanoma diagnosis and (ii) mortality in patients with melanoma. Methods: We conducted two cohort studies using data from the U.K. Clinical Practice Research Datalink (1997–2017) and Danish nationwide registries (1997–2016). In study 1, we compared the risk of first melanoma diagnosis in bereaved vs. matched nonbereaved people using stratified Cox regression. In study 2 we estimated hazard ratios (HRs) for death from melanoma in bereaved compared with nonbereaved individuals with melanoma using Cox regression. We estimated HRs separately for the U.K. and for Denmark, and then pooled the data to perform a random‐effects meta‐analysis. Results: In study 1, the pooled adjusted HR for the association between partner bereavement and melanoma diagnosis was 0·88 [95% confidence interval (CI) 0·84–0·92] across the entire follow‐up period. In study 2, we observed increased melanoma‐specific mortality in people experiencing partner bereavement across the entire follow‐up period (HR 1·17, 95% CI 1·06–1·30), with the peak occurring during the first year of follow‐up (HR 1·31, 95% CI 1·07–1·60). Conclusions: We found decreased risk of melanoma diagnosis, but increased mortality associated with partner bereavement. These findings may be partly explained by delayed detection resulting from the loss of a partner who could notice skin changes. Stress may play a role in melanoma progression. Our findings indicate the need for a low threshold for skin examination in individuals whose partners have died. What is already known about this topic? Psychological stress has been proposed as a risk factor for the development and progression of cancer, including melanoma, but evidence is conflicting.Clinical evidence is limited by small sample sizes, potential recall bias associated with self‐report, and heterogeneous stress definitions. What does this study add? We found a decreased risk of melanoma diagnosis, but increased mortality associated with partner bereavement.While stress might play a role in the progression of melanoma, an alternative explanation is that bereaved people no longer have a close person to help notice skin changes, leading to delayed melanoma detection. Linked Comment:Talaganis et al. Br J Dermatol 2020; 183:607–608. Linked Comment:Talaganis et al. Br J Dermatol 2020; 183:607–608. Plain language summary available online [ABSTRACT FROM AUTHOR]

Summary: Background: Stress is commonly cited as a risk factor for psoriasis and atopic eczema, but such evidence is limited. Objectives: To investigate the association between partner bereavement (an extreme life stressor) and psoriasis or atopic eczema. Methods: We conducted cohort studies using data from the U.K. Clinical Practice Research Datalink (1997–2017) and Danish nationwide registries (1997–2016). The exposed cohort was partners who experienced partner bereavement. The comparison cohort was up to 10 nonbereaved partners, matched to each bereaved partner by age, sex, county of residence (Denmark) and general practice (U.K.). Outcomes were the first recorded diagnosis of psoriasis or atopic eczema. We estimated hazard ratios (HRs) and confidence intervals (CIs) using a stratified Cox proportional hazards model in both settings, which were then pooled in a meta‐analysis. Results: The pooled adjusted HR for the association between bereavement and psoriasis was 1·01 (95% CI 0·98–1·04) across the entire follow‐up. Similar results were found in other shorter follow‐up periods. Pooled adjusted HRs for the association between bereavement and atopic eczema were 0·97 (95% CI 0·84–1·12) across the entire follow‐up, 1·09 (95% CI 0·86–1·38) within 0–30 days, 1·18 (95% CI 1·04–1·35) within 0–90 days, 1·14 (95% CI 1·06–1·22) within 0–365 days and 1·07 (95% CI 1·02–1·12) within 0–1095 days. Conclusions: We found a modest increase in the risk of atopic eczema within 3 years following bereavement, which peaked in the first 3 months. Acute stress may play a role in triggering onset of new atopic eczema or relapse of atopic eczema previously in remission. We observed no evidence for increased long‐term risk of psoriasis and atopic eczema following bereavement. What's already known about this topic? Psychological stress is commonly cited as a risk factor for psoriasis and atopic eczema. However, clinical evidence supporting such associations is limited.Current epidemiological evidence for the relationship is limited by small sample sizes and difficulty measuring stress. What does this study add? In two population‐based cohort studies, there was no evidence of an increased risk of psoriasis associated with partner bereavement.There was a short‐term increased risk of atopic eczema in the 3 years following partner bereavement, which peaked during the first year. However, there was no evidence of an increased long‐term risk of atopic eczema.Acute stress may trigger onset or relapse of atopic eczema, leading to an increased risk of atopic eczema in the short term following partner bereavement. Linked Comment: von Kobyletzki. Br J Dermatol 2020; 183:207. Plain language summary available online [ABSTRACT FROM AUTHOR]

The British referendum on continued EU membership in 2016 was infused with Brexiteer discourse relating to a fairer UK relationship with African countries inside the Commonwealth. Prominent campaigners including Boris Johnson and Daniel Hannan regularly spoke of the EU's mercantilist trade and aid policies in sub-Saharan Africa as a means to underscore the supranational project's unsavoury relationship with Anglophone developing countries. Brexit, it was claimed, would usher in a new era whereby the UK Department for International Development (DFID) - and a resurgent UK Department for International Trade (DFIT) - would have the opportunity to offer humanitarian aid and free trade unencumbered by the cynicism of the European Commission. Recent policy papers from both DFID and DFIT, however, have made clear that the UK intends to replicate the Economic Partnership Agreements (EPAs) under negotiation between the European Commission and sub-regions of the African, Caribbean and Pacific (ACP) bloc. This is despite Brexiteer discourse about the EPAs' apparent pitfalls relating to non-tariff barriers and the import-flooding of African markets. Perhaps more worryingly, meanwhile, DFID and DFIT publications highlight the need for UK Development Finance Institutions (DFIs) - notably the CDC Group - to robustly compete with their EU counterparts, to gain better market share for UK businesses within emerging African markets. In this context, the article argues that Brexit will intensify a 'new scramble for Africa' and highlights emerging challenges for European development cooperation vis-à-vis normative pledges to sustainable development. Additionally, it considers possible African responses via reflection on the writings of Kwame Nkrumah regarding 'neo-colonialism'. [ABSTRACT FROM AUTHOR]

Background: In the UK, an estimated one third of people with dementia have not received a diagnosis. Good evidence suggests that dementia risk is increased among widowed individuals; however, it is not clear if they are being diagnosed in routine primary care.Objective: This study aimed to investigate if bereavement influenced the probability of having received a dementia diagnosis.Methods: A population-based cohort study using UK electronic health records, between 1997 and 2017, among 247,586 opposite-sex partners. Those experiencing partner bereavement were matched (age, sex, and date of bereavement) to a non-bereaved person living in a partnership. Multivariate cox regression was performed.Results: Partner bereavement was associated with an increased risk of receiving a diagnosis of dementia in the first three months (hazard ratio (HR) 1.43, 95% CI 1.20-1.71) and first six months (HR 1.24, 95% CI 1.09-1.41), while there was a small reduced risk of getting a dementia diagnosis over all follow-up (HR 0.94, 95% CI 0.89-0.98).Conclusions: Partner bereavement appears to lead to a short-term increased risk of the surviving partner receiving a diagnosis of dementia, suggesting that bereavement unmasks existing undiagnosed dementia. Over the longer term, however, bereaved individuals are less likely to have a diagnosis of dementia in their health records than non-bereaved individuals. [ABSTRACT FROM AUTHOR]

Summary: Background: Basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC), together known as keratinocyte cancers (KCs), are the commonest cancer in white ethnic populations. Recent improvements to registry data collection in England has allowed more accurate analysis of the epidemiology of BCC and cSCC and for the first time we are able to provide an accurate (representative) tumour burden for KC in the U.K. Objectives: To estimate the incidence of BCC and cSCC in the U.K. Methods: A cohort of patients with KCs between 2013 and 2015 were identified using linkage to diagnostic codes derived from pathology reports collected into the national cancer registry. Data from England's cancer registry were combined with data from Scotland, Northern Ireland and Wales. European age‐standardized incidence rates (EASRs) of the first BCC and cSCC per patient per annum (PPPA) were calculated. Results: In the U.K, the EASR of the first BCC and cSCC PPPA in 2013–15 were 285 and 77 per 100 000 person years, respectively (211 120 KCs total in 2015). The mean annual percentage increase was 5% between 2013 and 2015 for both BCC and cSCC. By counting the first KC PPPA, we include an additional 51% KCs compared with the previous reporting technique which counts only the first BCC and cSCC in a patient's lifetime, yet it represents a probable underestimation of 5–11% of the true tumour count. Conclusions: Based on an improved methodology, a more representative incidence of KC is presented, which is essential to healthcare planning and will lead to improved understanding of the epidemiology of KC. What's already known about this topic? Keratinocyte cancers (KCs) are the most common cancers affecting white ethnic populations.The incidence of basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) is increasing worldwide including the U.K., most commonly in elderly male Caucasian patients.These cancers are traditionally substantially underreported and frequently excluded from national cancer statistics. What does this study add? Using improved data collection methods in England and validated tumour‐reporting techniques, we report the most accurate BCC and cSCC incidence data for the U.K. ever published.Identifying the first BCC and cSCC per patient per annum, the incidence of BCC and cSCC in the U.K. (excluding Wales) was 285 and 77 per 100 000 person years, respectively, between 2013 and 2015, with more than 210 000 KCs in the U.K. in 2015. Linked Editorial: Whiteman. Br J Dermatol 2019; 181:434–435. Plain language summary available online Respond to this article [ABSTRACT FROM AUTHOR]

We examined the association between mood disorders and risk of herpes zoster in two case-control studies using data from nationwide Danish registries and practices in the UK Clinical Practice Research Datalink. We included incident zoster cases diagnosed in general practice (using systemic antivirals as a proxy in Denmark) or hospital during 1997-2013 in Denmark (n = 190,671) and during 2000-2013 in the United Kingdom (n = 177,361). We risk-set sampled 4 matched population controls per case. Conditional logistic regression analyses adjusting for zoster risk factors showed that the odds ratios for previous mood disorder among cases versus controls were 1.15 (99% confidence interval (CI): 1.12,1.19; prevalence 7.1% vs. 6.0%) in Denmark and 1.12 (99% CI: 1.11,1.14; prevalence 31.6% vs. 29.2%) in the United Kingdom. In Denmark, odds ratios were higher for anxiety (1.23; 99% CI: 1.17,1.30) and severe stress and adjustment disorder (1.24; 99% CI: 1.18,1.30) than for depression (1.11; 99% CI: 1.07,1.14). In the United Kingdom, odds ratios for these conditions were similar: 1.12 (99% CI: 1.10,1.13), 1.12 (99% CI: 1.10,1.14), and 1.14 (99% CI: 1.10,1.19) for depression, anxiety, and severe stress and adjustment disorder, respectively. In conclusion, mood disorders were associated with an increased risk of zoster. [ABSTRACT FROM AUTHOR]

Background Statins are commonly prescribed worldwide and recent evidence suggests that they may increase the risk of herpes zoster ( HZ). Objectives To quantify the effect of statin exposure on the risk of HZ in the U.K. Methods A matched case-control study was conducted using data from U.K. primary care and hospital records. Patients > 18 years with an incident diagnosis of HZ were matched to up to four controls for age, sex and general practice. Patients were included in the statin exposure group if they had ever used a statin, and the daily dosage of the most recent statin prescription and the time since the most recent statin prescription were also recorded. The primary outcome was an incident diagnosis of HZ. Odds ratios ( ORs) were estimated from conditional logistic regression and adjusted for potential confounders. Results A total of 144 959 incident cases of HZ were matched to 549 336 controls. Adjusted analysis suggested strong evidence for an increase in the risk of HZ related to statin exposure ( OR 1·13, 95% confidence interval 1·11-1·15). There was also an increased risk when dosages were increased for patients who were currently or had recently been receiving statin treatment ( Ptrend < 0·001), and we found an attenuation of the increased risk of HZ in previous statin users as the time since last statin exposure increased ( Ptrend < 0·001). Conclusions These findings are consistent with the hypothesis that statin therapy leads to an increase in the risk of HZ. [ABSTRACT FROM AUTHOR]

Brexit will of course have major implications for trade between Commonwealth African nations and the European continent. In the short term, the European Commission’s Economic Partnership Agreements with regional groups such as the East African Community will be complicated by the UK’s decision to leave the European project. Moreover, there are longer-term consequences to be considered, not least the role which the UK—as an independent trade actor—will adopt in its trade relations with Commonwealth African countries. This article examines the impact of Brexit for Commonwealth African nations’ trade with Europe (including the UK). It particularly points to several potential pitfalls arising from the Brexit referendum vis-à-vis African development. [ABSTRACT FROM AUTHOR]

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Were women agents of their own political emancipation or did politicians preemptively grant rights to them in a bid for electoral success? This article claims that both electoral politics and the ordinary strategies of women’s movements explain the timing of female suffrage. Drawing on archival evidence from the United Kingdom, I show how in an electoral environment where the incumbent Liberals saw disadvantage to reform, an enterprising group of Liberal suffragists formed a pact with the Labour party, trading economic resources for the party’s promise to push for suffrage reform. The Election Fighting Fund, as the pact was called, was key to securing women’s place in the 1918 Representation of the People Act. In raising the possibility that ordinary instead of revolutionary tactics proved key to voting rights reform, women emerge as an interesting new case for the study of democratization. [ABSTRACT FROM PUBLISHER]

The article presents information on a study conducted on the Deprivation of Liberty Safeguards (DoLS), introduced in England and Wales to protect the interests of people suffering from learning disabilities, dementia and neurological conditions. Under the DoLS, whenever a hospital or a care home believes somebody in their care may be deprived of their liberty, they should apply to the local authority in order to get an authorization to detain them.

Background The Quality and Outcomes Framework (QOF) has specific targets for body mass index (BMI) and blood pressure recording in major mental illness (MMI), diabetes, and chronic kidney disease (CKD). Although aspects of MMI (schizophrenia, bipolar disorder, and related psychoses) are incentivised, barriers to care may occur. Aim To compare payment, population achievement, and exception rates for blood pressure and BMI recording in MMI relative to diabetes and CKD across the UK. Design and setting Analysis of 2012/2013 QOF data from 9731 UK general practices 2 years after the introduction of the mental health, BMI, and blood pressure QOF indicators. Method Payment, exception, and population achievement rates for the MMI and CKD blood pressure indicators and the MMI and diabetes BMI indicators were calculated and compared. Results UK payment and population achievement rates for BMI recording for MMI were significantly lower than for diabetes (payment: 92.7% versus 95.5% and population achievement: 84.0% versus 92.5%, P<0.001) and exception rates were higher (8.1% versus 2.0%, P<0.001). For blood pressure recording, UK payment and population achievement rates were significantly lower for MMI than for CKD (94.1% versus 97.8% and 87.0% versus 97.1%, P<0.001), while exception rate was higher (6.5% versus 0.0%, P<0.001). This was observed for all countries. Compared with England, Northern Ireland had higher population achievement rates for both mental health indicators, whereas Scotland and Wales had lower rates. There were no cross-jurisdiction differences for CKD and diabetes. Conclusion Differences in payment, exception, and population achievement rates for blood pressure and BMI recording for MMI relative to CKD and diabetes were observed across the UK. These findings suggest potential inequalities in the monitoring of physical health in MMI within the UK primary care system. [ABSTRACT FROM AUTHOR]

It is estimated that more than 3 million healthcare workers worldwide suffer needlestick and splash injuries whilst at work resulting in the potential transmission of blood-borne pathogens via exposure to bodily fluids. Under-reporting and the subsequent management of occupational injuries is a problem both in the United Kingdom and abroad. Many expatriate health care workers will work in low resource settings where the risk of transmission is greatest but in contrast to wealthier countries such as the United Kingdom, there is often a lack of effective systems for its safe management. This article provides important information about this risk and how to minimise it. The reasons for an increased risk in transmission, its subsequent management and pre-departure planning are discussed, together with the evidence for initiation of post-exposure prophylaxis; current National and International guidelines as well as the urgent need for International standardisation of these is also discussed. [ABSTRACT FROM AUTHOR]

Objectives. The objectives of this study were to determine the prevalence of PsA in The Health Improvement Network (THIN), a large population-based medical records database in the UK, to examine factors associated with prevalent PsA among patients with psoriasis and to describe the use of DMARDs in patients with PsA.Methods. Two cohorts were derived from THIN to examine the prevalence of PsA in a cross-sectional study among all patients aged 18–90 years and among a subcohort of 4900 psoriasis patients aged 45–65 years. Prescription codes were used to describe therapies after the diagnosis of PsA. Associations for prevalent PsA among psoriasis patients were assessed using logistic regression analysis.Results. Among 4.8 million patients in THIN between the ages of 18 and 90 years, 9045 patients had at least one medical code for PsA, giving an overall prevalence of 0.19% (95% CI 0.19%, 0.19%). Of those patients, 45.9% with PsA have been prescribed DMARDs. Among the 4064 confirmed psoriasis patients, the prevalence of PsA was 8.6% (95% CI 7.7%, 9.5%). PsA was more prevalent among patients with severe psoriasis [odds ratio (OR) 3.34; 95% CI 2.40, 4.65], obesity (OR 1.77; 95% CI 1.30, 2.41) and duration of psoriasis for &geq;10 years (OR 7.42; 95% CI 3.86, 14.25) in the fully adjusted model.Conclusion. The prevalence of PsA in THIN is consistent with previous population-based estimates. Limitations include a definition of PsA based on a diagnostic code rather than Classification Criteria for Psoriatic Arthritis (CASPAR) criteria. Given the large population of PsA patients, THIN is an important resource for the study of PsA. [ABSTRACT FROM PUBLISHER]

Pyoderma gangrenosum (PG) is an important disease with significant complications. The objectives of this study were to determine incidence and mortality of PG and strength of reported associations. A retrospective cohort study was completed using computerized medical records from the General Practice Research Database, a large representative UK database. Patients with PG and three groups of age-, sex-, and practice-matched controls-general population, rheumatoid arthritis (RA), and inflammatory bowel disease (IBD) controls-were included in the study. Incidence and mortality were determined and validation undertaken to inform diagnostic accuracy. In all there were 313 people with the median age of 59 (interquartile range 41-72) years, and of them 185 (59%) were female. The adjusted incidence rate standardized to European standard population was 0.63 (95% confidence interval (CI) 0.57-0.71) per 100,000 person-years. The risk of death was three times higher than that for general controls (adjusted hazard ratio=3.03, 95% CI 1.84-4.73, P<0.001), 72% higher than that for IBD controls (adjusted hazard ratio=1.72, 95% CI 1.17-2.59, P=0.013), with a borderline increase compared with RA controls (adjusted hazard ratio=1.55, 95% CI 1.01-2.37, P=0.045). Disease associations were present in 110 (33%) participants: IBD, n=67 (20.2%); RA, n=39 (11.8%); and hematological disorders, n=13 (3.9%). To our knowledge, there are no previous population-based studies of the epidemiology of PG, an important disease with significantly increased mortality. [ABSTRACT FROM AUTHOR]

Increasing epidemiological evidence suggests independent associations between psoriasis and cardiovascular and metabolic disease. Our objective was to test the hypothesis that directly assessed psoriasis severity relates to the prevalence of metabolic syndrome and its components. A population-based, cross-sectional study was undertaken using computerized medical records from the Health Improvement Network Study population including individuals in the age group of 45-65 years with psoriasis and practice-matched controls. The diagnosis and extent of psoriasis were determined using provider-based questionnaires. Metabolic syndrome was defined using the National Cholesterol Education Program Adult Treatment Panel III criteria. A total of 44,715 individuals were included: 4,065 with psoriasis and 40,650 controls. In all, 2,044 participants had mild psoriasis (2% body surface area (BSA)), 1,377 had moderate psoriasis (3-10% BSA), and 475 had severe psoriasis (>10% BSA). Psoriasis was associated with metabolic syndrome, adjusted odds ratio (adj. OR 1.41, 95% confidence interval (CI) 1.31-1.51), varying in a 'dose-response' manner, from mild (adj. OR 1.22, 95% CI 1.11-1.35) to severe psoriasis (adj. OR 1.98, 95% CI 1.62-2.43). Psoriasis is associated with metabolic syndrome and the association increases with increasing disease severity. Furthermore, associations with obesity, hypertriglyceridemia, and hyperglycemia increase with increasing disease severity independently of other metabolic syndrome components. These findings suggest that screening for metabolic disease should be considered for psoriasis, especially when it is severe. [ABSTRACT FROM AUTHOR]

Previous small studies and case reports have suggested that neurological disorders may be associated with bullous pemphigoid (BP). The objective of this study was to assess BP risk in patients with neurological diseases. Computerized medical records from the Health Improvement Network, a large population-based UK general practice database, were used to conduct a matched case-control analysis. Conditional logistic regression was used to calculate odds ratios for specified neurological disorders. Comparing cases (n=868) to controls (n=3,453), stroke was seen in 8 vs. 5%, odds ratio (OR) 1.8 (1.3-2.5); dementia in 7 vs. 2%, OR 3.4 (2.4-4.8); Parkinson's disease in 3 vs. 1%, OR 3.0 (1.8-5.0); epilepsy in 2 vs. 1%, OR 1.7 (1.0-3.0); and multiple sclerosis in 1 vs 0.1% (OR 10.7 (2.8-40.2). Estimates were not altered greatly when diagnoses up to 3 years before BP were excluded, except the association with epilepsy was no longer significant. Significant associations were only observed where neurological disease was diagnosed before the onset of pemphigoid. Study findings, except the association with epilepsy, were robust to sensitivity analysis. Strong associations were observed between specific neurological diseases and the later development of BP, supporting possible causal associations. Mechanisms for disease occurrence based on these findings include immobility or age-related autoimmunity. [ABSTRACT FROM AUTHOR]

Abstract: Both observed and modelled data have been examined from the ten UN-ECE Level II forest intensive monitoring sites in the UK to determine the changes and potential impact on soil solution chemistry resulting from changes in acid deposition inputs. The sites represent a range of forest tree types, soil sensitivities and pollutant deposition inputs found in the UK. The dynamic biogeochemical SAFE model was used to explore temporal changes in soil and soil solution chemical parameters that have been used as indicators for potential forest ecosystem and tree damage in national and international assessments of critical loads. The observed data and model results show that there is significant inter-site variation. The model indicates that the historical pollutant inputs have resulted in significant soil acidification at most of the sites. Model predictions generally match current day observations. Recently declining pollutant inputs have reduced and in some cases reversed the trend of increasing soil acidification. A discussion of the results in terms of critical loads, recovery, their wider implications and uncertainty is presented. [Copyright &y& Elsevier]

This paper discusses the impact on mental health service users of the computerised healthcare programme currently being developed by the NHS that aims to make healthcare information available on a much wider basis than is currently the case. The potential benefits of electronic health records are considerable in terms of enhancing effective and safe healthcare. Yet electronic databases, whatever their purported aim, open up the potential for greater surveillance in a state where dissidence is becoming less easily tolerated and technological advances allow greater inroads into private lives. With a specific focus upon service users considered to pose a risk to other people, and drawing upon qualitative research jointly conducted by the author, this paper focuses upon the use of risk assessments in practice, the accuracy of information about risk, service users' rights re access to information, their involvement in risk assessment and the objectivity of risk information. The paper concludes with a discussion of possible outcomes for mental health service users and professionals. [ABSTRACT FROM AUTHOR]

Objective To determine the incidence of and mortality from bullous pemphigoid and pemphigus vulgaris in the United Kingdom. Design Retrospective historical cohort study. Setting Computerised medical records from the health improvement network, a large population based UK general practice database. Participants Patients with pemphigus vulgaris and bullous pemphigoid diagnostic codes and age, sex, and practice matched controls. Main outcome measures Incidence and mortality compared with the control population by calendar period, age group, sex, geographical region, and degree of social deprivation. Results 869 people with bullous pemphigoid and 138 people with pemphigus vulgaris were identified. The median age at presentation for bullous pemphigoid was 80 (range 23-102) years, and 534 (61%) patients were female. The median age at presentation for pemphigus vulgaris was 71 (21-102) years, and 91 (66%) patients were female. Incidences of bullous pemphigoid and pernphigusvulgaris were 4.3 (95% confidence interval 4.0 to 4.6) and 0.7 (0.6 to 0.8) per 100 000 person years. The incidence of bullous pemphigoid increased overtime; the average yearly increase was 17% (incidence rate ratio=1.2,95% confidence interval 1.1 to 1.2). An average yearly increase in incidence of pemphigus vulgaris of 11% (incidence rate ratio=l.l, 1.0 to 1.2) occurred. The risk of death for patients with bullous pemphigoid was twice as great as for controls (adjusted hazard ratio=2.3, 95% confidence interval 2.0 to 2.7). For pemphigus vulgaris, the risk of death was three times greater than for controls (adjusted hazard ratio=3.3, 2.2 to 5.2). Conclusions Incidences of bullous pemphigoid and pemphigus vulgaris are increasing. The reasons for the changes in incidence are not clearly understood but have implications for identifying causative factors. Both disorders are associated with a high risk of death. Previous estimates may have underestimated the risk of death associated with these diseases. [ABSTRACT FROM AUTHOR]