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Prevalence of generalised anxiety disorders is widespread in Great Britain. Previous small-scale research has shown variations in minor tranquiliser prescribing, identifying several potential predictors of prescribing volume. Objective: This study aimed to investigate the relationship between general practice minor tranquiliser prescribing rates and practice population and general practice characteristics for all general practices in England.Methods: Multiple regression analysis of minor tranquiliser prescribing volumes during 2004/2005 for 8,291 English general practices with general practice and population variables obtained from the General Medical Services (GMS) statistics, Quality and Outcomes Framework (QOF), 2001 Census and 2004 Index of Multiple Deprivation (IMD). Results: The highest rates of minor tranquiliser prescribing were in areas with the greatest local deprivation while general practices situated in areas with larger proportions of residents of black ethnic origin had lower rates of prescribing. Other predictors of increased prescribing were general practices with older general practitioners and general practices with older registered practice populations.Conclusion: Our findings show that there is wide variation of minor tranquilisers prescribing across England which has implications regarding access to treatment and inequity of service provision. Future research should determine the barriers to equitable prescribing amongst general practices serving larger populations of black ethnic origin.

Background: The drive for integrative systems and collaboration across organizations and professions involved in the provision of health and social care has led to the development of a number of scales and models that conceptualize collaborative behavior. Few models have captured the dynamics of the collaboration between community pharmacy and general medicine, 2 professional groups that are increasingly being encouraged to adopt more collaborative practices to improve patient care.Objectives: This article presents a new model of collaboration derived from interviews with general practitioners (GPs) and community pharmacists in England involved in service provision that required some form of collaboration.Methods: Qualitative interviews were conducted with purposive samples of 13 GPs and 18 community pharmacists involved in the provision of local pharmaceutical services pilots and 14 GPs and 13 community pharmacists involved in the provision of repeat dispensing.Results: The model highlights key components of collaboration, including the importance of trust, communication, professional respect, and "knowing" each other. It is argued here that previous models fail to recognize the asymmetry and differentiation between GPs and community pharmacists, including differences in perception toward and importance assigned to trust and communication. GPs were found to adopt demarcation strategies toward community pharmacies and pharmacists, with independent pharmacies being favored over multiple chains and regular pharmacists favored over locum/sessional pharmacists. This differentiation was repeatedly highlighted by GPs and found to affect their ability or willingness to collaborate.Conclusion: The model provides a foundation for the future development of strategy and research focused on the improvement or study of collaborative relationships between community pharmacy and general practice. [ABSTRACT FROM AUTHOR]

Prescribing errors are common, they result in adverse events and harm to patients and it is unclear how best to prevent them because recommendations are more often based on surmized rather than empirically collected data. The aim of this systematic review was to identify all informative published evidence concerning the causes of and factors associated with prescribing errors in specialist and non-specialist hospitals, collate it, analyse it qualitatively and synthesize conclusions from it. Seven electronic databases were searched for articles published between 1985-July 2008. The reference lists of all informative studies were searched for additional citations. To be included, a study had to be of handwritten prescriptions for adult or child inpatients that reported empirically collected data on the causes of or factors associated with errors. Publications in languages other than English and studies that evaluated errors for only one disease, one route of administration or one type of prescribing error were excluded. Seventeen papers reporting 16 studies, selected from 1268 papers identified by the search, were included in the review. Studies from the US and the UK in university-affiliated hospitals predominated (10/16 [62%]). The definition of a prescribing error varied widely and the included studies were highly heterogeneous. Causes were grouped according to Reason's model of accident causation into active failures, error-provoking conditions and latent conditions. The active failure most frequently cited was a mistake due to inadequate knowledge of the drug or the patient. Skills-based slips and memory lapses were also common. Where error-provoking conditions were reported, there was at least one per error. These included lack of training or experience, fatigue, stress, high workload for the prescriber and inadequate communication between healthcare professionals. Latent conditions included reluctance to question senior colleagues and inadequate provision of training. Prescribing errors are often multifactorial, with several active failures and error-provoking conditions often acting together to cause them. In the face of such complexity, solutions addressing a single cause, such as lack of knowledge, are likely to have only limited benefit. Further rigorous study, seeking potential ways of reducing error, needs to be conducted. Multifactorial interventions across many parts of the system are likely to be required. [ABSTRACT FROM AUTHOR]

Prescribing errors affect patient safety throughout hospital practice. Previous reviews of studies have often targeted specific populations or settings, or did not adopt a systematic approach to reviewing the literature. Therefore, we set out to systematically review the prevalence, incidence and nature of prescribing errors in hospital inpatients. MEDLINE, EMBASE, CINAHL and International Pharmaceutical Abstracts (all from 1985 to October 2007) were searched for studies of prescriptions for adult or child hospital inpatients giving enough data to calculate an error rate. Electronic prescriptions and errors for single diseases, routes of administration or types of prescribing error were excluded, as were non-English language publications. Median error rate (interquartile range [IQR]) was 7% (2-14%) of medication orders, 52 (8-227) errors per 100 admissions and 24 (6-212) errors per 1000 patient days. Most studies (84%) were conducted in single hospitals and originated from the US or UK (72%). Most errors were intercepted and reported before they caused harm, although two studies reported adverse drug events. Errors were most common with antimicrobials and more common in adults (median 18% of orders [ten studies, IQR 7-25%]) than children (median 4% [six studies, IQR 2-17%]). Incorrect dosage was the most common error. Overall, it is clear that prescribing errors are a common occurrence, affecting 7% of medication orders, 2% of patient days and 50% of hospital admissions. However, the reported rates of prescribing errors varied greatly and this could be partly explained by variations in the definition of a prescribing error, the methods used to collect error data and the setting of the study. Furthermore, a lack of standardization between severity scales prevented any comparison of error severity across studies. Future research should address the wide disparity of data-collection methods and definitions that bedevils comparison of error rates or meta-analysis of different studies. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To assess the relative efficacy and safety of zolmitriptan in the treatment of acute migraine attacks. BACKGROUND: Zolmitriptan is a second-generation triptan developed for the treatment of migraine. Numerous randomized controlled trials (RCTs) have been carried out to compare different dosages and formulations of zolmitriptan against other treatments for acute migraine. METHODS: Random effects meta-analysis of 24 RCTs, including 15,408 patients suffering from acute migraine attacks. Subgroup analyses compared differences in response between different dosages and formulations of zolmitriptan, and other triptan comparators. RESULTS: Zolmitriptan 2.5 mg tablet was found to be as effective as almotriptan 12.5 mg, eletriptan 40 mg, sumatriptan 50 mg and 100 mg and more effective than naratriptan 2.5 mg in terms of 2-hour pain-free rates. Likewise, zolmitriptan 5 mg tablet was as effective as sumatriptan 50 mg and 100 mg in 2-hour pain-free rates. Compared against zolmitriptan 2.5 mg tablet, eletriptan 80 mg was more effective in achieving headache relief, pain-free and sustained pain-free responses, and rizatriptan 10 mg was more effective in terms of sustained pain-free rates. Zolmitriptan 2.5 mg tablet was associated with a lower risk of adverse events than eletriptan 80 mg but higher risk than naratriptan 2.5 mg and rizatriptan 10 mg. Zolmitriptan 5 mg tablet was superior to zolmitriptan 2.5 mg tablet in achieving 1- and 2-hour pain-free response. There were no significant differences in 1- and 2-hour headache relief and adverse event rates between the different formulations of zolmitriptan 2.5 mg. CONCLUSIONS: Zolmitriptan 2.5 mg tablet is an effective treatment for acute attacks of migraine showing similar efficacy to almotriptan 12.5 mg, eletriptan 40 mg, and sumatriptan 50 mg, and being more effective than naratriptan 2.5 mg in terms of pain-free response at 2 hours post dose. Zolmitriptan 2.5 mg tablet was also as effective as rizatriptan 10 mg in terms of headache relief and pain-free response but less effective in terms of sustained pain-free response. [ABSTRACT FROM AUTHOR]

Introduction: More evidence for patterns of healthcare utilisation and associated costs among people receiving opioid agonist therapy (OAT) is needed. We investigated primary and secondary healthcare usage and costs among methadone and buprenorphine recipients in England., Methods: We conducted a cohort study using the Clinical Practice Research Datalink GOLD and Aurum databases of patients who were prescribed OAT between 1 January 2007 and 31 July 2019. The cohort was linked to Hospital Episode Statistics admitted patient care, outpatient and emergency department data, neighbourhood- and practice-level Index of Multiple Deprivation quintiles and mortality records. Negative binomial regression models were applied to estimate weighted rate ratios (wRR) of healthcare utilisation. Total and mean costs were calculated using Unit Costs of Health and Social Care and the National Healthcare Service Payment by Results National Tariffs., Results: Among 12,639 patients observed over 39,016 person-years, we found higher rate of hospital admissions (wRR 1.18; 1.08-1.28) among methadone compared with buprenorphine recipients. The commonest hospital discharge diagnoses among methadone patients were infectious diseases (19.2%), mental and behavioural disorders (17.0%) and drug-related poisoning (16.5%); the three commonest among buprenorphine patients were mental and behavioural diseases (21.5%), endocrine (13.8%) and genitourinary system diseases (13.1%). Methadone patients had similar mean costs compared with buprenorphine patients (cost difference: £539.01; 432.11-1006.69)., Discussion and Conclusions: Differences in healthcare utilisation frequency for methadone versus buprenorphine recipients were observed. The differences in associated costs were mainly driven by hospital admissions. These findings offer valuable insights for optimising care strategies and resource allocation for OAT recipients., (© 2024 The Author(s). Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Background: Evidence is sparse regarding service usage and the clinical management of people recently discharged from inpatient psychiatric care who die by suicide., Aim: To improve understanding of how people discharged from inpatient mental health care are supported by primary care during this high-risk transition., Design & Setting: A nested case-control study, utilising interlinked primary and secondary care records in England for people who died within a year of discharge between 2001 and 2019, matched on age, sex, practice-level deprivation, and region with up to 20 living discharged people., Method: We described patterns of consultation, prescription of psychotropic medication, and continuity of care for people who died by suicide and those who survived. Mutually adjusted relative risk estimates were generated for a range of primary care and clinical variables., Results: More than 40% of patients who died within 2 weeks of discharge and >80% of patients who died within 1 year of discharge had at least one primary care consultation within the respective time periods. Evidence of discharge communication from hospital was infrequent. Within-practice continuity of care was relatively high. Those who died by suicide were less likely to consult within 2 weeks of discharge (adjusted odds ratio [AOR] 0.61 [95% confidence interval {CI} = 0.42 to 0.89]), more likely to consult in the week before death (AOR 1.71 [95% CI = 1.36 to 2.15]), be prescribed multiple types of psychotropic medication (AOR 1.73 [95% CI = 1.28 to 2.33]), experience readmission, and have a diagnosis outside of the 'severe mental illness' definition., Conclusion: Primary care clinicians have opportunities to intervene and should prioritise patients experiencing transition from inpatient care. Clear communication and liaison between services is essential to provide timely support., (Copyright © 2024, The Authors.)

Background: Acute otitis media with discharge (AOMd) results from a tympanic membrane perforation secondary to a middle ear infection. Currently, the impact of AOMd on children and young people (CYP) and their families is not well understood. There is also a need to explore the experience of healthcare professionals in treating AOMd. Interviews with CYP and their parents, and focus groups with medical professionals, were conducted to explore these objectives., Methods: A total of 26 parents of CYP (age range: 7 months to 15 years) with a history of AOMd (within the last year) and 28 medical professionals were recruited across the UK between August 2023 and March 2024. Healthcare professionals were from primary care (n=17), ear, nose and throat (ENT) (n=7) and emergency medicine (n=4) backgrounds. Thematic analysis was performed independently by three reviewers., Results: The majority of CYP (n=25/26) (96.2%) had suffered from multiple episodes of AOMd. AOMd has a physical, psychological, educational, financial and social impact on CYP and their parents. Parents found accessing healthcare services and information difficult, which increased parental anxiety. Antibiotic overuse was also a concern among parents. The majority of general practitioners and emergency care staff described using oral amoxicillin, compared with ENT doctors who predominantly prescribed topical antibiotics., Conclusions: AOMd has a significant impact on CYP and their parent's daily lives. Need for clear, easily accessible patient information was identified as a priority by the parents of CYP with AOMd. Evidence-based management guidelines should be developed once high-quality evidence is available., Trial Registration Number: ISCTRN43760., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Health policy in the UK and globally regarding dementia, emphasises prevention and risk reduction. These goals could be facilitated by automated assessment of dementia risk in primary care using routinely collected patient data. However, existing applicable tools are weak at identifying patients at high risk for dementia. We set out to develop improved risk prediction models deployable in primary care., Methods: Electronic health records (EHRs) for patients aged 60-89 from 393 English general practices were extracted from the Clinical Practice Research Datalink (CPRD) GOLD database. 235 and 158 practices respectively were randomly assigned to development and validation cohorts. Separate dementia risk models were developed for patients aged 60-79 (development cohort n = 616,366; validation cohort n = 419,126) and 80-89 (n = 175,131 and n = 118,717). The outcome was incident dementia within 5 years and more than 60 evidence-based risk factors were evaluated. Risk models were developed and validated using multivariable Cox regression., Results: The age 60-79 development cohort included 10,841 incident cases of dementia (6.3 per 1,000 person-years) and the age 80-89 development cohort included 15,994 (40.2 per 1,000 person-years). Discrimination and calibration for the resulting age 60-79 model were good (Harrell's C 0.78 (95% CI: 0.78 to 0.79); Royston's D 1.74 (1.70 to 1.78); calibration slope 0.98 (0.96 to 1.01)), with 37% of patients in the top 1% of risk scores receiving a dementia diagnosis within 5 years. Fit statistics were lower for the age 80-89 model but dementia incidence was higher and 79% of those in the top 1% of risk scores subsequently developed dementia., Conclusion: Our models can identify individuals at higher risk of dementia using routinely collected information from their primary care record, and outperform an existing EHR-based tool. Discriminative ability was greatest for those aged 60-79, but the model for those aged 80-89 may also be clinical useful., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Reeves et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Generalized pustular psoriasis (GPP) and palmoplantar pustulosis (PPP) are chronic inflammatory skin conditions. Accumulating evidence shows that GPP and PPP have different characteristics to plaque psoriasis and are distinct clinical entities., Objectives: To assess the epidemiology, comorbidities, mortality and healthcare use for patients in England with GPP and PPP versus those with plaque psoriasis., Methods: We carried out a cohort study involving analyses of longitudinal electronic health record data in the Clinical Practice Research Datalink Aurum database and linked hospital and mortality data between 2008 and 2019. The primary study outcome was the incidence and prevalence rates of GPP, PPP and plaque psoriasis in England. Secondary outcomes included survival rates and healthcare resource use (HCRU) by disease type., Results: We identified 373 patients with GPP, 1828 with PPP and 224 223 with plaque psoriasis. Mean (SD) age was 55.9 (18.6) years for patients with GPP, 51.5 (16.4) years for those with PPP and 48.5 (19.1) years for those with plaque psoriasis; 62.5% and 65.9% of patients with GPP and PPP, respectively, were women, vs. 49.4% of those with plaque psoriasis. About half of patients were overweight or obese at baseline (GPP 48.6%, PPP 56.0%, plaque psoriasis 45.9%). The incidence rates for GPP, PPP and plaque psoriasis were 0.25 [95% confidence interval (CI) 0.21-0.28], 2.01 (95% CI 1.92-2.11) and 103.2 (95% CI 102.5-103.9) per 100 000 person-years, respectively. From 2008 to 2019, the prevalence rates per 100 000 persons ranged from 1.61 to 3.0 for GPP, from 1.1 to 18.7 for PPP and from 1771.0 to 1903.8 for plaque psoriasis. Survival rates were lower for patients with GPP, particularly those who were > 55 years of age and those with a history of one or more comorbidities in each cohort. HCRU was lower in the cohort with plaque psoriasis and highest in the cohort with GPP, particularly among those who had more than one GPP flare., Conclusions: Our results provide further evidence that, in England, GPP is a distinct disease with different epidemiology, lower survival and higher HCRU than plaque psoriasis., Competing Interests: Conflicts of interest M.F. and MO.Y.L. are employed by Boehringer Ingelheim Ltd. S.P. was employed by Boehringer Ingelheim Ltd when this work was done and is now employed by MSD. C.E.M.G. reports research grants or honoraria from AbbVie, Almirall, AnaptysBio, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Dermavant, Eli Lilly, Evelo Bioscience, GSK, Inmagene, Janssen, Kyowa Kirin, Novartis, ONO Pharmaceuticals, UCB Pharma and the LEO Foundation. R.B.W. has received research grants or consulting fees from AbbVie, Almirall, Amgen, Arena, Astellas, Avillion, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, DiCE, Eli Lilly, GSK, Janssen, LEO Pharma, Medac, Novartis, Pfizer, Sanofi, Sun Pharma, UCB and UNION, and is supported by the Manchester National Institute for Health and Care Research (NIHR) Biomedical Research Centre. D.M.A. reports research grants from AbbVie, Almirall, Celgene, Eli Lilly, Janssen, Novartis, UCB and the LEO Foundation., (© The Author(s) 2024. Published by Oxford University Press on behalf of British Association of Dermatologists.)

Non-technical skills are recognised as important in various work domains, but have been the subject of debate regarding their role in ergonomics/human factors, given their focus on human behaviour itself rather than the interaction between people and systems. This study aimed to examine the relationship between non-technical skills and the work system in which they are enacted. The study setting was community pharmacies in England. Qualitative data were obtained from observation of seven pharmacists and semi-structured interviews with 16 pharmacists, and subjected to thematic analysis. Elements of their work system were found to be related to their non-technical skills; either by creating a need for the skill in the first place, or by facilitating or inhibiting its enactment. The findings highlight the importance of considering the work system that contextualises individuals' and teams' behaviour, in addition to the behaviour itself, when investigating non-technical skills.

Background and Objectives: METHODS: A structured search strategy encompassing databases including MEDLINE, Embase, CINAHL Plus, PsycINFO and Cochrane Library was implemented from inception to October 2023. Included studies focused on interventions targeting opioid reduction in adults following major surgeries. The risk of bias was evaluated using Cochrane risk-of-bias tool V.2 (RoB 2) and non-randomised studies of interventions (ROBINS-I) tools, and Cohen's d effect sizes were calculated. BCTs were identified using a validated taxonomy., Results: 22 studies, comprising 7 clinical trials and 15 cohort studies, were included, with varying risks of bias. Educational (n=12), guideline-focused (n=3), multifaceted (n=5) and pharmacist-led (n=2) interventions demonstrated diverse effect sizes (small-medium n=10, large n=12). A total of 23 unique BCTs were identified across studies, occurring 140 times. No significant association was observed between the number of BCTs and effect size, and interventions with large effect sizes predominantly targeted healthcare professionals. Key BCTs in interventions with the largest effect sizes included behaviour instructions, behaviour substitution, goal setting (outcome), social support (practical), social support (unspecified), pharmacological support, prompts/cues, feedback on behaviour, environmental modification, graded tasks, outcome goal review, health consequences information, action planning, social comparison, credible source, outcome feedback and social reward., Conclusions: Understanding the dominant BCTs in highly effective interventions provides valuable insights for future opioid tapering strategy implementations. Further research and validation are necessary to establish associations between BCTs and effectiveness, considering additional influencing factors., Prospero Registration Number: CRD42022290060., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: Historically, atherosclerotic cardiovascular disease (ASCVD) risk profile mitigation has had a predominant focus on low density lipoprotein cholesterol (LDL-C). In this narrative review we explore the residual ASCVD risk profile beyond LDL-C with a focus on hypertriglyceridaemia, recent clinical trials of therapeutics targeting hypertriglyceridaemia and novel modalities addressing other residual ASCVD risk factors., Findings: Hypertriglyceridaemia remains a significant ASCVD risk despite low LDL-C in statin or proprotein convertase subtilisin/kexin type 9 inhibitor-treated patients. Large population-based observational studies have consistently demonstrated an association between hypertriglyceridaemia with ASCVD. This relationship is complicated by the co-existence of low high-density lipoprotein cholesterol. Despite significantly improving atherogenic dyslipidaemia, the most recent clinical trial outcome has cast doubt on the utility of pharmacologically lowering triglyceride concentrations using fibrates. On the other hand, purified eicosapentaenoic acid (EPA), but not in combination with docosahexaenoic acid (DHA), has produced favourable ASCVD outcomes. The outcome of these trials suggests alternate pathways involved in ASCVD risk modulation. Several other pharmacotherapies have been proposed to address other ASCVD risk factors targeting inflammation, thrombotic and metabolic factors., Implications: Hypertriglyceridaemia poses a significant residual ASCVD risk in patients already on LDL-C lowering therapy. Results from pharmacologically lowering triglyceride are conflicting. The role of fibrates and combination of EPA and DHA is under question but there is now convincing evidence of ASCVD risk reduction with pure EPA in a subgroup of patients with hypertriglyceridaemia. Clinical guidelines should be updated in line with recent clinical trials evidence. Novel agents targeting non-conventional ASCVD risks need further evaluation., Competing Interests: HS: Received personal fees from Amgen, Akcea, Synageva, NAPP, Novartis, Takeda, Sanofi, Pfizer and Kowa & received research grants and donations from Akcea, Pfizer, MSD, AMGEN, Genzyme-Sanofi, Synageva, Amryt, Synageva and Alexion. DA: reports research grants from Boehringer-Ingelheim, Bristol Myers Squibb, Janssen, and the LEO Foundation. JS: received grants and research support from Astra Zeneca, Daiichi-Sankyo, Eli Lilly and Company and Novo Nordisk; speaker fees from Novartis, Astra Zeneca, Daiichi-Sankyo and Sanofi; and consultancy fees from Amgen, Boehringer Ingelheim, Eli Lilly and Company and Sanofi. PD: Received honoraria from Sobi, Novartis, Amgen, Daiichi Sankyo, Sanofi and Amarin. SR: Received honoraria from NOVARTIS, AMGEN, Astra Zeneca, Ultragenyx, Sanofi, Foresite Labs, and research grants from Astra Zeneca. IG-B: received personal honoraria for consulting from Amgen, Regeneron, Aegereon, Akcea Therapeutics, Daiichi-Sankyo, Novartis, Ultragenyx, Sanofi and Amarin. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Bashir, Schofield, Downie, France, Ashcroft, Wright, Romeo, Gouni-Berthold, Maan, Durrington and Soran.)

Introduction: There have been some concerns about the impact of temporary doctors, otherwise known as locums, on patient safety and the quality of care. Despite these concerns, research has paid little attention to the implications of locum working on patient experience., Methods: A qualitative semi-structured interview study was conducted with 130 participants including locums, people working with locums and patients with experience of being seen or treated by locums. Analysis was conducted using a reflexive thematic approach and abductive analysis to position themes against wider knowledge., Results: Three main themes were constructed through analysis: (1) Awareness and disclosure; patients were not always aware if their doctor was a locum, and there was some debate about whether patients had a right to know, particularly if locum working presented quality and safety risks. (2) Continuity and accessibility of care; access was regarded as priority for acute conditions, but for long-term or serious conditions, patients preferred to see a permanent doctor who knew their history, although it was acknowledged that locums could provide fresh perspectives. (3) Communication and practice; locums and patients described how consultations were approached differently when doctors worked as locums. Patients evaluated their interactions based on how safe they felt with practitioners., Conclusion: Patients reported that they were unlikely to have continuity of care with any doctors delivering care, regardless of their contractual status. Locums sometimes provided new perspectives on care which could be beneficial for patient outcomes, but for patients with long-term, complex or serious conditions continuity of care was important, and these patients may avoid or delay seeking care when locums are the only available option., Patient or Public Contribution: Patients and carers were involved in our study from inception to dissemination. Our Patient and Public Involvement (PPI) forum was involved throughout project design and planning and gave us feedback and guidance on research materials and outputs (e.g., study protocol, participant information sheets, survey tools, interview schedules, emerging findings). Our PPI forum co-produced our patient interview schedule, two members of our PPI forum led the patient focus groups and all were involved in analysis of patient interviews. Our PPI Chair was involved in the preparation of this manuscript., (© 2024 The Author(s). Health Expectations published by John Wiley & Sons Ltd.)

Objectives: To quantify prevalence, harms, and NHS costs in England of problematic oral non-steroidal anti-inflammatory drug (NSAID) prescribing in high risk groups., Design: Population based cohort and economic modelling study., Setting: Economic models estimating patient harm associated with NSAID specific hazardous prescribing events, and cost to the English NHS, over a 10 year period, were combined with trends of hazardous prescribing event to estimate national levels of patient harm and NHS costs., Participants: Eligible participants were prescribed oral NSAIDs and were in five high risk groups: older adults (≥65 years) with no gastroprotection; people who concurrently took oral anticoagulants; or those with heart failure, chronic kidney disease, or a history of peptic ulcer., Main Outcome Measures: Prevalence of hazardous prescribing events, by each event and overall, discounted quality adjusted life years (QALYs) lost, and cost to the NHS in England of managing harm., Results: QALY losses and cost increases were observed for each hazardous prescribing event ( v no hazardous prescribing event). Mean QALYs per person were between 0.01 (95% credibility interval (CI) 0.01 to 0.02) lower with history of peptic ulcer, to 0.11 (0.04 to 0.19) lower with chronic kidney disease. Mean cost increases ranged from a non-statistically significant £14 (€17; $18) (95% CI -£71 to £98) in heart failure, to a statistically significant £1097 (£236 to £2542) in people concurrently taking anticoagulants. Prevalence of hazardous prescribing events per 1000 patients ranged from 0.11 in people who have had a peptic ulcer to 1.70 in older adults. Nationally, the most common hazardous prescribing event (older adults with no gastroprotection) resulted in 1929 (1416 to 2452) QALYs lost, costing £2.46m (£0.65m to £4.68m). The greatest impact was in people concurrently taking oral anticoagulants: 2143 (894 to 4073) QALYs lost, costing £25.41m (£5.25m to £60.01m). Over 10 years, total QALYs lost were estimated to be 6335 (4471 to 8658) and an NHS cost for England of £31.43m (£9.28m to £67.11m)., Conclusions: NSAIDs continue to be a source of avoidable harm and healthcare cost in these five high risk populations, especially in inducing an acute event in people with chronic condition and people taking oral anticoagulants., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: Funding from the NIHR; DMA reports research grants from NIHR, AbbVie, Almirall, Celgene, Eli Lilly, Janssen, Novartis, UCB, and the Leo Foundation. AC, EC, BG, DM, LP, and GR report research grants from NIHR. AC reports research grants from NIHR, UKRI, and Industrial Challenge Fund. AJA reports research grants from NIHR and was National Clinical Director for NHS England at the time of the study. RAE reports research grants from NIHR and Abbott., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Psoriasis significantly burdens patients' lives, but there is limited data on this in Brazil., Methods: Between May 2022 and January 2023, we conducted a cross-sectional online survey of 563 Brazilian residents aged ≥18 years who had been diagnosed with psoriasis. Spearman's correlation (r) was used to test the correlation between self-assessed disease severity (Simplified Psoriasis Index [saSPI] extent score; range 0 [clear/minor] to 40 [widespread/severe]) and health-related quality of life (QoL, score of 1 means perfect health) and capability (ICECAP-A: score of 1 means full capability) measures. Multivariable linear regression was used to identify predictors of QoL and capability. A thematic analysis examined the free-text responses and identified common themes., Results: The mean age of participants was 42.1 ± 12.4 years, and over half had at least one other long-term condition. The mean QoL score was 0.59 ± 0.25, and the mean capability score was 0.71 ± 0.21. At the time of survey completion, over 80% of respondents reported some level of pain and/or discomfort, and 86% reported feeling anxious and/or depressed. The mean self-assessed saSPI was 7.8 ± 8.6, which negatively correlated with health-related QoL (r = -0.49, P < 0.05) and capability (r = -0.44, P < 0.05). Significant predictors of poorer QoL and reduced capability included high saSPI, number of psoriasis flares and comorbidities, female gender, Black ethnicity, and employment status (unemployed, long-term sick). Frequently reported areas that impacted patients were social stigma/prejudice, powerlessness, lack of education and public awareness, and difficulty obtaining appropriate care/treatment., Conclusions: We found that the clinical manifestations, severity, and associated comorbidities of psoriasis negatively impacted health-related QoL and capability, along with feelings of stigmatization and barriers to specialist treatment. This highlights the need for better access to care and awareness of the disease to improve the lives of people living with psoriasis in Brazil., (© 2024 The Author(s). International Journal of Dermatology published by Wiley Periodicals LLC on behalf of the International Society of Dermatology.)

Background: An increasing number of people are using multiple medications each day, named polypharmacy. This is driven by an ageing population, increasing multimorbidity, and single disease-focussed guidelines. Medications carry obvious benefits, yet polypharmacy is also linked to adverse consequences including adverse drug events, drug-drug and drug-disease interactions, poor patient experience and wasted resources. Problematic polypharmacy is 'the prescribing of multiple medicines inappropriately, or where the intended benefits are not realised'. Identifying people with problematic polypharmacy is complex, as multiple medicines can be suitable for people with several chronic conditions requiring more treatment. Hence, polypharmacy is often potentially problematic, rather than always inappropriate, dependent on clinical context and individual benefit vs risk. There is a need to improve how we identify and evaluate these patients by extending beyond simple counts of medicines to include individual factors and long-term conditions., Aim: To produce a Polypharmacy Assessment Score to identify a population with unusual levels of prescribing who may be at risk of potentially problematic polypharmacy., Methods: Analyses will be performed in three parts: 1. A prediction model will be constructed using observed medications count as the dependent variable, with age, gender and long-term conditions as independent variables. A 'Polypharmacy Assessment Score' will then be constructed through calculating the differences between the observed and expected count of prescribed medications, thereby highlighting people that have unexpected levels of prescribing. Parts 2 and 3 will examine different aspects of validity of the Polypharmacy Assessment Score: 2. To assess 'construct validity', cross-sectional analyses will evaluate high-risk prescribing within populations defined by a range of Polypharmacy Assessment Scores, using both explicit (STOPP/START criteria) and implicit (Medication Appropriateness Index) measures of inappropriate prescribing. 3. To assess 'predictive validity', a retrospective cohort study will explore differences in clinical outcomes (adverse drug reactions, unplanned hospitalisation and all-cause mortality) between differing scores., Discussion: Developing a cross-cutting measure of polypharmacy may allow healthcare professionals to prioritise and risk stratify patients with polypharmacy using unusual levels of prescribing. This would be an improvement from current approaches of either using simple cutoffs or narrow prescribing criteria., (© 2024. Crown.)

Background: With the global challenge of antimicrobial resistance intensified during the COVID-19 pandemic, evaluating adverse events (AEs) post-antibiotic treatment for common infections is crucial. This study aims to examines the changes in incidence rates of AEs during the COVID-19 pandemic and predict AE risk following antibiotic prescriptions for common infections, considering their previous antibiotic exposure and other long-term clinical conditions., Methods: With the approval of NHS England, we used OpenSAFELY platform and analysed electronic health records from patients aged 18-110, prescribed antibiotics for urinary tract infection (UTI), lower respiratory tract infections (LRTI), upper respiratory tract infections (URTI), sinusitis, otitis externa, and otitis media between January 2019 and June 2023. We evaluated the temporal trends in the incidence rate of AEs for each infection, analysing monthly changes over time. The survival probability of emergency AE hospitalisation was estimated in each COVID-19 period (period 1: 1 January 2019 to 25 March 2020, period 2: 26 March 2020 to 8 March 2021, period 3: 9 March 2021 to 30 June 2023) using the Kaplan-Meier approach. Prognostic models, using Cox proportional hazards regression, were developed and validated to predict AE risk within 30 days post-prescription using the records in Period 1., Results: Out of 9.4 million patients who received antibiotics, 0.6% of UTI, 0.3% of URTI, and 0.5% of LRTI patients experienced AEs. UTI and LRTI patients demonstrated a higher risk of AEs, with a noted increase in AE incidence during the COVID-19 pandemic. Higher comorbidity and recent antibiotic use emerged as significant AE predictors. The developed models exhibited good calibration and discrimination, especially for UTIs and LRTIs, with a C-statistic above 0.70., Conclusions: The study reveals a variable incidence of AEs post-antibiotic treatment for common infections, with UTI and LRTI patients facing higher risks. AE risks varied between infections and COVID-19 periods. These findings underscore the necessity for cautious antibiotic prescribing and call for further exploration into the intricate dynamics between antibiotic use, AEs, and the pandemic., (© 2024. The Author(s).)

Aims: To compare the predictive performance of CHA 2 DS 2 -VASc and HAS-BLED scores in atrial fibrillation (AF) patients with and without cancer., Methods and Results: Using data from the Clinical Practice Research Datalink in England, we performed a retrospective cohort study of patients with new diagnoses of AF from 2009 to 2019. Cancer was defined as history of breast, prostate, colorectal, lung, or haematological cancer. We calculated the CHA 2 DS 2 -VASc and HAS-BLED scores for the 1-year risk of stroke and major bleeding events. Scores performance was estimated by discrimination [area under the receiver operating characteristic curve (AUC)] and calibration plots. Of 141 796 patients with AF, 10.3% had cancer. The CHA 2 DS 2 -VASc score had good to modest discrimination in prostate cancer AUC = 0.74 (95% confidence interval: 0.71, 0.77), haematological cancer AUC = 0.71 (0.66, 0.76), colorectal cancer AUC = 0.70 (0.66, 0.75), breast cancer AUC = 0.70 (0.66, 0.74), and lung cancer AUC = 0.69 (0.60, 0.79), compared with no-cancer AUC = 0.73 (0.72, 0.74). HAS-BLED discrimination was poor in prostate cancer AUC = 0.58 (0.55, 0.61), haematological cancer AUC = 0.59 (0.55, 0.64), colorectal cancer AUC = 0.57 (0.53, 0.61), breast cancer AUC = 0.56 (0.52, 0.61), and lung cancer AUC = 0.59 (0.51, 0.67), compared with no-cancer AUC = 0.61 (0.60, 0.62). Both the CHA 2 DS 2 -VASc score and HAS-BLED score were well calibrated across all study cohorts., Conclusion: Amongst certain cancer cohorts in the AF population, CHA 2 DS 2 -VASc performs similarly in predicting stroke to AF patients without cancer. Our findings highlight the importance of cancer diagnosis during the development of risk scores and opportunities to optimize the HAS-BLED risk score to better serve cancer patients with AF., Competing Interests: Conflict of interest: I have read the journal’s policy and the authors of this manuscript have the following competing interests: D.M.A. received research grants from AbbVie, Almirall, Celgene, Eli Lilly, Janssen, Novartis, UCB, and the Leo Foundation. The remaining authors have nothing to disclose., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Previous studies have demonstrated the association between antibiotic use and severe COVID-19 outcomes. This study aimed to explore detailed antibiotic exposure characteristics among COVID-19 patients. Using the OpenSAFELY platform, which integrates extensive health data and covers 40% of the population in England, the study analysed 3.16 million COVID-19 patients with at least two prior antibiotic prescriptions. These patients were compared to up to six matched controls without hospitalisation records. A machine learning model categorised patients into ten groups based on their antibiotic exposure history over the three years before their COVID-19 diagnosis. The study found that for COVID-19 patients, the total number of prior antibiotic prescriptions, diversity of antibiotic types, broad-spectrum antibiotic prescriptions, time between first and last antibiotics, and recent antibiotic use were associated with an increased risk of severe COVID-19 outcomes. Patients in the highest decile of antibiotic exposure had an adjusted odds ratio of 4.8 for severe outcomes compared to those in the lowest decile. These findings suggest a potential link between extensive antibiotic use and the risk of severe COVID-19. This highlights the need for more judicious antibiotic prescribing in primary care, primarily for patients with higher risks of infection-related complications, which may better offset the potential adverse effects of repeated antibiotic use.

Background: The impact of the COVID-19 pandemic on the mental health of children and young people (CYP) has been widely reported. Primary care electronic health records were utilised to examine trends in the diagnosing, recording and treating of these common mental disorders by ethnicity and social deprivation in Greater Manchester, England., Methods: Time-series analyses conducted using Greater Manchester Care Record (GMCR) data examined all diagnosed episodes of anxiety disorders and depression and prescribing of anxiolytics and antidepressants among patients aged 6-24 years. The 41-month observation period was split into three epochs: Pre-pandemic (1/2019-2/2020); Pandemic Phase 1 (3/2020-6/2021); Pandemic Phase 2 (7/2021-5/2022). Rate ratios for all CYP specific to sex, age, ethnicity, and neighbourhood-level Indices of Multiple Deprivation (IMD) quintile were modelled using negative binomial regression., Results: Depression and anxiety disorder rates were highest in females, CYP aged 19-24, and White and 'Other' ethnic groups. During Pandemic Phase 1, rates for these diagnoses fell in all demographic subgroups and then rose to similar levels as those recorded pre-pandemic. In Pandemic Phase 2, rates in Black and Mixed-ethnicity females rose to a significantly greater degree (by 54% and 62%, respectively) than those in White females. Prescribing rates increased throughout the study period, with significantly greater rises observed in non-White females and males. The temporal trends were mostly homogeneous across deprivation quintiles., Conclusion: The observed fluctuations in frequency of recorded common mental illness diagnoses likely reflect service accessibility and patients' differential propensities to consult as well as changing levels of distress and psychopathology in the population. However, psychotropic medication prescribing increased throughout the observation period, possibly indicating a sustained decline in mental health among CYP, and also clinicians' responses to problems presented. The comparatively greater increases in frequencies of diagnosis recording and medication prescribing among ethnic minority groups warrants further investigation., (© 2024 The Author(s). Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.)

Background: Vitiligo is a chronic autoimmune disease characterised by depigmented skin patches, which can pose substantial psychosocial challenges particularly in individuals with dark skin tones. Despite its impact on quality of life, there is an absence of standardised global epidemiological data. We sought to address this gap with the present study., Methods: In this study we did a systematic review and modelling analysis to estimate the global, regional, and national prevalence and incidence of vitiligo. We did a comprehensive search of nine digital libraries (PubMed, Embase, Web of Science, Scientific Electronic Library Online, KCI Korean Journal Database, Russian Science Citation Index, Western Pacific Region Index Medicus, Informit, and Health Research and Development Information Network) from inception up to May 25, 2023. We included cross-sectional or cohort studies reporting the incidence rate or prevalence of vitiligo, or data from which incidence rate or prevalence could be calculated, in the general population of a country or area of a country. Summary estimate data were extracted. A main outcome was to estimate the worldwide, regional, and country-specific lifetime prevalence of vitiligo diagnosed by physicians or dermatologists among the general population and in adults and children (as per age groups defined in included studies). We used a Bayesian hierarchical linear mixed model to estimate prevalence, and calculated number of affected individuals using the UN population structure in 2022. In estimating lifetime prevalence, studies reporting point or period prevalence were excluded. Our other main outcome was to estimate incidence rates of vitiligo, but due to a small number of studies, the data on incidence were presented in a descriptive summary. This study was registered on PROSPERO, CRD42023390433., Findings: Our search identified 22 192 records, of which 90 studies met our inclusion criteria. Of these studies, six focused on the incidence of vitiligo, 79 reported on the prevalence of vitiligo, and five provided data on both incidence and prevalence. 71 studies reported on lifetime prevalence. In the most recent years studied, incidence rates in the general population ranged from 24·7 cases (95% CI 24·3-25·2) per 100 000 person-years in South Korea in 2019, to 61·0 cases (60·6-61·4) in the USA in 2017. In individual studies, incidence rates showed an increasing trend over the periods studied. The global lifetime prevalence of vitiligo diagnosed by a physician or dermatologist was estimated at 0·36% (95% credible interval [CrI] 0·24-0·54) in the general population (28·5 million people [95% CrI 18·9-42·6]), 0·67% (0·43-1·07) in the adult population (37·1 million adults [23·9-58·9]), and 0·24% (0·16-0·37) in the child population (5·8 million children [3·8-8·9]). Vitiligo prevalence was higher in adults than in children across all regions. Central Europe and south Asia reported the highest prevalence (0·52% [0·28-1·07] and 0·52% [0·33-0·82], respectively, in the general population)., Interpretation: This study highlights the need for standardised epidemiological data collection globally to inform public health policies and improve vitiligo diagnosis and management. Emphasis on the impact on individuals with darker skin tones is crucial to reducing stigma and improving quality of life. Furthermore, our study highlights the need to conduct more research in regions and populations that have been historically under-represented, to effectively address the worldwide burden of vitiligo., Funding: None., Competing Interests: Declaration of interests IH reports being a consultant for AbbVie, Pfizer, Bayer, Incyte, UCB, Boeringher Ingelheim, Estee Lauder, Ferndale Laboratories, L’Oréal, Arcutis, Avita Novartis, Gladerma, Janssen, Clinuvel, and Almirall. KE reports being a consultant for AbbVie, Incyte, La Roche-Posay, Pfizer, Pierre Fabre, Sanofi, and MSD. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)