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Sign language is a form of communication medium for speech and hearing disabled people. It has various forms with different troublesome patterns, which are difficult for the general mass to comprehend. Bengali sign language (BdSL) is one of the difficult sign languages due to its immense number of alphabet, words, and expression techniques. Machine translation can ease the difficulty for disabled people to communicate with generals. From the machine learning (ML) domain, computer vision can be the solution for them, and every ML solution requires a optimized model and a proper dataset. Therefore, in this research work, we have created a BdSL dataset and named `KU-BdSL', which consists of 30 classes describing 38 consonants ('banjonborno') of the Bengali alphabet. The dataset includes 1500 images of hand signs in total, each representing Bengali consonant(s). Thirty-nine participants (30 males and 9 females) of different ages (21-38 years) participated in the creation of this dataset. We adopted smartphones to capture the images due to the availability of their high-definition cameras. We believe that this dataset can be beneficial to the deaf and dumb (D&D) community. Identification of Bengali consonants of BdSL from images or videos is feasible using the dataset. It can also be employed for a human-machine interface for disabled people. In the future, we will work on the vowels and word level of BdSL., (© 2023 The Authors.)

Primary care remains the point of access to the NHS as well as having key roles in care coordination and prescribing. Therefore, embedding of genomic medicine in the NHS relies on successful implementation into the primary care landscape. Primary care is currently facing considerable challenges, including increasing numbers of patients and consultations per GP, multiple health conditions and polypharmacy, all contributing to increasing workload within a resource-constrained system. Although genomic medicine has enormous potential to benefit patients, its successful implementation demands alignment with existing skills and working practices, development of underpinning informatics infrastructure, integration into care pathways with consideration of commissioning and leadership. Here, we set out current initiatives and future strategies to support primary care colleagues in the delivery of genomic medicine, covering issues of workforce development and education, primary care leadership, and data and digital considerations., (© Royal College of Physicians 2023. All rights reserved.)

In November 2021 Claire Fuller led a national piece of work looking at primary care within integrated care systems (ICSs) to identify what was working well and why. The published report from this piece of work became known as the Fuller Stocktake. 1 In this interview, Professor Fuller sets out the process and principles behind the Stocktake., (© Royal College of Physicians 2023. All rights reserved.)

Purpose: When combined with radiotherapy, limb salvage surgery is an alternative to amputation. This study sought to determine the limb-sparing treatment outcomes in patients diagnosed with soft tissue extremity sarcomas treated at our institution., Materials and Methods: All adult patients with extremity soft tissue sarcoma treated with the radical limb salvage strategy at Shaukat Khanum Memorial Cancer Hospital and Research Canter, Lahore, Pakistan, between January 2017 and December 2019 were retrospectively assessed., Results: A total of 122 patients were included in the study. The mean age was 42 years (range 19-82), and 64 (52.5%) were males. The majority of patients, 65 (53.3%), were diagnosed with stage III and grade III disease according to American Joint Committee on Cancer TNM classification (Eighth edition). The most common surgical modality was wide local excision that was performed in 106 (86.9%) patients. Adjuvant radiation treatment was given in 111 (91%) patients, whereas 11 (9%) patients received neoadjuvant radiation treatment. The mean dose was 58 Gy (range: 46-66 Gy). Eighty-two (67.2%) of the patients were disease-free on post-treatment radiologic scans with disease recurrence observed in 40 (32.8%) patients. The median disease-free survival was 8 months (95% CI, 5.45 to 10.55). Local recurrence and distant metastases developed in 16 (13%) and 24 (20%) patients, respectively., Conclusion: About two thirds of patients with extremity soft tissue sarcoma were successfully treated with limb salvage strategy, surgery, and radiation therapy. However, high rate of relapse warrants further novel strategies in this patient population.

Seasonal vaccination against influenza and in-pandemic COVID-19 vaccination are top public health priorities; vaccines are the primary means of reducing infections and also controlling pressures on health systems. During the 2018-2019 influenza season, we conducted a study of the knowledge, attitudes, and behaviours of 159 general practitioners (GPs) and 189 patients aged ≥65 years in England using a combination of qualitative and quantitative approaches to document beliefs about seasonal influenza and seasonal influenza vaccine. GPs were surveyed before and after a continuing medical education (CME) module on influenza disease and vaccination with an adjuvanted trivalent influenza vaccine (aTIV) designed for patients aged ≥65 years, and patients were surveyed before and after a routine visit with a GP who participated in the CME portion of the study. The CME course was associated with significantly increased GP confidence in their ability to address patients' questions and concerns about influenza disease and vaccination ( p < 0.001). Patients reported significantly increased confidence in the effectiveness and safety of aTIV after meeting their GP. Overall, 82.2% of the study population were vaccinated against influenza (including 137 patients vaccinated during the GP visit and 15 patients who had been previously vaccinated), a rate higher than the English national average vaccine uptake of 72.0% that season. These findings support the value of GP-patient interactions to foster vaccine acceptance.

Medical students represent a significant part of the health-care community and are active members of the coronavirus disease 2019 (COVID-19) response. This study aimed to evaluate various factors associated with COVID-19 vaccine intention among medical students via an online anonymous survey. A total of 370 students completed the online survey, with 229 (61.89%) not vaccinated for COVID-19. Of students not yet vaccinated, 45 (19.65%) were unsure or did not intend to accept the vaccine, while 184 (80.35%) intend to be vaccinated within 6 months. Overall, female gender, health status, clinical science enrollment, and the practice of COVID-19 preventative behaviors significantly correlated with the intention to be vaccinated within 6 months. Greater perceived risk for contracting COVID-19, lesser beliefs that the COVID-19 vaccination trials were rushed, and greater beliefs that being vaccinated would help complete their medical education were uniquely associated with the intention to be vaccinated within 6 months. Collectively, this study identified several factors that influenced medical students' intention to receive the COVID-19 vaccination. This information may be used in future immunization strategies to increase the vaccination rates among this group of future medical professionals.

Introduction Extremity soft-tissue sarcomas are uncommon malignancies of mesenchymal tissue, it accounts for <1 % of cancers and has a high recurrence rate with positive resection margins and unplanned excision. This study aims to determine the influence of unplanned excision and resection margins on local recurrence, metastasis, and overall survival in soft tissue sarcoma of the extremities. Methods A retrospective review was conducted from January 2005 to December 2015 on all the patients with soft tissue sarcoma of the extremities. Age, sex, histopathology, site, tumor grade, biopsy type, recurrence, metastasis, and end outcome were analyzed. Kaplan-Meir curves were used for Survival analysis, and log-rank or the Cox proportional-hazards regression model was used for Significance analysis. The data were entered into SPSS version 20, and Statistical significance was set at a p-value ≤0.05. Results One hundred forty-five patients with soft tissue sarcoma of extremities were managed with a mean follow-up of 76.3+/-6.7 months. Undifferentiated pleomorphic sarcoma 47 (32.4%) was the most common pathology found in this cohort, followed by Synovial sarcoma 34 (23.4%) and Liposarcoma 19 (13.1%). The most common site of occurrence was lower extremity 102 (70.3%). All the patients had residual disease after unplanned excisions; 107 underwent R0 resection, while 38 underwent R1 resection. Five-year overall survival was 70.2 & 71.1 % for R1 & R0 resections, respectively, and 71.3% for excisional and 74.2% for incisional biopsy. The tumor grade significantly influences overall survival, while other variables were not found to affect Recurrence-free survival and metastasis-free survival. Conclusion The data indicates that the high-grade tumor has a negative influence on overall survival, while resection margins width and unplanned excision have no significant effect on local recurrence, Metastasis free survival, and overall survival; however, before excision, adequate planning and awareness among general surgeons is necessary to improve the surgical morbidity and financial burden over the health care facilities., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Shafiq et al.)

Acacia modesta (AM) and Opuntia monocantha (OM) are distributed in Pakistan, Afghanistan and India. Both of these plants have different pharmacological properties. This study was designed to evaluate anticancer potential of Acacia modesta (AM) and Opuntia monocantha (OM). Liver cancer cell line HepG2 was used for assessment of anticancer activity. For the evaluation of anti-proliferative effects, cell viability and cell death in all groups of cells were evaluated via MTT, crystal violet and trypan blue assays. For the evaluation of apoptosis ELISA of p53 performed. Furthermore, LDH assay to find out the ability of malignant cells to metabolize pyruvate to lactate and antioxidant enzymes activity (GSH, CAT and SOD) at the end HPLC was performed to find active compound of AM and OM. Cytotoxicity (MTT), Viability assays (trypan blue, crystal viability, MUSE analysis) showed more dead, less live cells in plant treated groups with increase of concentration. Scratch assay for the anti-migratory effect of these plants showed treated groups have not ability to heal scratch/wound. ELISA of p53 for cellular apoptosis showed more release of p53 in treated groups. Antioxidant assay via glutathione (GSH), superoxide dismutase (SOD), catalase (CAT) showed less anti-oxidative potential in treated cancer groups. LDH assay showed more lactate dehydrogenase release in treated groups compared with untreated. HPLC analysis showed the presence of phytochemicals such as steroids, alkaloids, phenols, flavonoids, saponins, tannins, anthraquinone and amino acids in AM and OM plant extracts. Based on all these findings, it can be concluded that ethanolic extracts of Acacia modesta and Opuntia monocantha have promising anti-cancer potential.

Objectives: To assess the feasibility and uptake of a community-based prostate cancer (PCa) screening programme selecting men according to their genetic risk of PCa. To assess the uptake of PCa screening investigations by men invited for screening. The uptake of the pilot study would guide the opening of the larger BARCODE1 study recruiting 5000 men., Subjects and Methods: Healthy males aged 55-69 years were invited to participate via their general practitioners (GPs). Saliva samples were collected via mailed collection kits. After DNA extraction, genotyping was conducted using a study specific assay. Genetic risk was based on genotyping 130 germline PCa risk single nucleotide polymorphisms (SNPs). A polygenic risk score (PRS) was calculated for each participant using the sum of weighted alleles for 130 SNPs. Study participants with a PRS lying above the 90th centile value were invited for PCa screening by prostate magnetic resonance imaging (MRI) and biopsy., Results: Invitation letters were sent to 1434 men. The overall study uptake was 26% (375/1436) and 87% of responders were eligible for study entry. DNA genotyping data were available for 297 men and 25 were invited for screening. After exclusions due to medical comorbidity/invitations declined, 18 of 25 men (72%) underwent MRI and biopsy of the prostate. There were seven diagnoses of PCa (38.9%). All cancers were low-risk and were managed with active surveillance., Conclusion: The BARCODE1 Pilot has shown this community study in the UK to be feasible, with an overall uptake of 26%. The main BARCODE1 study is now open and will recruit 5000 men. The results of BARCODE1 will be important in defining the role of genetic profiling in targeted PCa population screening. Patient Summary What is the paper about? Very few prostate cancer screening programmes currently exist anywhere in the world. Our pilot study investigated if men in the UK would find it acceptable to have a genetic test based on a saliva sample to examine their risk of prostate cancer development. This test would guide whether men are offered prostate cancer screening tests. What does it mean for patients? We found that the study design was acceptable: 26% of men invited to take part agreed to have the test. The majority of men who were found to have an increased genetic risk of prostate cancer underwent further tests offered (prostate MRI scan and biopsy). We have now expanded the study to enrol 5000 men. The BARCODE1 study will be important in examining whether this approach could be used for large-scale population prostate cancer screening., (© 2021 The Authors BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

We have produced gene expression profiles of all 302 neurons of the C. elegans nervous system that match the single-cell resolution of its anatomy and wiring diagram. Our results suggest that individual neuron classes can be solely identified by combinatorial expression of specific gene families. For example, each neuron class expresses distinct codes of ∼23 neuropeptide genes and ∼36 neuropeptide receptors, delineating a complex and expansive "wireless" signaling network. To demonstrate the utility of this comprehensive gene expression catalog, we used computational approaches to (1) identify cis-regulatory elements for neuron-specific gene expression and (2) reveal adhesion proteins with potential roles in process placement and synaptic specificity. Our expression data are available at https://cengen.org and can be interrogated at the web application CengenApp. We expect that this neuron-specific directory of gene expression will spur investigations of underlying mechanisms that define anatomy, connectivity, and function throughout the C. elegans nervous system., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The generation of the enormous diversity of neuronal cell types in a differentiating nervous system entails the activation of neuron type-specific gene batteries. To examine the regulatory logic that controls the expression of neuron type-specific gene batteries, we interrogate single cell expression profiles of all 118 neuron classes of the Caenorhabditis elegans nervous system for the presence of DNA binding motifs of 136 neuronally expressed C. elegans transcription factors. Using a phylogenetic footprinting pipeline, we identify cis- regulatory motif enrichments among neuron class-specific gene batteries and we identify cognate transcription factors for 117 of the 118 neuron classes. In addition to predicting novel regulators of neuronal identities, our nervous system-wide analysis at single cell resolution supports the hypothesis that many transcription factors directly co-regulate the cohort of effector genes that define a neuron type, thereby corroborating the concept of so-called terminal selectors of neuronal identity. Our analysis provides a blueprint for how individual components of an entire nervous system are genetically specified., Competing Interests: LG, ST, KL, LP, MR, MB, IR, EY, RP, NS, MH, DM No competing interests declared, OH Reviewing editor, eLife, (© 2021, Glenwinkel et al.)

Sexual differentiation is controlled by diverse master regulatory factors across the animal kingdom. The transcription factor TRA-1 is the master regulator of somatic sexual differentiation in the nematode C. elegans, where it was reported to be expressed sex-specifically in the non-gonadal soma of hermaphrodites. Using a gfp-tagged allele of tra-1, we reveal unanticipated dynamics of TRA-1 protein expression in five dimensions: space, time, sex, environment, and subcellular localization. We show temporal regulation of TRA-1 protein accumulation in somatic tissues with different onsets of expression in different tissue types, indicating that sexual identity is not uniformly imposed. In hermaphrodites, neuronal expression is initially highly restricted and then increases variably between individuals during larval development until reaching panneuronal expression in the fourth larval stage. Unexpectedly, TRA-1 also accumulates in a subset of sex-shared neurons in the male. Additionally, a food signal is required to turn on TRA-1 expression in the intestine, and environmental stressors shut off TRA-1 expression in the entire non-gonadal soma, suggesting that somatic sexual differentiation may be affected by external conditions. We show that, in contrast to the protein degradation mechanisms that control TRA-1 accumulation in the adult, the temporal, sexual, and spatial specificities of TRA-1 accumulation during development are regulated transcriptionally. A nuclear hormone receptor, daf-12, previously implicated in developmental timing in C. elegans, contributes to temporal accumulation of TRA-1 in the nervous system. Our studies reveal a mosaic and dynamic nature of sexual identity acquisition and uncover hormonal control mechanisms for sexual differentiation of the brain., Competing Interests: Declaration of Interests The authors declare no competing interests., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Primary care telephone consultations are increasingly used for patient triage, reviews, and providing clinical information. They are also a key postgraduate training component yet little is known about GP trainees' preparation for, or experiences and perceptions of, them., Aim: To understand the experiences, perceptions, and training of GP trainees in conducting telephone consultations., Design & Setting: A mixed-methods study was undertaken of North Central and East London (NCEL) GP trainees., Method: A cross-sectional electronic survey of trainees was performed with subsequent semi-structured interviews. Survey data were analysed using descriptive statistics, and qualitative data using thematic analysis., Results: The survey response was 16% ( n = 100/618), and 10 participated in semi-structured interviews. Trainees felt least confident with complicated telephone consulting, and there was a strong positive correlation between the percentage reporting having received training and their confidence ( R 2 = 0.71, P <0.0001). Positive experiences included managing workload and convenience. Negative experiences included complex encounters, communication barriers, and absence of examination. Trainees reported that training for telephone consultations needed strengthening, and that recently introduced audio-clinical observation tools (COTs) were useful. Positive correlations were found between the length of out-of-hours (OOH) but not in-hours training and the level of supervision or feedback received for telephone consultations., Conclusion: This project sheds light on GP trainees' current experiences of telephone consultations and the need to enhance future training. The findings will inform a wider debate among stakeholders and postgraduate learners regarding training for telephone consultations, and potentially for other remote technologies., (Copyright © 2020, The Authors.)

Background: Quality improvement (QI) is a priority for general practice, and GPs are expected to participate in and provide evidence of QI activity. There is growing interest in harnessing the potential of electronic health records (EHR) to improve patient care by supporting practices to find cases that could benefit from a medicines review., Aim: To develop scalable and reproducible prescribing safety reports using patient-level EHR data., Design and Setting: UK general practices that contribute de-identified patient data to the Clinical Practice Research Datalink (CPRD)., Method: A scoping phase used stakeholder consultations to identify primary care QI needs and potential indicators. QI reports containing real data were sent to 12 pilot practices that used Vision GP software and had expressed interest. The scale-up phase involved automating production and distribution of reports to all contributing practices that used both Vision and EMIS software systems. Benchmarking reports with patient-level case review lists for two prescribing safety indicators were sent to 457 practices in December 2017 following the initial scale-up (Figure 2)., Results: Two indicators were selected from the Royal College of General Practitioners Patient Safety Toolkit following stakeholder consultations for the pilot phase involving 12 GP practices. Pilot phase interviews showed that reports were used to review individual patient care, implement wider QI actions in the practice, and for appraisal and revalidation., Conclusion: Electronic health record data can be used to provide standardised, reproducible reports that can be delivered at scale with minimal resource requirements. These can be used in a national QI initiative that impacts directly on patient care., (© British Journal of General Practice 2019.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Background: Rapidly undertaken age-stratified serology studies can produce valuable data about a new emerging infection including background population immunity and seroincidence during an influenza pandemic. Traditionally seroepidemiology studies have used surplus laboratory sera with little or no clinical information or have been expensive detailed population based studies. We propose collecting population based sera from the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), a sentinel network with extensive clinical data., Aim: To pilot a mechanism to undertake population based surveys that collect serological specimens and associated patient data to measure seropositivity and seroincidence due to seasonal influenza, and create a population based serology bank. METHODS AND ANALYSIS: Setting and Participants: We will recruit 6 RCGP RSC practices already taking nasopharyngeal virology swabs. Patients who attend a scheduled blood test will be consented to donate additional blood samples. Approximately 100-150 blood samples will be collected from each of the following age bands - 18- 29, 30- 39, 40- 49, 50- 59, 60- 69 and 70+ years., Methods: We will send the samples to the Public Health England (PHE) Seroepidemiology Unit for processing and storage. These samples will be tested for influenza antibodies, using haemagglutination inhibition assays. Serology results will be pseudonymised, sent to the RCGP RSC and combined using existing processes at the RCGP RSC secure hub. The influenza seroprevalence results from the RCGP cohort will be compared against those from the annual PHE influenza residual serosurvey., Ethics and Dissemination: Ethical approval was granted by the Proportionate Review Sub- Committee of the London - Camden & Kings Cross on 6 February 2018. This study received approval from Health Research Authority on 7 February 2018. On completion the results will be made available via peer-reviewed journals., Competing Interests: Competing interests: Simon de Lusignan has received grant funding through University of Surrey from GSK to report vaccine adverse events and attended advisory boards for Sanofi and Seqirus., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Living in a conurbation, urban, or rural environment is an important determinant of health. For example, conurbation and rural living is associated with increased respiratory and allergic conditions, whereas a farm or rural upbringing has been shown to be a protective factor against this., Objective: The objective of the study was to assess differences in general practice presentations of allergic and infectious disease in those exposed to conurbation or urban living compared with rural environments., Methods: The population was a nationally representative sample of 175 English general practices covering a population of over 1.6 million patients registered with sentinel network general practices. General practice presentation rates per 100,000 population were reported for allergic rhinitis, asthma, and infectious conditions grouped into upper and lower respiratory tract infections, urinary tract infection, and acute gastroenteritis by the UK Office for National Statistics urban-rural category. We used multivariate logistic regression adjusting for age, sex, ethnicity, deprivation, comorbidities, and smoking status, reporting odds ratios (ORs) with 95% CIs., Results: For allergic rhinitis, the OR was 1.13 (95% CI 1.04-1.23; P=.003) for urban and 1.29 (95% CI 1.19-1.41; P<.001) for conurbation compared with rural dwellers. Conurbation living was associated with a lower OR for both asthma (OR 0.70, 95% CI 0.67-0.73; P<.001) and lower respiratory tract infections (OR 0.94, 95% CI 0.90-0.98; P=.005). Compared with rural dwellers, the OR for upper respiratory tract infection was greater in urban (OR 1.06, 95% CI 1.03-1.08; P<.001) but no different in conurbation dwellers (OR 1.00, 95% CI 0.97-1.03; P=.93). Acute gastroenteritis followed the same pattern: the OR was 1.13 (95% CI 1.01-1.25; P=.03) for urban dwellers and 1.04 (95% CI 0.93-1.17; P=.46) for conurbation dwellers. The OR for urinary tract infection was lower for urban dwellers (OR 0.94, 95% CI 0.89-0.99; P=.02) but higher in conurbation dwellers (OR 1.06, 95% CI 1.00-1.13; P=.04)., Conclusions: Those living in conurbations or urban areas were more likely to consult a general practice for allergic rhinitis and upper respiratory tract infection. Both conurbation and rural living were associated with an increased risk of urinary tract infection. Living in rural areas was associated with an increased risk of asthma and lower respiratory tract infections. The data suggest that living environment may affect rates of consultations for certain conditions. Longitudinal analyses of these data would be useful in providing insights into important determinants., (©Simon de Lusignan, Christopher McGee, Rebecca Webb, Mark Joy, Rachel Byford, Ivelina Yonova, Mariya Hriskova, Filipa Matos Ferreira, Alex J Elliot, Gillian Smith, Imran Rafi. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 26.11.2018.)

Objectives: Recent evidence has highlighted the high prevalence and impact of multimorbidity, but the evidence base for improving management is limited. We have tested a new complex intervention for multimorbidity (the 3D model). The paper describes the baseline characteristics of practices and patients in order to establish the external validity of trial participants. It also explores current 'usual primary care' for multimorbidity, against which the 3D intervention was tested., Design: Analysis of baseline data from patients in a cluster-randomised controlled trial and additional data from practice staff., Setting: Primary care in the UK., Participants: Patients with multimorbidity (n=5253) and 154 practice staff., Primary and Secondary Outcome Measures: Using surveys and routinely available data, we compared the characteristics of participating and non-participating practices and participating and non-participating eligible patients.Baseline questionnaire data from patient participants was used to examine participant illness burden, treatment burden and perceptions of receiving patient-centred care. We obtained data about usual care preintervention from practice staff using questionnaires and a structured pro forma., Results: Participating practices were slightly larger, in less deprived areas, and with slightly higher scores for patient satisfaction compared with non-participating practices. Patients with dementia or learning difficulties were likely to be excluded by their general practitioners, but comparison of participants with non-participants identified only minor differences in characteristics, suggesting that the sample was otherwise representative. Patients reported substantial illness burden, and an important minority reported high treatment burden. Although patients reported relatively high levels of satisfaction with care, many reported not having received potentially important components of care., Conclusion: This trial achieved good levels of external validity. Although patients were generally satisfied with primary care services, there was significant room for improvement in important aspects of care for multimorbidity that are targeted by the 3D intervention., Trial Registration Number: ISRCTN06180958; Post-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY. Published by BMJ.)

Background: The Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) comprises over 100 general practices in England, with a population of around 1 million, providing a public health surveillance system for England and data for research., Aim: To demonstrate the scope of data with the RCGP Annual Report 2014-2015 (May 2014 to April 2015) by describing disparities in the presentation of six common conditions included in the report., Design and Setting: This is a report of respiratory and communicable disease incidence from a primary care sentinel network in England., Method: Incidence rates and demographic profiles are described for common cold, acute otitis media, pneumonia, influenza-like illness, herpes zoster, and scarlet fever. The impact of age, sex, ethnicity, and deprivation on the diagnosis of each condition is explored using a multivariate logistic regression., Results: With the exception of herpes zoster, all conditions followed a seasonal pattern. Apart from pneumonia and scarlet fever, the odds of presenting with any of the selected conditions were greater for females (P<0.001). Older people had a greater probability of a pneumonia diagnosis (≥75 years, odds ratio [OR] 6.37; P<0.001). Common cold and influenza-like illness were more likely in people from ethnic minorities than white people, while the converse was true for acute otitis media and herpes zoster. There were higher odds of acute otitis media and herpes zoster diagnosis among the less deprived (least deprived quintile, OR 1.32 and 1.48, respectively; P<0.001)., Conclusion: The RCGP RSC database provides insight into the content and range of GP workload and provides insight into current public health concerns. Further research is needed to explore these disparities in presentation to primary care., (© British Journal of General Practice 2017.)

Introduction: An increasing number of people are living with multimorbidity. The evidence base for how best to manage these patients is weak. Current clinical guidelines generally focus on single conditions, which may not reflect the needs of patients with multimorbidity. The aim of the 3D study is to develop, implement and evaluate an intervention to improve the management of patients with multimorbidity in general practice., Methods and Analysis: This is a pragmatic two-arm cluster randomised controlled trial. 32 general practices around Bristol, Greater Manchester and Glasgow will be randomised to receive either the '3D intervention' or usual care. 3D is a complex intervention including components affecting practice organisation, the conduct of patient reviews, integration with secondary care and measures to promote change in practice organisation. Changes include improving continuity of care and replacing reviews of each disease with patient-centred reviews with a focus on patients' quality of life, mental health and polypharmacy. We aim to recruit 1383 patients who have 3 or more chronic conditions. This provides 90% power at 5% significance level to detect an effect size of 0.27 SDs in the primary outcome, which is health-related quality of life at 15 months using the EQ-5D-5L. Secondary outcome measures assess patient centredness, illness burden and treatment burden. The primary analysis will be a multilevel regression model adjusted for baseline, stratification/minimisation, clustering and important co-variables. Nested process evaluation will assess implementation, mechanisms of effectiveness and interaction of the intervention with local context. Economic analysis of cost-consequences and cost-effectiveness will be based on quality-adjusted life years., Ethics and Dissemination: This study has approval from South-West (Frenchay) National Health Service (NHS) Research Ethics Committee (14/SW/0011). Findings will be disseminated via final report, peer-reviewed publications and guidance to healthcare professionals, commissioners and policymakers., Trial Registration Number: ISRCTN06180958; Pre-results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Recording concerns about child maltreatment, including minor concerns, is recommended by the General Medical Council (GMC) and National Institute for Health and Clinical Excellence (NICE) but there is evidence of substantial under-recording., Aim: To determine whether a simple coding strategy improved recording of maltreatment-related concerns in electronic primary care records., Design and Setting: Clinical audit of rates of maltreatment-related coding before January 2010-December 2011 and after January-December 2012 implementation of a simple coding strategy in 11 English family practices. The strategy included encouraging general practitioners to use, always and as a minimum, the Read code 'Child is cause for concern'. A total of 25,106 children aged 0-18 years were registered with these practices. We also undertook a qualitative service evaluation to investigate barriers to recording., Method: Outcomes were recording of 1) any maltreatment-related codes, 2) child protection proceedings and 3) child was a cause for concern., Results: We found increased recording of any maltreatment-related code (rate ratio 1.4; 95% CI 1.1-1.6), child protection procedures (RR 1.4; 95% CI 1.1-1.6) and cause for concern (RR 2.5; 95% CI 1.8-3.4) after implementation of the coding strategy. Clinicians cited the simplicity of the coding strategy as the most important factor assisting implementation., Conclusion: This simple coding strategy improved clinician's recording of maltreatment-related concerns in a small sample of practices with some 'buy-in'. Further research should investigate how recording can best support the doctor-patient relationship. HOW THIS FITS IN: Recording concerns about child maltreatment, including minor concerns, is recommended by the General Medical Council (GMC) and National Institute for Health and Clinical Excellence (NICE), but there is evidence of substantial under-recording. We describe a simple clinical coding strategy that helped general practitioners to improve recording of maltreatment-related concerns. These improvements could improve case finding of children at risk and information sharing.

Background: Recruitment to research studies in primary care is challenging despite widespread implementation of electronic patient record (EPR) systems which potentially make it easier to identify eligible cases., Methods: Literature review and applying the learning from a European research readiness assessment tool, the TRANSFoRm International Research Readiness instrument (TIRRE), to the context of the English NHS in order to develop a model to assess a practice's research readiness., Results: Seven dimensions of research readiness were identified: (1) Data readiness: Is there good data quality in EPR systems; (2) Record readiness: Are EPR data able to identify eligible cases and other study data; (3) Organisational readiness: Are the health system and socio-cultural environment supportive; (4) Governance readiness: Does the study meet legal and local health system regulatory compliance; (5) Study-specific readiness; (6) Business process readiness: Are business processes tilted in favour of participation: including capacity and capability to take on extra work, financial incentives as well as intangibles such as social and intellectual capital; (7) Patient readiness: Are systems in place to recruit patients and obtain informed consent?, Conclusions: The model might enable the development of interventions to increase participation in primary care-based research and become a tool to measure the progress of practice networks towards the most advanced state of readiness.

Strict control of systolic blood pressure is known to slow progression of chronic kidney disease (CKD). Here we compared audit-based education (ABE) to guidelines and prompts or usual practice in lowering systolic blood pressure in people with CKD. This 2-year cluster randomized trial included 93 volunteer general practices randomized into three arms with 30 ABE practices, 32 with guidelines and prompts, and 31 usual practices. An intervention effect on the primary outcome, systolic blood pressure, was calculated using a multilevel model to predict changes after the intervention. The prevalence of CKD was 7.29% (41,183 of 565,016 patients) with all cardiovascular comorbidities more common in those with CKD. Our models showed that the systolic blood pressure was significantly lowered by 2.41 mm Hg (CI 0.59-4.29 mm Hg), in the ABE practices with an odds ratio of achieving at least a 5 mm Hg reduction in systolic blood pressure of 1.24 (CI 1.05-1.45). Practices exposed to guidelines and prompts produced no significant change compared to usual practice. Male gender, ABE, ischemic heart disease, and congestive heart failure were independently associated with a greater lowering of systolic blood pressure but the converse applied to hypertension and age over 75 years. There were no reports of harm. Thus, individuals receiving ABE are more likely to achieve a lower blood pressure than those receiving only usual practice. The findings should be interpreted with caution due to the wide confidence intervals.

Background: In England, guidance from National Institute for Clinical Excellence (NICE) states women with a family history of breast cancer presenting to primary care should be reassured or referred.We reviewed the evidence for interventions that might be applied in primary care and conducted an audit of whether low risk women are correctly advised and flagged., Methods: We conducted a literature review to identify modifiable risk factors. We extracted routinely collected data from the computerised medical record systems of 6 general practices (population approximately 30,000); of the variables identified in the guidance. We implemented a quality improvement (QI) intervention called audit-based education (ABE) comparing participant practices with guidelines and each other before and after; we report odds ratios (OR) of any change in data recording., Results: The review revealed evidence for advising on: diet, weight control, physical exercise, and alcohol. The proportion of patients with recordings of family history of: disease, neoplasms, and breast cancer were: 39.3%, 5.1% and 1.3% respectively. There was no significant change in the recording of family history of disease or cancer; OR 1.02 (95% CI 0.98-1.06); and 1.08 (95% CI 0.99-1.17) respectively. Recording of alcohol consumption and smoking both increased significantly; OR 1.36 (95% CI 1.30-1.43); and 1.42 (95% CI 1.27-1.60) respectively. Recording lifestyle advice fell; OR 0.84 (95% CI 0.81-0.88)., Conclusions: The study informs about current data recording and willingness to engage in ABE. Recording of risk factors improved after the intervention. Further QI is needed to achieve adherence to current guidance.

Background: There are ongoing concerns about the quality of care provision for allergy in primary care., Aims: To identify current training provision in allergy to GP trainees and to understand how this could be enhanced., Methods: A cross-sectional survey of GP Speciality Training (GPST) programme directors was undertaken. Programme directors of the 174 GPST schemes were sent an online questionnaire which was informed by the content of the Royal College of General Practitioners curriculum. Quantitative data were descriptively analysed and a thematic analysis was undertaken of free text responses., Results: We obtained responses from 146 directors representing 106 training programmes. Responses indicated that two-thirds (62%, 95% CI 53.1 to 71.5) of programmes were providing at least some allergy training, with the remaining third stating that they either provided no training or were unsure. Overall, one-third (33%, 95% CI 22.7 to 42.2) of programme directors believed that all the relevant allergy-related curriculum requirements were being met. Where provided, this training was believed to be best for organ-specific allergic disorders but was thought to be poorer for systemic allergic disorders, particularly food allergy where 67% (95% CI 57.5 to 76.5) of respondents indicated that training was poor. There was considerable interest in increasing the allergy training provided, preferably through eLearning modules and problem-based learning materials supported by those with relevant specialist knowledge., Conclusions: This UK-wide survey has identified important gaps in the training of GP trainees in relation to allergy care. Addressing these gaps, particularly in the management of systemic allergic disorders, should help to improve delivery of primary care-based allergy care.