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Objectives: To examine the accuracy and impact of artificial intelligence (AI) software assistance in lung cancer screening using CT., Methods: A systematic review of CE-marked, AI-based software for automated detection and analysis of nodules in CT lung cancer screening was conducted. Multiple databases including Medline, Embase and Cochrane CENTRAL were searched from 2012 to March 2023. Primary research reporting test accuracy or impact on reading time or clinical management was included. QUADAS-2 and QUADAS-C were used to assess risk of bias. We undertook narrative synthesis., Results: Eleven studies evaluating six different AI-based software and reporting on 19 770 patients were eligible. All were at high risk of bias with multiple applicability concerns. Compared with unaided reading, AI-assisted reading was faster and generally improved sensitivity (+5% to +20% for detecting/categorising actionable nodules; +3% to +15% for detecting/categorising malignant nodules), with lower specificity (-7% to -3% for correctly detecting/categorising people without actionable nodules; -8% to -6% for correctly detecting/categorising people without malignant nodules). AI assistance tended to increase the proportion of nodules allocated to higher risk categories. Assuming 0.5% cancer prevalence, these results would translate into additional 150-750 cancers detected per million people attending screening but lead to an additional 59 700 to 79 600 people attending screening without cancer receiving unnecessary CT surveillance., Conclusions: AI assistance in lung cancer screening may improve sensitivity but increases the number of false-positive results and unnecessary surveillance. Future research needs to increase the specificity of AI-assisted reading and minimise risk of bias and applicability concerns through improved study design., Prospero Registration Number: CRD42021298449., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure. All authors involved in Warwick Evidence are wholly or partly funded by the NIHR. STP and AG are funded by the NIHR on personal fellowships. STP serves as Chair of the UK National Screening Committee Research and Methodology group, but this work is independent research not associated with that role., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

The purpose of syndromic surveillance is to provide early warning of public health incidents, real-time situational awareness during incidents and emergencies, and reassurance of the lack of impact on the population, particularly during mass gatherings. The United Kingdom Health Security Agency (UKHSA) currently coordinates a real-time syndromic surveillance service that encompasses 6 national syndromic surveillance systems reporting on daily health care usage across England. Each working day, UKHSA analyzes syndromic data from over 200,000 daily patient encounters with the National Health Service, monitoring over 140 unique syndromic indicators, risk assessing over 50 daily statistical exceedances, and taking and recommending public health action on these daily. This English syndromic surveillance service had its origins as a small exploratory pilot in a single region of England in 1999 involving a new pilot telehealth service, initially reporting only on "cold or flu" calls. This pilot showed the value of syndromic surveillance in England, providing advanced warning of the start of seasonal influenza activity over existing laboratory-based surveillance systems. Since this initial pilot, a program of real-time syndromic surveillance has evolved from the single-system, -region, -indicator pilot (using manual data transfer methods) to an all-hazard, multisystem, automated national service. The suite of systems now monitors a wide range of syndromes, from acute respiratory illness to diarrhea to cardiac conditions, and is widely used in routine public health surveillance and for monitoring seasonal respiratory disease and incidents such as the COVID-19 pandemic. Here, we describe the 25-year evolution of the English syndromic surveillance system, focusing on the expansion and improvements in data sources and data management, the technological and digital enablers, and novel methods of data analytics and visualization., (©Alex J Elliot, Helen E Hughes, Sally E Harcourt, Sue Smith, Paul Loveridge, Roger A Morbey, Amardeep Bains, Obaghe Edeghere, Natalia R Jones, Daniel Todkill, Gillian E Smith. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 17.09.2024.)

IntroductionRespiratory sentinel surveillance systems leveraging computerised medical records (CMR) use phenotyping algorithms to identify cases of interest, such as acute respiratory infection (ARI). The Oxford-Royal College of General Practitioners Research and Surveillance Centre (RSC) is the English primary care-based sentinel surveillance network.AimThis study describes and validates the RSC's new ARI phenotyping algorithm.MethodsWe developed the phenotyping algorithm using a framework aligned with international interoperability standards. We validated our algorithm by comparing ARI events identified during the 2022/23 influenza season in England through use of both old and new algorithms. We compared clinical codes commonly used for recording ARI.ResultsThe new algorithm identified an additional 860,039 cases and excluded 52,258, resulting in a net increase of 807,781 cases (33.84%) of ARI compared to the old algorithm, with totals of 3,194,224 cases versus 2,386,443 cases. Of the 860,039 newly identified cases, the majority (63.7%) were due to identification of symptom codes suggestive of an ARI diagnosis not detected by the old algorithm. The 52,258 cases incorrectly identified by the old algorithm were due to inadvertent identification of chronic, recurrent, non-infectious and other non-ARI disease.ConclusionWe developed a new ARI phenotyping algorithm that more accurately identifies cases of ARI from the CMR. This will benefit public health by providing more accurate surveillance reports to public health authorities. This new algorithm can serve as a blueprint for other CMR-based surveillance systems wishing to develop similar phenotyping algorithms.

Since November 2023, the absolute number of attendances at emergency departments for pneumonia among children aged 5-14 years in England have been above expected levels for the time of year. This increased signal peaked during March 2024 but then persisted into early summer 2024 despite decreases in prevalence of seasonal respiratory pathogens. Record linkage between emergency department and laboratory databases points to this unusual activity being driven largely by Mycoplasma pneumoniae .

Competing Interests: AS has served on Scottish Government's Chief Medical Officer's COVID-19 Advisory Group and Standing Committee on Pandemic Preparedness, and UK New and Emerging Respiratory Virus Threats Advisory Group Risk Stratification Subgroup COVID-19 advisory groups; is a PI of EAVE II; and has received grants to University of Oxford for vaccine related work from GSK. SdeL is Director of the RSC; has received research funding through University of Oxford for vaccine-related research from AstraZeneca, GSK, Moderna, MSD, Pfizer, Sanofi, and Seqirus; SdeL has been members of advisory boards for AstraZeneca, GSK, Sanofi, and Seqirus, with any funding paid to University of Oxford. All other authors declare no competing interests. This study was funded by the UK Health Security Agency.

Introduction: Antimicrobial resistance (AMR) is a major public health threat. With the growing emphasis on patient-centred care/ shared decision making, it is important for healthcare professionals' (HCPs) who prescribe, dispense, administer and/or monitor antimicrobials to be adequately equipped to facilitate appropriate antimicrobial use. We systematically identified existing interventions which aim to improve HCPs interaction with patients and examined barriers and facilitators of appropriate the use of such interventions and appropriate antimicrobial use among both HCPs and patientsantimicrobial use while using these interventions., Methods: We searched MEDLINE, EMBASE, Web of Science, Google Scholar, and internet (via Google search engine). We included primary studies, published in English from 2010 to 2023 [PROSPERO (CRD42023395642)]. The protocol was preregistered with PROSPERO (CRD42023395642). We performed quality assessment using mixed methods appraisal tool. We applied narrative synthesis and used the COM-B (Capability, Opportunity, Motivation -Behaviour) as a theoretical framework for barriers and facilitators at HCP and patient levels., Results: Of 9,172 citations retrieved from database searches, From 4,979 citations remained after removal of duplicates. We included 59 studies spanning over 13 countries. Interventions often involved multiple components beyond HCPs' interaction with patients. From 24 studies reporting barriers and facilitators, we identified issues relating to capability (such as, knowledge/understanding about AMR, diagnostic uncertainties, awareness of interventions and forgetfulness); opportunity (such as, time constraint and intervention accessibility) and motivation (such as, patient's desire for antibiotics and fear of litigation)., Conclusion: The findings of this review should be considered by intervention designers/adopters and policy makers to improve utilisation and effectiveness., Competing Interests: DA-O, DT, and EG were employed by the funder of the study, UK Health Security Agency (UKHSA). 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., (Copyright © 2024 Ayorinde, Ghosh, Shaikh, Adetunji, Brown, Jordan, Gilham, Todkill and Ashiru-Oredope.)

Background: Prepandemic sentinel surveillance focused on improved management of winter pressures, with influenza-like illness (ILI) being the key clinical indicator. The World Health Organization (WHO) global standards for influenza surveillance include monitoring acute respiratory infection (ARI) and ILI. The WHO's mosaic framework recommends that the surveillance strategies of countries include the virological monitoring of respiratory viruses with pandemic potential such as influenza. The Oxford-Royal College of General Practitioner Research and Surveillance Centre (RSC) in collaboration with the UK Health Security Agency (UKHSA) has provided sentinel surveillance since 1967, including virology since 1993., Objective: We aim to describe the RSC's plans for sentinel surveillance in the 2023-2024 season and evaluate these plans against the WHO mosaic framework., Methods: Our approach, which includes patient and public involvement, contributes to surveillance objectives across all 3 domains of the mosaic framework. We will generate an ARI phenotype to enable reporting of this indicator in addition to ILI. These data will support UKHSA's sentinel surveillance, including vaccine effectiveness and burden of disease studies. The panel of virology tests analyzed in UKHSA's reference laboratory will remain unchanged, with additional plans for point-of-care testing, pneumococcus testing, and asymptomatic screening. Our sampling framework for serological surveillance will provide greater representativeness and more samples from younger people. We will create a biomedical resource that enables linkage between clinical data held in the RSC and virology data, including sequencing data, held by the UKHSA. We describe the governance framework for the RSC., Results: We are co-designing our communication about data sharing and sampling, contextualized by the mosaic framework, with national and general practice patient and public involvement groups. We present our ARI digital phenotype and the key data RSC network members are requested to include in computerized medical records. We will share data with the UKHSA to report vaccine effectiveness for COVID-19 and influenza, assess the disease burden of respiratory syncytial virus, and perform syndromic surveillance. Virological surveillance will include COVID-19, influenza, respiratory syncytial virus, and other common respiratory viruses. We plan to pilot point-of-care testing for group A streptococcus, urine tests for pneumococcus, and asymptomatic testing. We will integrate test requests and results with the laboratory-computerized medical record system. A biomedical resource will enable research linking clinical data to virology data. The legal basis for the RSC's pseudonymized data extract is The Health Service (Control of Patient Information) Regulations 2002, and all nonsurveillance uses require research ethics approval., Conclusions: The RSC extended its surveillance activities to meet more but not all of the mosaic framework's objectives. We have introduced an ARI indicator. We seek to expand our surveillance scope and could do more around transmissibility and the benefits and risks of nonvaccine therapies., (©Xinchun Gu, Conall Watson, Utkarsh Agrawal, Heather Whitaker, William H. Elson, Sneha Anand, Ray Borrow, Anna Buckingham, Elizabeth Button, Lottie Curtis, Dominic Dunn, Alex J. Elliot, Filipa Ferreira, Rosalind Goudie, Uy Hoang, Katja Hoschler, Gavin Jamie, Debasish Kar, Beatrix Kele, Meredith Leston, Ezra Linley, Jack Macartney, Gemma L Marsden, Cecilia Okusi, Omid Parvizi, Catherine Quinot, Praveen Sebastianpillai, Vanashree Sexton, Gillian Smith, Timea Suli, Nicholas P B Thomas, Catherine Thompson, Daniel Todkill, Rashmi Wimalaratna, Matthew Inada-Kim, Nick Andrews, Victoria Tzortziou-Brown, Rachel Byford, Maria Zambon, Jamie Lopez-Bernal, Simon de Lusignan. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 03.04.2024.)

Background: Tackling the public health challenge of antimicrobial resistance (AMR) requires promotion of appropriate antimicrobial use by health-care professionals. The objective of this review was to identify interventions that facilitate appropriate antimicrobial behaviours when health-care professionals interact with patients and any considerations for factors associated with health inequalities., Methods: For this systematic review, we searched electronic databases (MEDLINE, EMBASE, Web of Science and Google Scholar) from Jan 31, 2023, to Feb 8, 2023. We included search terms such as antimicrobial use/prescribing, health-care professionals, and AMR programmes. We included any relevant primary study published from year 2010 and in English. We conducted forward and backward citation searching from included studies on March 27, 2023. We extracted information on the interventions following the Template for Intervention Description and Replication (TIDieR) guideline and examined reports on how the interventions might impact on inequalities. We performed quality assessment using the Mixed Methods Appraisal Tool (MMAT). We conducted descriptive synthesis. The protocol is registered with PROSPERO (CRD42023395642)., Findings: After screening 4979 records, we included 59 studies. Most studies were randomised trials (n=25) and qualitative/mixed methods studies (n=16). Included studies covered 16 countries, particularly the UK (n=16) and the USA (n=13). Most studies (n=34) fulfilled at least 80% of the relevant quality criteria, but 12 studies fulfilled less than 50%. Many interventions were established strategies (eg, TARGET: Treat Antibiotics Responsibly, Guidance, Education and Tools). Patient interaction elements of the interventions often involved using education materials (eg, digital/paper leaflets, and videos) and point-of-care testing. While many studies (n=49) included participants from disadvantaged groups, only three examined how outcomes differ between groups. In those studies, antimicrobial prescription was not associated with age, sex, and level of learning disability. Some other studies reported issues with language barriers and potential digital exclusion, especially for older people., Interpretation: We might have missed some relevant studies due to publication year and language restrictions. Notwithstanding, this review showed that the potential impact of factors associated with health inequalities are not routinely considered during the implementation and evaluation of interventions to improve health-care professionals' interaction with patients. Future work should routinely consider this to help mitigate potential inequalities., Funding: UK Health Security Agency., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

The SARS-CoV-2 pandemic has been characterized by the repeated emergence of genetically distinct virus variants of increased transmissibility and immune evasion compared to pre-existing lineages. In many countries, their containment required the intervention of public health authorities and the imposition of control measures. While the primary role of testing is to identify infection, target treatment, and limit spread (through isolation and contact tracing), a secondary benefit is in terms of surveillance and the early detection of new variants. Here we study the spatial invasion and early spread of the Alpha, Delta and Omicron (BA.1 and BA.2) variants in England from September 2020 to February 2022 using the random neighbourhood covering (RaNCover) method. This is a statistical technique for the detection of aberrations in spatial point processes, which we tailored here to community PCR (polymerase-chain-reaction) test data where the TaqPath kit provides a proxy measure of the switch between variants. Retrospectively, RaNCover detected the earliest signals associated with the four novel variants that led to large infection waves in England. With suitable data our method therefore has the potential to rapidly detect outbreaks of future SARS-CoV-2 variants, thus helping to inform targeted public health interventions.

Chickenpox is a common childhood disease caused by varicella-zoster virus (VZV). VZV vaccination is not part of the UK childhood immunisation programme, but its potential inclusion is regularly assessed. It is therefore important to understand the ongoing burden of VZV in the community to inform vaccine policy decisions. General practitioner (GP) chickenpox consultations were studied from 1 September 2016 to 9 December 2022. Over the study period, the mean weekly chickenpox consultation rate per 100,000 population in England was 3.4, with a regular peak occurring between weeks 13 and 15. Overall, rates decreased over time, from a mean weekly rate of 5.5 in 2017 to 4.2 in 2019. The highest mean weekly rates were among children aged 1-4 years. There was no typical epidemic peak during the COVID-19 pandemic, but in 2022, rates were proportionally higher among children aged < 1 year old compared to pre-pandemic years. Chickenpox GP consultation rates decreased in England, continuing a longer-term decline in the community. The COVID-19 pandemic impacted rates, likely caused by the introduction of non-pharmaceutical interventions to prevent SARS-CoV-2 transmission. The lasting impact of the interruption of typical disease transmission remains to be seen, but it is important to monitor the chickenpox burden to inform decisions on vaccine programmes.

Seasonal peaks in infectious disease incidence put pressures on health services. Therefore, early warning of the timing and magnitude of peak activity during seasonal epidemics can provide information for public health practitioners to take appropriate action. Whilst many infectious diseases have predictable seasonality, newly emerging diseases and the impact of public health interventions can result in unprecedented seasonal activity. We propose a Machine Learning process for generating short-term forecasts, where models are selected based on their ability to correctly forecast peaks in activity, and can be useful during atypical seasons. We have validated our forecasts using typical and atypical seasonal activity, using respiratory syncytial virus (RSV) activity during 2019-2021 as an example. During the winter of 2020/21 the usual winter peak in RSV activity in England did not occur but was 'deferred' until the Spring of 2021. We compare a range of Machine Learning regression models, with alternate models including different independent variables, e.g. with or without seasonality or trend variables. We show that the best-fitting model which minimises daily forecast errors is not the best model for forecasting peaks when the selection criterion is based on peak timing and magnitude. Furthermore, we show that best-fitting models for typical seasons contain different variables to those for atypical seasons. Specifically, including seasonality in models improves performance during typical seasons but worsens it for the atypical seasons., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Morbey 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.)

Objective: Countries routinely offering acellular pertussis vaccine, where long-term protection is not sustained, have the challenge of selecting an optimal schedule to minimise disease among young infants. We conducted a narrative systematic review and synthesis of information to evaluate different pertussis immunisation strategies at controlling pertussis disease, hospitalisation, deaths, and vaccine effectiveness among young infants., Methods: We conducted a review of the literature on studies about the primary, booster, and/or maternal vaccination series and synthesised findings narratively. Countries offering the first three doses of vaccine within six-months of life and a booster on or before the second year or life were defined as accelerated primary and booster schedules, respectively. Countries offering primary and booster doses later were defined as extended primary and booster schedules. All search results were screened, and articles reviewed and reconciled, by two authors. The Risk of Bias in Non-randomised Studies of Intervention tool was used to evaluate the risk of bias., Findings: A total of 98 studies were included in the analyses and the following recurring themes were described: timing of vaccination, vaccine coverage, waning immunity/vaccine effectiveness, direct and indirect effectiveness, switching from an accelerated to extended schedule, impact of changes in testing. The risk of bias was generally low to moderate for most studies., Conclusion: Comparing schedules is challenging and there was insufficient evidence to that one schedule was superior to another. Countries must select a schedule that maintains high vaccine coverage and reduced the risk of delaying the delivery vaccines to protect infants., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: The UK Health Security Agency (UKHSA) has provided vaccine manufacturers with post-marketing surveillance reports which the companies are required to submit to the UK Licensing Authority in compliance with their Risk Management Strategy, and a cost recovery charge is made for these reports., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Syndromic surveillance was originally developed to provide early warning compared to laboratory surveillance, but it is increasing used for real-time situational awareness. When a potential threat to public health is identified, a rapid assessment of its impact is required for public health management. When threats are localised, analysis is more complex as local trends need to be separated from national trends and differences compared to unaffected areas may be due to confounding factors such as deprivation or age distributions. Accounting for confounding factors usually requires an in-depth study, which takes time. Therefore, a tool is required which can provide a rapid estimate of local incidents using syndromic surveillance data.Here, we present 'DiD IT?', a new investigation tool designed to measure the impact of local threats to public health. 'DiD IT?' uses a difference-in-differences statistical approach to account for temporal and spatial confounding and provide a direct estimate of impact due to incidents. Temporal confounding differences are estimated by comparing unaffected locations during and outside of exposure periods. Whilst spatial confounding differences are estimated by comparing unaffected and exposed locations outside of the exposure period. Any remaining differences can be considered to be the direct effect of the local incident.We illustrate the potential utility of the tool through four examples of localised health protection incidents in England. The examples cover a range of data sources including general practitioner (GP) consultations, emergency department (ED) attendances and a telehealth call and online health symptom checker; and different types of incidents including, infectious disease outbreak, mass-gathering, extreme weather and an industrial fire. The examples use the UK Health Security Agency's ongoing real-time syndromic surveillance systems to show how results can be obtained in near real-time.The tool identified 700 additional online difficulty breathing assessments associated with a severe thunderstorm, 53 additional GP consultations during a mumps outbreak, 2-3 telehealth line calls following an industrial fire and that there was no significant increase in ED attendances during the G7 summit in 2021.DiD IT? can provide estimates for the direct impact of localised events in real-time as part of a syndromic surveillance system. Thus, it has the potential for enhancing surveillance and can be used to evaluate the effectiveness of extending national surveillance to a more granular local surveillance.

Background: The Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) is one of Europe's oldest sentinel systems, working with the UK Health Security Agency (UKHSA) and its predecessor bodies for 55 years. Its surveillance report now runs twice weekly, supplemented by online observatories. In addition to conducting sentinel surveillance from a nationally representative group of practices, the RSC is now also providing data for syndromic surveillance., Objective: The aim of this study was to describe the cohort profile at the start of the 2021-2022 surveillance season and recent changes to our surveillance practice., Methods: The RSC's pseudonymized primary care data, linked to hospital and other data, are held in the Oxford-RCGP Clinical Informatics Digital Hub, a Trusted Research Environment. We describe the RSC's cohort profile as of September 2021, divided into a Primary Care Sentinel Cohort (PCSC)-collecting virological and serological specimens-and a larger group of syndromic surveillance general practices (SSGPs). We report changes to our sampling strategy that brings the RSC into alignment with European Centre for Disease Control guidance and then compare our cohort's sociodemographic characteristics with Office for National Statistics data. We further describe influenza and COVID-19 vaccine coverage for the 2020-2021 season (week 40 of 2020 to week 39 of 2021), with the latter differentiated by vaccine brand. Finally, we report COVID-19-related outcomes in terms of hospitalization, intensive care unit (ICU) admission, and death., Results: As a response to COVID-19, the RSC grew from just over 500 PCSC practices in 2019 to 1879 practices in 2021 (PCSC, n=938; SSGP, n=1203). This represents 28.6% of English general practices and 30.59% (17,299,780/56,550,136) of the population. In the reporting period, the PCSC collected >8000 virology and >23,000 serology samples. The RSC population was broadly representative of the national population in terms of age, gender, ethnicity, National Health Service Region, socioeconomic status, obesity, and smoking habit. The RSC captured vaccine coverage data for influenza (n=5.4 million) and COVID-19, reporting dose one (n=11.9 million), two (n=11 million), and three (n=0.4 million) for the latter as well as brand-specific uptake data (AstraZeneca vaccine, n=11.6 million; Pfizer, n=10.8 million; and Moderna, n=0.7 million). The median (IQR) number of COVID-19 hospitalizations and ICU admissions was 1181 (559-1559) and 115 (50-174) per week, respectively., Conclusions: The RSC is broadly representative of the national population; its PCSC is geographically representative and its SSGPs are newly supporting UKHSA syndromic surveillance efforts. The network captures vaccine coverage and has expanded from reporting primary care attendances to providing data on onward hospital outcomes and deaths. The challenge remains to increase virological and serological sampling to monitor the effectiveness and waning of all vaccines available in a timely manner., (©Meredith Leston, William H Elson, Conall Watson, Anissa Lakhani, Carole Aspden, Clare R Bankhead, Ray Borrow, Elizabeth Button, Rachel Byford, Alex J Elliot, Xuejuan Fan, Uy Hoang, Ezra Linley, Jack Macartney, Brian D Nicholson, Cecilia Okusi, Mary Ramsay, Gillian Smith, Sue Smith, Mark Thomas, Dan Todkill, Ruby SM Tsang, William Victor, Alice J Williams, John Williams, Maria Zambon, Gary Howsam, Gayatri Amirthalingam, Jamie Lopez-Bernal, F D Richard Hobbs, Simon de Lusignan. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 19.12.2022.)

The rapid detection of outbreaks is a key step in the effective control and containment of infectious diseases. In particular, the identification of cases which might be epidemiologically linked is crucial in directing outbreak-containment efforts and shaping the intervention of public health authorities. Often this requires the detection of clusters of cases whose numbers exceed those expected by a background of sporadic cases. Quantifying exceedances rapidly is particularly challenging when only few cases are typically reported in a precise location and time. To address such important public health concerns, we present a general method which can detect spatio-temporal deviations from a Poisson point process and estimate the odds of an isolate being part of a cluster. This method can be applied to diseases where detailed geographical information is available. In addition, we propose an approach to explicitly take account of delays in microbial typing. As a case study, we considered invasive group A Streptococcus infection events as recorded and typed by Public Health England from 2015 to 2020., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Cavallaro 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.)

Extreme weather events present significant global threats to health. The National Ambulance Syndromic Surveillance System collects data on 18 syndromes through chief presenting complaint (CPC) codes. We aimed to determine the utility of ambulance data to monitor extreme temperature events for action. Daily total calls were observed between 01/01/2018−30/04/2019. Median daily ’Heat/Cold’ CPC calls during “known extreme temperature” (identified a priori), “extreme temperature”; (within 5th or 95th temperature percentiles for central England) and meteorological alert periods were compared to all other days using Wilcoxon signed-rank test. During the study period, 12,585,084 calls were recorded. In 2018, median daily “Heat/Cold” calls were higher during periods of known extreme temperature: heatwave (16/day, 736 total) and extreme cold weather events (28/day, 339 total) compared to all other days in 2018 (6/day, 1672 total). Median daily “Heat/Cold” calls during extreme temperature periods (16/day) were significantly higher than non-extreme temperature periods (5/day, p < 0.001). Ambulance data can be used to identify adverse impacts during periods of extreme temperature. Ambulance data are a low resource, rapid and flexible option providing real-time data on a range of indicators. We recommend ambulance data are used for the surveillance of presentations to healthcare related to extreme temperature events.

Background: Socioeconomic deprivation is associated with health inequality. Previous studies have described associations between primary care prescribing rates and deprivation for individual drugs or drug classes. We explore the correlation between socioeconomic deprivation and the rate of prescribing of individual pharmaceutical drugs, and drug classes, in primary care in England, to identify prescribing inequalities that would require further investigation., Methods: In this cross-sectional study, national primary care prescribing data, by primary care practice, were retrieved for the calendar year 2019 in England. Socioeconomic deprivation was quantified using the Index of Multiple Deprivation (IMD) score. Correlations were calculated using Spearman's rank correlation coefficient (ρ), adjusting for practice list size and demographics, with a Bonferroni-corrected p value threshold of 5×10 -5 ., Results: We included 1.05 billion prescription items dispensed from 6896 England practices. 142/206 (69%) drug classes and 505/774 (65%) drugs were significantly correlated with IMD score (p<5×10 -5 ). Of the 774 included drugs, 31 (4%) were moderately positively associated with IMD score (ρ>0.4). Only one was moderately negatively correlated with IMD score (ρ<-0.4), suggesting higher prescribing rates in more affluent areas. The drug classes most strongly associated with IMD score included opioid and non-opioid analgesics, antipsychotics and reflux medications. Drug classes most strongly associated with affluence included epinephrine, combined oral contraceptives and hormone replacement therapy., Conclusion: We identify novel associations of prescribing with deprivation. Further work is required to identify the underlying reasons for these associations so that appropriate interventions can be formulated to address drivers of inequality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Surveillance systems need to be evaluated to understand what the system can or cannot detect. The measures commonly used to quantify detection capabilities are sensitivity, positive predictive value and timeliness. However, the practical application of these measures to multi-purpose syndromic surveillance services is complex. Specifically, it is very difficult to link definitive lists of what the service is intended to detect and what was detected. First, we discuss issues arising from a multi-purpose system, which is designed to detect a wide range of health threats, and where individual indicators, e.g. 'fever', are also multi-purpose. Secondly, we discuss different methods of defining what can be detected, including historical events and simulations. Finally, we consider the additional complexity of evaluating a service which incorporates human decision-making alongside an automated detection algorithm. Understanding the complexities involved in evaluating multi-purpose systems helps design appropriate methods to describe their detection capabilities., Competing Interests: Competing Interests No Competing Interests., (This is an Open Access article. Authors own copyright of their articles appearing in the Journal of Public Health Informatics. Readers may copy articles without permission of the copyright owner(s), as long as the author and OJPHI are acknowledged in the copy and the copy is used for educational, not-for-profit purposes.)

Thunderstorm asthma is often characterised by a sudden surge in patients presenting with exacerbated symptoms of asthma linked to thunderstorm activity. Here, we describe a large spike in asthma and difficulty breathing symptoms observed across parts of England on 17 June 2021. The number of healthcare presentations during the asthma event was compared to expected levels for the overall population and across specific regions. Across affected geographical areas, emergency department attendances for asthma increased by 560% on 17 June compared to the average number of weekday daily attendances during the previous 4 weeks. General practitioner out of hours contacts increased by 349%, National Health Service (NHS) 111 calls 193%, NHS 111 online assessments 581% and ambulance call outs 54%. Increases were particularly noted in patient age groups 5-14 and 15-44 years. In non-affected regions, increases were small (<10%) or decreased, except for NHS 111 online assessments where there was an increase of 39%. A review of the meteorological conditions showed several localised, weak, or moderate thunderstorms specifically across parts of Southeast England on the night of June 16. In this unprecedented episode of asthma, the links to meteorologically defined thunderstorm activity were not as clear as previous episodes, with less evidence of 'severe' thunderstorm activity in those areas affected, prompting further discussion about the causes of these events and implications for public health management of the risk.

Background: In August 2020, an outbreak of Shiga toxin-producing Escherichia coli (STEC) O157:H7 occurred in the United Kingdom. Whole genome sequencing revealed that these cases formed a genetically distinct cluster., Methods: Hypotheses generated from case interviews were tested in analytical studies, and results informed environmental sampling and food chain analysis. A case-case study used non-outbreak 'comparison' STEC cases; a case-control study used a market research panel to recruit controls., Results: A total of 36 cases were identified; all cases reported symptom onset between August 3 and August 16, 2020. The majority of cases (83%) resided in the Midlands region of England and in Wales. A high proportion of cases reported eating out, with one fast-food restaurant chain mentioned by 64% (n = 23) of cases. Both the case-case study (adjusted odds ratio (aOR) 31.8, 95% confidence interval (CI) 1.6-624.9) and the case-control study (aOR 9.19, 95% CI 1.0-82.8) revealed statistically significant results, showing that the consumption of a specific fast-food product was independently associated with infection., Conclusions: Consumption of a specific fast-food product was a likely cause of this outbreak. The only ingredient specific to the product was cucumbers. The supply of cucumbers was immediately halted, and no further cases have been identified., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: In March 2018, NHS England published guidance for clinical commissioning groups (CCGs) to encourage implementation of policy to reduce primary care prescriptions of over-the-counter medications, including simple analgesia., Aim: To investigate the impact of guidance publication on prescribing rates of simple analgesia (oral paracetamol, oral ibuprofen, and topical non-steroidal anti-inflammatory drugs) in primary care; CCG guidance implementation intentions; and whether the guidance has created health inequality based on socioeconomic status., Design and Setting: Interrupted time series analysis of primary care prescribing data in England., Method: Practice-level prescribing data from January 2015 to March 2019 were obtained from NHS Digital. Interrupted time series analyses were used to assess the association of guidance publication with prescribing rates. The association between practice-level prescribing rates and Index of Multiple Deprivation scores before and after publication was quantified using multivariable Poisson regression. Freedom of information requests were submitted to all CCGs., Results: There was a statistically significant 4.4% reduction in prescribing of simple analgesia following guidance publication (adjusted incidence rate ratio 0.96, 95% CI = 0.92 to 0.99, P = 0.027), adjusting for underlying time trend and seasonality. There was considerable diversity across CCGs in whether or how they chose to implement the guidance. Practice-level prescribing rates were greater in more deprived areas., Conclusion: Guidance publication was associated with a small reduction in the prescribing rates of simple analgesia across England, without evidence of creating additional health inequality. Careful implementation by CCGs would be required to optimise cost saving to the NHS., (© The Authors.)

Objectives: To identify key predictors of general practitioner (GP) consultations for allergic rhinitis (AR) using meteorological and environmental data., Design: A retrospective, time series analysis of GP consultations for AR., Setting: A large GP surveillance network of GP practices in the London area., Participants: The study population was all persons who presented to general practices in London that report to the Public Health England GP in-hours syndromic surveillance system during the study period (3 April 2012 to 11 August 2014)., Primary Measure: Consultations for AR (numbers of consultations)., Results: During the study period there were 186 401 GP consultations for AR. High grass and nettle pollen counts (combined) were associated with the highest increases in consultations (for the category 216-270 grains/m 3 , relative risk (RR) 3.33, 95% CI 2.69 to 4.12) followed by high tree (oak, birch and plane combined) pollen counts (for the category 260-325 grains/m 3 , RR 1.69, 95% CI 1.32 to 2.15) and average daily temperatures between 15°C and 20°C (RR 1.47, 95% CI 1.20 to 1.81). Higher levels of nitrogen dioxide (NO 2 ) appeared to be associated with increased consultations (for the category 70-85 µg/m 3 , RR 1.33, 95% CI 1.03 to 1.71), but a significant effect was not found with ozone. Higher daily rainfall was associated with fewer consultations (15-20 mm/day; RR 0.812, 95% CI 0.674 to 0.980)., Conclusions: Changes in grass, nettle or tree pollen counts, temperatures between 15°C and 20°C, and (to a lesser extent) NO 2 concentrations were found to be associated with increased consultations for AR. Rainfall has a negative effect. In the context of climate change and continued exposures to environmental air pollution, intelligent use of these data will aid targeting public health messages and plan healthcare demand., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Concerns have been raised that women from deprived backgrounds are less likely to be receiving hormone replacement therapy (HRT) treatment and its benefits, although evidence in support of this is lacking., Aim: To investigate general practice HRT prescription trends and their association with markers of socioeconomic deprivation., Design and Setting: Cross-sectional study of primary care prescribing data in England in 2018., Method: Practice-level prescribing rate was defined as the number of items of HRT prescribed per 1000 registered female patients aged ≥40 years. The association between Index of Multiple Deprivation (IMD) score and HRT prescribing rate was tested using multivariate Poisson regression, adjusting for practice proportions of obesity, smoking, hypertension, diabetes, coronary heart disease and cerebrovascular disease, and practice list size., Results: The overall prescribing rate of HRT was 29% lower in practices from the most deprived quintile compared with the most affluent (incidence rate ratio [IRR] = 0.71; 95% confidence interval [CI] = 0.68 to 0.73). After adjusting for all cardiovascular disease outcomes and risk factors, the prescribing rate in the most deprived quintile was still 18% lower than in the least deprived quintile (adjusted IRR = 0.82; 95% CI = 0.77 to 0.86). In more deprived practices, there was a significantly higher tendency to prescribe oral HRT than transdermal preparations ( P <0.001)., Conclusion: This study highlights inequalities associated with HRT prescription. This may reflect a large unmet need in terms of menopause care in areas of deprivation. Further research is needed to identify the factors from patient and GP perspectives that may explain this., (© British Journal of General Practice 2020.)

Background: Benzodiazepines and Z-drugs (such as zopiclone) are widely prescribed in primary care. Given their association with addiction and dependence, understanding where and for whom these medications are being prescribed is a necessary step in addressing potentially harmful prescribing., Objective: To determine whether there is an association between primary care practice benzodiazepine and Z-drug prescribing and practice population socioeconomic status in England., Methods: This was a cross-sectional study. An aggregated data set was created to include primary care prescribing data for 2017, practice age and sex profiles and practice Index of Multiple Deprivation (IMD) scores-a marker of socioeconomic status. Drug doses were converted to their milligram-equivalent of diazepam to allow comparison. Multiple linear regression was used to examine the association between IMD and prescribing (for all benzodiazepines and Z-drugs in total, and individually), adjusting for practice sex (% male) and older age (>65 years) distribution (%)., Results: Benzodiazepine and Z-drug prescribing overall was positively associated with practice-level IMD score, with more prescribing in practices with more underserved patients, after adjusting for age and sex (P < 0.001), although the strength of the association varied by individual drug. Overall, however, IMD score, age and sex only explained a small proportion of the overall variation in prescribing across GP practices., Conclusion: Our findings may, in part, be a reflection of an underlying association between the indications for benzodiazepine and Z-drug prescribing and socioeconomic status. Further work is required to more accurately define the major contributors of prescribing variation., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Between 11-13 December 2018, local public health authorities in the West Midlands, England were alerted to 34 reports of diarrhoea with abdominal cramps. Symptom onset was ~10 h after diners ate Christmas meals at a restaurant between 7-9 December 2018. A retrospective case-control study, environmental and microbiological investigations were undertaken to determine the source and control the outbreak. An analytical study was undertaken with odds ratios (OR) and 95% confidence intervals (CI). Forty persons were recruited to the analytical study (28/40 cases). Multivariable analysis found that leeks in cheese sauce was the only item associated with illness (aOR 51.1; 95% CI 4.13-2492.1). Environmental investigations identified significant lapses in food safety, including lapses in temperature control during cooking and hot holding, likely cross-contamination between raw and cooked foods and the reuse of leftover cheese sauce for the next day's service. No food samples were taken during the exposure period. Two faecal samples were positive for Clostridium perfringens with one confirming the enterotoxigenic gene. Cheese sauce is an unusual vehicle for the organism and the first time this has been reported in England.

In January 2015, Public Health England and the United Kingdom (UK) Ministry of Defence investigated cases of diarrhoea and fever in military personnel recently returned to the UK after supporting the response to the Ebola epidemic in Sierra Leone. Tests for Ebola virus infection were negative. PCR tests detected the ipaH gene in 10/12 faecal specimens, and Shigella boydii serotype 20 was isolated from 7 patients. A case control study was undertaken and analysed using multivariable logistic regression. Consumption of a coronation chicken lunch at the transit camp in Sierra Leone (SL) 24-48 h prior to departure for the UK was significantly associated with disease [adjusted odds ratio (OR) 28.15, 95 % CI: 1.87-422.65]. In the context of heightened concern during the Ebola epidemic, this outbreak highlights the importance of rapid and effective microbiological and epidemiological investigations to identify the aetiological agent in patients presenting with fever and diarrhoea.

Introduction The Public Health England (PHE; United Kingdom) Real-Time Syndromic Surveillance Team (ReSST) currently operates four national syndromic surveillance systems, including an emergency department system. A system based on ambulance data might provide an additional measure of the "severe" end of the clinical disease spectrum. This report describes the findings and lessons learned from the development and preliminary assessment of a pilot syndromic surveillance system using ambulance data from the West Midlands (WM) region in England. Hypothesis/Problem Is an Ambulance Data Syndromic Surveillance System (ADSSS) feasible and of utility in enhancing the existing suite of PHE syndromic surveillance systems?, Methods: An ADSSS was designed, implemented, and a pilot conducted from September 1, 2015 through March 1, 2016. Surveillance cases were defined as calls to the West Midlands Ambulance Service (WMAS) regarding patients who were assigned any of 11 specified chief presenting complaints (CPCs) during the pilot period. The WMAS collected anonymized data on cases and transferred the dataset daily to ReSST, which contained anonymized information on patients' demographics, partial postcode of patients' location, and CPC. The 11 CPCs covered a broad range of syndromes. The dataset was analyzed descriptively each week to determine trends and key epidemiological characteristics of patients, and an automated statistical algorithm was employed daily to detect higher than expected number of calls. A preliminary assessment was undertaken to assess the feasibility, utility (including quality of key indicators), and timeliness of the system for syndromic surveillance purposes. Lessons learned and challenges were identified and recorded during the design and implementation of the system., Results: The pilot ADSSS collected 207,331 records of individual ambulance calls (daily mean=1,133; range=923-1,350). The ADSSS was found to be timely in detecting seasonal changes in patterns of respiratory infections and increases in case numbers during seasonal events., Conclusions: Further validation is necessary; however, the findings from the assessment of the pilot ADSSS suggest that selected, but not all, ambulance indicators appear to have some utility for syndromic surveillance purposes in England. There are certain challenges that need to be addressed when designing and implementing similar systems. Todkill D , Loveridge P , Elliot AJ , Morbey RA , Edeghere O , Rayment-Bishop T , Rayment-Bishop C , Thornes JE , Smith G . Utility of ambulance data for real-time syndromic surveillance: a pilot in the West Midlands region, United Kingdom. Prehosp Disaster Med. 2017;32(6):667-672.

Objective: Allergic rhinitis (AR) is a global health problem, potentially impacting individuals' sleep, work and social life. We aimed to use a surveillance network of general practitioners (GPs) to describe the epidemiology of AR consultations in England., Setting: A large GP surveillance network covering approximately 53% of the English population., Methods: GP consultations for AR across England between 30 December 2002 and 31 December 2014 were analysed. Using more granular data available between 2 April 2012 and 31 December 2014 rates and rate ratios (RR) of AR were further analysed in different age groups, gender, rural-urban classification and index of multiple deprivation score quintile of location of GP., Results: The mean weekly rate for AR consultations was 19.8 consultations per 100 000 GP registered patients (range 1.13-207), with a regular peak occurring during June (weeks 24-26), and a smaller peak during April. Between 1 April 2012 and 31 December 2014, the highest mean daily rates of consultations per 1 00 000 were: in age group 5-14 years (rate=8.02, RR 6.65, 95% CI 6.38 to 6.93); females (rate=4.57, RR 1.12 95% CI 1.12 to 1.13); persons registered at a GP in the most socioeconomically deprived quintile local authority (rate=5.69, RR 1.48, 95% CI 1.47 to 1.49) or in an urban area with major conurbation (rate=5.91, RR 1.78, 95% CI 1.69 to 1.87)., Conclusions: AR rates were higher in those aged 5-14 years, females and in urban and socioeconomically deprived areas. This needs to be viewed in the context of this study's limitations but should be considered in health promotion and service planning., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction In preparation for the London 2012 Olympic Games, existing syndromic surveillance systems operating in England were expanded to include daily general practitioner (GP) out-of-hours (OOH) contacts and emergency department (ED) attendances at sentinel sites (the GP OOH and ED syndromic surveillance systems: GPOOHS and EDSSS). Hypothesis/Problem The further development of syndromic surveillance systems in time for the London 2012 Olympic Games provided a unique opportunity to investigate the impact of a large mass-gathering event on public health and health services as monitored in near real-time by syndromic surveillance of GP OOH contacts and ED attendances. This can, in turn, aid the planning of future events., Methods: The EDSSS and GPOOHS data for London and England from July 13 to August 26, 2012, and a similar period in 2013, were divided into three distinct time periods: pre-Olympic period (July 13-26, 2012); Olympic period (July 27 to August 12); and post-Olympic period (August 13-26, 2012). Time series of selected syndromic indicators in 2012 and 2013 were plotted, compared, and risk assessed by members of the Real-time Syndromic Surveillance Team (ReSST) in Public Health England (PHE). Student's t test was used to test any identified changes in pattern of attendance., Results: Very few differences were found between years or between the weeks which preceded and followed the Olympics. One significant exception was noted: a statistically significant increase (P value = .0003) in attendances for "chemicals, poisons, and overdoses, including alcohol" and "acute alcohol intoxication" were observed in London EDs coinciding with the timing of the Olympic opening ceremony (9:00 pm July 27, 2012 to 01:00 am July 28, 2012)., Conclusions: Syndromic surveillance was able to provide near to real-time monitoring and could identify hourly changes in patterns of presentation during the London 2012 Olympic Games. Reassurance can be provided to planners of future mass-gathering events that there was no discernible impact in overall attendances to sentinel EDs or GP OOH services in the host country. The increase in attendances for alcohol-related causes during the opening ceremony, however, may provide an opportunity for future public health interventions. Todkill D , Hughes HE , Elliot AJ , Morbey RA , Edeghere O , Harcourt S , Hughes T , Endericks T , McCloskey B , Catchpole M , Ibbotson S , Smith G . An observational study using English syndromic surveillance data collected during the 2012 London Olympics - what did syndromic surveillance show and what can we learn for future mass-gathering events? Prehosp Disaster Med. 2016;31(6):628-634.

To determine whether the recommended screening interval for diabetic retinopathy (DR) in the UK can safely be extended beyond 1 year. Systematic review of clinical and cost-effectiveness studies. Nine databases were searched with no date restrictions. Randomised controlled trials (RCTs), cohort studies, prognostic or economic modelling studies which described the incidence and progression of DR in populations with type 1 diabetes mellitus or type 2 diabetes mellitus of either sex and of any age reporting incidence and progression of DR in relation to screening interval (vs annual screening interval) and/or prognostic factors were included. Narrative synthesis was undertaken. 14,013 papers were identified, of which 11 observational studies, 5 risk stratification modelling studies and 9 economic studies were included. Data were available for 262,541 patients of whom at least 228,649 (87%) had type 2 diabetes. There were no RCTs. Studies concluded that there is little difference between clinical outcomes from screening 1 yearly or 2 yearly in low-risk patients. However there was high loss to follow-up (13-31%), heterogeneity in definitions of low risk and variation in screening and grading protocols for prior retinopathy results. Observational and economic modelling studies in low-risk patients show little difference in clinical outcomes between 1-year and 2-year screening intervals. The lack of experimental research designs and heterogeneity in definition of low risk considerably limits the reliability and validity of this conclusion. Cost-effectiveness findings were mixed. There is insufficient evidence to recommend a move to extend the screening interval beyond 1 year., (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: Two major determinants of cardiovascular disease (CVD) are a sedentary lifestyle and stress. Qigong involves physical exercise, mind regulation and breathing control to restore the flow of Qi (a pivotal life energy). As it is thought to help reduce stress and involves exercise, qigong may be an effective strategy for the primary prevention of CVD., Objectives: To determine the effectiveness of qigong for the primary prevention of CVD., Search Methods: We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (November 2014, Issue 10 of 12); MEDLINE (Ovid) (1946 to 2014 October week 4); EMBASE Classic + EMBASE (Ovid) (1947 to 2014 November 4); Web of Science Core Collection (1970 to 31 October 2014); Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database and Health Economics Evaluations Database (November 2014, Issue 4 of 4). We searched several Asian databases (inception to July 2013) and the Allied and Complementary Medicine Database (AMED) (inception to December 2013), as well as trial registers and reference lists of reviews and articles; we also approached experts in the field and applied no language restrictions in our search., Selection Criteria: Randomised controlled trials lasting at least three months involving healthy adults or those at high risk of CVD. Trials examined any type of qigong, and comparison groups provided no intervention or minimal intervention. Outcomes of interest included clinical CVD events and major CVD risk factors. We did not include trials that involved multi-factorial lifestyle interventions or weight loss., Data Collection and Analysis: Two review authors independently selected trials for inclusion. Two review authors extracted data from included studies and assessed the risk of bias., Main Results: We identified 11 completed trials (1369 participants) and one ongoing trial. Trials were heterogeneous in participants recruited, qigong duration and length of follow-up periods. We were unable to ascertain the risk of bias in nine trials published in Chinese, as insufficient methodological details were reported and we were unable to contact the study authors to clarify this.We performed no meta-analyses, as trials were small and were at significant risk of bias. Clinical events were detailed in subsequent reports of two trials when statistically significant effects of qigong were seen for all-cause mortality, stroke mortality and stroke incidence at 20 to 30 years after completion of the trials. However, these trials were designed to examine outcomes in the short term, and it is not clear whether qigong was practised during extended periods of follow-up; therefore effects cannot be attributed to the intervention. None of the included studies reported other non-fatal CVD events.Six trials provided data that could be used to examine the effects of qigong on blood pressure. Reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were seen in three and two trials, respectively. Three trials examined the effects of qigong on blood lipids when favourable effects were seen in one trial for total cholesterol, low-density lipoprotein (LDL) cholesterol and triglycerides, and two trials showed favourable effects on high-density lipoprotein (HDL) cholesterol. The only trial considered at low risk of selection and detection bias did not demonstrate statistically significant effects on CVD risk factors with qigong, but this study was small and was underpowered. None of the included studies reported incidence of type 2 diabetes (T2D), adverse events, quality of life or costs., Authors' Conclusions: Currently, very limited evidence is available on the effectiveness of qigong for the primary prevention of CVD. Most of the trials included in this review are likely to be at high risk of bias, so we have very low confidence in the validity of the results. Publication of the ongoing trial will add to the limited evidence base, but further trials of high methodological quality with sufficient sample size and follow-up are needed to be incorporated in an update of this review before the effectiveness of qigong for CVD prevention can be established.

Objectives: Poor knowledge of eye health, concerns about the cost of spectacles, mistrust of optometrists and limited geographical access in socio-economically deprived areas are barriers to accessing regular eye examinations and result in low uptake and subsequent late presentation to ophthalmology clinics. Personal Medical Services (PMS) were introduced in the late 1990 s to provide locally negotiated solutions to problems associated with inequalities in access to primary care. An equivalent approach to delivery of optometric services could address inequalities in the uptake of eye examinations., Study Design: One-way and multiway sensitivity analyses., Methods: Variations in assumptions were included in the models for equipment and accommodation costs, uptake and length of appointments. The sensitivity analyses thresholds were cost-per-person tested below the GOS1 fee paid by the NHS and achieving break-even between income and expenditure, assuming no cross-subsidy from profits from sales of optical appliances., Results: Cost per test ranged from £ 24.01 to £ 64.80 and subsidy required varied from £ 14,490 to £ 108,046. Unused capacity utilised for local enhanced service schemes such as glaucoma referral refinement reduced the subsidy needed., Conclusions: In order to support the financial viability of primary eye care in socio-economically deprived communities, income is required from additional subsidies or from sources other than eye examinations, such as ophthalmic or other optometric community services. This would require a significant shift of activity from secondary to primary care locations. The subsidy required could also be justified by the utility gain from earlier detection of preventable sight loss., (Copyright © 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: Cardiovascular disease (CVD) remains the number one cause of death and disability worldwide and public health interventions focus on modifiable risk factors, such as diet. Coenzyme Q10 (CoQ10) is an antioxidant that is naturally synthesised by the body and can also be taken as a dietary supplement. Studies have shown that a CoQ10 deficiency is associated with cardiovascular disease., Objectives: To determine the effects of coenzyme Q10 supplementation as a single ingredient for the primary prevention of CVD., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 11); MEDLINE (Ovid, 1946 to November week 3 2013); EMBASE (Ovid, 1947 to 27 November 2013) and other relevant resources on 2 December 2013. We applied no language restrictions., Selection Criteria: Randomised controlled trials (RCTs) lasting at least three months involving healthy adults or those at high risk of CVD but without a diagnosis of CVD. Trials investigated the supplementation of CoQ10 alone as a single supplement. The comparison group was no intervention or placebo. The outcomes of interest were CVD clinical events and major CVD risk factors, adverse effects and costs. We excluded any trials involving multifactorial lifestyle interventions to avoid confounding., Data Collection and Analysis: Two authors independently selected trials for inclusion, abstracted data and assessed the risk of bias.We contacted authors for additional information where necessary., Main Results: We identified six RCTs with a total of 218 participants randomised, one trial awaiting classification and five ongoing trials. All trials were conducted in participants at high risk of CVD, two trials examined CoQ10 supplementation alone and four examined CoQ10 supplementation in patients on statin therapy; we analysed these separately. All six trials were small-scale, recruiting between 20 and 52 participants; one trial was at high risk of bias for incomplete outcome data and one for selective reporting; all studies were unclear in the method of allocation and therefore for selection bias. The dose of CoQ10 varied between 100 mg/day and 200 mg/day and the duration of the interventions was similar at around three months.No studies reported mortality or non-fatal cardiovascular events. None of the included studies provided data on adverse events.Two trials examined the effect of CoQ10 on blood pressure. For systolic blood pressure we did not perform a meta-analysis due to significant heterogeneity. In one trial CoQ10 supplementation had no effect on systolic blood pressure (mean difference (MD) -1.90 mmHg, 95% confidence interval (CI) -13.17 to 9.37, 51 patients randomised). In the other trial there was a statistically significant reduction in systolic blood pressure (MD -15.00 mmHg, 95% CI -19.06 to -10.94, 20 patients randomised). For diastolic blood pressure we performed a random-effects meta-analysis, which showed no evidence of effect of CoQ10 supplementation when these two small trials were pooled (MD -1.62 mmHg, 95% CI -5.2 to 1.96).One trial (51 patients randomised) looked at the effect of CoQ10 on lipid levels. The trial showed no evidence of effect of CoQ10 supplementation on total cholesterol (MD 0.30 mmol/L, 95% CI -0.10 to 0.70), high-density lipoprotein (HDL)-cholesterol (MD 0.02 mmol/L, 95% CI -0.13 to 0.17) or triglycerides (MD 0.05 mmol/L, 95% CI -0.42 to 0.52).Of the four trials that investigated CoQ10 supplementation in patients on statin therapy, three of them showed that simultaneous administration of CoQ10 did not significantly influence lipid levels or systolic blood pressure levels between the two groups. The fourth trial showed a significant increase in the change in total and low-density lipoprotein (LDL)-cholesterol at three months across the four arms of the trial (α-tocopherol, CoQ10, CoQ10 + α-tocopherol and placebo), however the way in which the data were presented meant that we were unable to determine if there was any significant difference between the CoQ10 only and placebo arms. In contrast, there was no significant difference in the change in HDL-cholesterol and triglycerides after three months between the four arms of the trial., Authors' Conclusions: There are very few studies to date examining CoQ10 for the primary prevention of CVD. The results from the ongoing studies will add to the evidence base. Due to the small number of underpowered trials contributing to the analyses, the results presented should be treated with caution and further high quality trials with longer-term follow-up are needed to determine the effects on cardiovascular events.

Background: There are an increasing number of interventions being delivered online, and an expanding body of research to assess the effectiveness of such interventions. Yet, little is known about the motivations for participating in online research. Furthermore, internet interventions and online research studies are characterised by poor adherence and high attrition rates. This study aimed to explore participant motivations for taking part in an online trial of an internet intervention and the reasons for continuing., Methods: Semi-structured telephone interviews were conducted with twenty members of the intervention arm of an internet-based randomised control trial evaluating an online cognitive behavioural tool to improve mental wellbeing. The qualitative interviews were analysed using the Framework Approach to identify themes and subthemes, through familiarization with the data, identifying a thematic framework, charting, indexing, mapping and interpreting the data., Results: A number of key themes emerged. Trusted brands were key to participants feeling secure in engaging with the trial due to the association with institutions such as the UK National Health Service and the lead University conducting the research. Participants had a number of motivations for signing up with the study; altruism, low mood and as a replacement for a physical health professional. Participants felt the need for the language used in the intervention to be tailored to them as individuals. The majority of those interviewed also described multiple benefits from the intervention, which could have been a reason for them to persist., Conclusion: The nascent field of research on internet delivered healthcare needs to take account of participant views, as have been identified in this trial and future studies would benefit from applying its findings.