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Introduction People living with asthma require regular reviews to address their concerns and questions, assess control, review medication, and support self-management. However, practical barriers to attending face-to-face consultations might limit routine reviews. Reviewing asthma using asynchronous digital health interventions could be convenient for patients and an efficient way of maintaining communication between patients and healthcare professionals and improving health outcomes. We, therefore, aim to conduct a mixed-methods systematic review to assess the effectiveness of reviewing asthma by asynchronous digital health interventions and explore the views of patients and healthcare professionals about the role of such interventions in delivering asthma care. Methods We will search MEDLINE, Embase, Scopus, PsycInfo, CINAHL, and Cochrane Library from 2001 to present without imposing any language restrictions. We are interested in studies of asynchronous digital health interventions used either as a single intervention or contributing to mixed modes of review. Two review authors will independently screen titles and abstracts, and retrieve potentially relevant studies for full assessment against the eligibility criteria and extract data. Disagreements will be resolved by discussion with the review team. We will use ‘Downs and Black’ checklist, ‘Critical Appraisal Skills Programme’, and ‘Mixed Methods Appraisal Tool’ to assess methodological quality of quantitative, qualitative, and mixed-methods studies respectively. After synthesising quantitative (narrative synthesis) and qualitative (thematic synthesis) data separately, we will integrate them following methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Conclusion The findings of this review will provide insights into the role of asynchronous digital health interventions in the routine care of people living with asthma. Trial registration Systematic review registration: PROSPERO registration number: CRD42022344224.

IntroductionCOVID-19 is commonly experienced as an acute illness, yet some people continue to have symptoms that persist for weeks, or months (commonly referred to as ‘long-COVID’). It remains unclear which patients are at highest risk of developing long-COVID. In this protocol, we describe plans to develop a prediction model to identify individuals at risk of developing long-COVID.Methods and analysisWe will use the national Early Pandemic Evaluation and Enhanced Surveillance of COVID-19 (EAVE II) platform, a population-level linked dataset of routine electronic healthcare data from 5.4 million individuals in Scotland. We will identify potential indicators for long-COVID by identifying patterns in primary care data linked to information from out-of-hours general practitioner encounters, accident and emergency visits, hospital admissions, outpatient visits, medication prescribing/dispensing and mortality. We will investigate the potential indicators of long-COVID by performing a matched analysis between those with a positive reverse transcriptase PCR (RT-PCR) test for SARS-CoV-2 infection and two control groups: (1) individuals with at least one negative RT-PCR test and never tested positive; (2) the general population (everyone who did not test positive) of Scotland. Cluster analysis will then be used to determine the final definition of the outcome measure for long-COVID. We will then derive, internally and externally validate a prediction model to identify the epidemiological risk factors associated with long-COVID.Ethics and disseminationThe EAVE II study has obtained approvals from the Research Ethics Committee (reference: 12/SS/0201), and the Public Benefit and Privacy Panel for Health and Social Care (reference: 1920-0279). Study findings will be published in peer-reviewed journals and presented at conferences. Understanding the predictors for long-COVID and identifying the patient groups at greatest risk of persisting symptoms will inform future treatments and preventative strategies for long-COVID.

BackgroundThe COVID-19 pandemic’s impact on people with asthma is poorly understood. We hypothesised that lockdown restrictions were associated with reductions in severe asthma exacerbations requiring emergency asthma admissions and/or leading to death.MethodsUsing data from Public Health Scotland and the Secure Anonymised Information Linkage Databank in Wales, we compared weekly counts of emergency admissions and deaths due to asthma over the first 18 weeks in 2020 with the national averages over 2015–2019. We modelled the impact of instigating lockdown on these outcomes using interrupted time-series analysis. Using fixed-effect meta-analysis, we derived pooled estimates of the overall changes in trends across the two nations. We also investigated trends in asthma-related primary care prescribing and emergency department (ED) attendances in Wales.ResultsLockdown was associated with a 36% pooled reduction in emergency admissions for asthma (incidence rate ratio, IRR: 0.64, 95% CI: 0.49 to 0.83, p value 0.001) across both countries. There was no significant change in asthma deaths (pooled IRR: 0.57, 95% CI: 0.17 to 1.94, p value 0.37). ED asthma attendances in Wales declined during lockdown (IRR: 0.85, 95% CI: 0.73 to 0.99, p value 0.03). A large spike of 121% more inhaled corticosteroids and 133% more oral corticosteroid prescriptions was seen in Wales in the week before lockdown.ConclusionsNational lockdowns were associated with substantial reductions in severe asthma exacerbations leading to hospital admission across both Scotland and Wales, with no corresponding increase in asthma deaths.

Background While evidence from randomised controlled trials shows that telemonitoring for hypertension is associated with improved blood pressure (BP) control, healthcare systems have been slow to implement it, partly because of inadequate integration with existing clinical practices and electronic records. Neither is it clear if trial findings will be replicated in routine clinical practice at scale. We aimed to explore the feasibility and impact of implementing an integrated telemonitoring system for hypertension into routine primary care. Methods and findings This was a quasi-experimental implementation study with embedded qualitative process evaluation set in primary care in Lothian, Scotland. We described the overall uptake of telemonitoring and uptake in a subgroup of representative practices, used routinely acquired data for a records-based controlled before-and-after study, and collected qualitative data from staff and patient interviews and practice observation. The main outcome measures were intervention uptake, change in BP, change in clinician appointment use, and participants’ views on features that facilitated or impeded uptake of the intervention. Seventy-five primary care practices enrolled 3,200 patients with established hypertension. In an evaluation subgroup of 8 practices (905 patients of whom 427 [47%] were female and with median age of 64 years [IQR 56–70, range 22–89] and median Scottish Index of Multiple Deprivation 2012 decile of 8 [IQR 6–10]), mean systolic BP fell by 6.55 mm Hg (SD 15.17), and mean diastolic BP by 4.23 mm Hg (SD 8.68). Compared with the previous year, participating patients made 19% fewer face-to-face appointments, compared with 11% fewer in patients with hypertension who were not telemonitoring. Total consultation time for participants fell by 15.4 minutes (SD 68.4), compared with 5.5 minutes (SD 84.4) in non-telemonitored patients. The convenience of remote collection of BP readings and integration of these readings into routine clinical care was crucial to the success of the implementation. Limitations include the fact that practices and patient participants were self-selected, and younger and more affluent than non-participating patients, and the possibility that regression to the mean may have contributed to the reduction in BP. Routinely acquired data are limited in terms of completeness and accuracy. Conclusions Telemonitoring for hypertension can be implemented into routine primary care at scale with little impact on clinician workload and results in reductions in BP similar to those in large UK trials. Integrating the telemonitoring readings into routine data handling was crucial to the success of this initiative., Brian McKinstry and colleagues reveal the importance of telemonitoring in hypertension monitoring., Author summary Why was this study done? Although uncontrolled hypertension is the biggest remediable cause of stroke and myocardial infarction, and anti-hypertensive medications are effective, many patients have uncontrolled blood pressure (BP). Despite strong evidence that telemonitoring encourages medication use and is effective at lowering BP, clinicians have been slow to adopt it, in part due to poor integration with routine clinical processes. We wanted to see if an integrated telemonitoring system would be taken up by primary care clinicians at scale, what impact this would have on their workload, and if changes in BP would match those of randomised controlled trials. What did the researchers do and find? Based on our previous research with clinicians on the desirable attributes of a telemonitoring system, NHS Lothian developed an integrated system that provided regular summaries of patient home-monitored BP readings to their general practitioner, which were delivered alongside routine laboratory results. We observed the rollout of this system, interviewing patients and clinicians about their attitudes towards innovations to determine what worked and did not in terms increasing uptake. In a group of 8 practices, we collected routinely acquired data on BP, clinician appointments, and other resource use and compared these to the previous year. Resource use was compared with patients in these practices with high BP who did not use telemonitoring. We found that the intervention was popular in many but not all practices. Patients who used the system had fewer appointments in the year of the intervention compared with the previous year. BP fell in the intervention group, in line with findings of UK randomised controlled trials. What do these findings mean? The findings suggest that introducing telemonitoring to routine practice at scale is feasible. Although not definitive, the findings provide some reassurance that the intervention did not increase practice workload and that in routine practice the improvements in BP control were similar to those in controlled trials. However, the people who took part were not entirely typical of practice populations as a whole, being on average younger and slightly more affluent. The findings support plans to introduce telemonitoring more generally, but within an evaluative framework.

ObjectiveSimple forms of blood pressure (BP) telemonitoring require patients to text readings to central servers creating an opportunity for both entry error and manipulation. We wished to determine if there was an apparent preference for particular end digits and entries which were just below target BPs which might suggest evidence of data manipulation.DesignProspective cohort studySetting37 socioeconomically diverse primary care practices from South East Scotland.ParticipantsPatients were recruited with hypertension to a telemonitoring service in which patients submitted home BP readings by manually transcribing the measurements into text messages for transmission (‘patient-texted system’). These readings were compared with those from primary care patients with uncontrolled hypertension using a system in which readings were automatically transmitted, eliminating the possibility of manipulation of values (‘automatic-transmission system’).MethodsA generalised estimating equations method was used to compare BP readings between the patient-texted and automatic-transmission systems, while taking into account clustering of readings within patients.ResultsA total of 44 150 BP readings were analysed on 1068 patients using the patient-texted system compared with 20 705 readings on 199 patients using the automatic-transmission system. Compared with the automatic-transmission data, the patient-texted data showed a significantly higher proportion of occurrences of both systolic and diastolic BP having a zero end digit (OR 2.1, 95% CI 1.7 to 2.6) although incidence was ConclusionEnd-digit preference for zero numbers and specific-value preference for readings just below the alert threshold exist among patients in self-reporting their BP using telemonitoring. However, the proportion of readings affected is small and unlikely to be clinically important.Trial registration numberISRCTN72614272; Post-results.

Background1.2 million appointments in Scottish primary care annually are used solely for checking blood pressure (BP). While evidence from randomised controlled trials (RCTs) shows that telemonitoring of BP produces significant reductions, it has not been mainstreamed because of difficulties in integrating telemonitoring with routine medical care. With NHS Lothian a system was developed which extracted data from a telemonitoring provider website, and delivered it as a routine DOCMAN report to GP practices without need for logons.AimTo determine the feasibility of implementing telemonitoring of high blood pressure (HBP) at scale in primary care and the potential of using routinely acquired data for exploring clinical and resource-use impacts.MethodPractice recorded BP, prescribing, and appointments data were transferred for all people with HBP to a safe-haven. We compared before and after BPs at 1 year from participants and non-participants. Patient and clinician interviews.ResultsOver 2400 people were recruited to telemonitoring overall. Over a year, BP control improved in both telemonitoring participants and non-participants. Mean systolic BP (SBP) fell by 6.6 mmHg in participants and 3.5 mmHg in non-participants. In uncontrolled participants (SBP >135 mmHg home-monitored) average fall was 15 mmHg. Proportion with very poor control BP (SBP >150 mmHg) fell from 13.6% to 3.4%. Appointment data were challenging to interpret, but there was little change from the previous year in face-to-face appointment time and total appointments. Patients and clinicians were positive about the implementationConclusionThe study demonstrated an improvement in BP control similar to effects in RCTs in routine general practice with little impact on workload using routinely acquired data providing strong support for mainstreaming low-cost telemonitoring for HBP.

BackgroundGovernment leaders have called for increased use of video-consulting (VC) in clinical practice. Although provided by the private sector, it is rarely used in NHS primary care. It is unclear how VC differs from telephone (TC) or face-to-face consulting (FTFC), or how useful clinicians and patients find it.AimTo assess the feasibility and acceptability to patients and clinicians of running a VC service in general practice and to explore differences in duration and content compared with FTFC and TC.MethodVC equipment was installed in six GP practices and 13 clinicians were asked to identify patients who required follow-up consultations and who had access to a smart-device or laptop. They were offered the choice of a VC, TC, or FTFC. Consultations were audiorecorded and content analysed using the RIAS system. Patient and clinician views were obtained by questionnaires and interviews.ResultsOne hundred and forty-seven patients were recruited (FTFC = 51, TC = 51, VC = 45). VC users were generally younger. VCs and TCs were shorter (mean VC 5.9, TC 5.6, FTFCs 9.6 minutes), addressed fewer problems (mean VC 1.5, TC 1.7, FTFC 2.0) and had less information exchange than FTFCs. Technical problems were common, but VCs offered significant advantages over TC in terms of non-verbal communication. VC was considered particularly useful to working and housebound people and for those with mental health problems.ConclusionVC has distinct advantages over TC. When integrated into current systems VC will provide an alternative to FTFC. Where formal physical examination is not required (discussing test results, medication changes and mental health) it offers considerable time savings to patients.

Trent Focus, a Research and Development Support Unit, have introduced the ‘Designated Research Team’ (DRT) approach to building research capacity. This approach funds protected time to develop research ideas and skills for a team with limited research experience. This paper uses the example of a successful team of podiatry researchers to illustrate the approach to, and outcomes of, a DRT. It draws on documentary analysis of meeting notes and annual reports, and team members’ views collected during a recorded reflective session of the team at the end of the funding period. The DRT were successful in achieving agreed outcomes, including completing the project, submitting and publishing in peer reviewed journals, and presenting at conferences. They were also able to attract further funding, and engage with international collaborations and research activity. The unique contribution of this paper is that it focuses on facilitating factors to building research capacity based on a practice example. These include: enabling protected time, effective managerial support, applied and timely research training at relevant levels to expertise, immediate access to supervision and mentorship, a critical mass of research expertise within the team, and an encouraging workplace environment. Importantly, research undertaken was seen as a means to improve practice and the status of the professional group. ‘Accessible’ academic support including outreach work and attitudes of the team members and supervisors towards teaching and learning were important. Process factors enabling success include the use of project management techniques, clear delegation of tasks, effective lines of communication and accountability, and high levels of social capital and commitment between team members. The paper highlights ways forward to using these facilitating factors to build further research capacity, and to use this approach to highlight other areas of research capacity outcome measures.

The purpose of the study was to test the completeness and accuracy of data from general practice clinical computer systems for research. A cross-sectional survey was used to measure: (1) accuracy and completeness of diagnostic data; (2) completeness and timeliness of clinical measurements; and (3) completeness of risk factor data. High levels of completeness were found for recorded blood pressure (over 80 per cent) and for body mass index (75 per cent), which differed between population groups. Depending on the case definition used, a sevenfold variation was found in the prevalence of depression; fivefold for peptic ulcer disease; threefold for hyperlipidaemia; and very little for hypothyroidism. These results illustrate how routine clinical data in selected high recording practices are now achieving reasonable levels of accuracy and completeness for a range of key variables, although there is substantial inter-practice variation. The data quality opens exciting possibilities for study design.

BACKGROUND: Informed decision-making approaches to cancer screening emphasise the importance of decisions being determined by individuals' own values and preferences. However, advice from a trusted source may also contribute to autonomous decision-making. This study examined preferences regarding a recommendation from the NHS and information provision in the context of colorectal cancer (CRC) screening.METHODS: In face-to-face interviews, a population-based sample of adults across Britain (n = 1964; age 50-80 years) indicated their preference between: (1) a strong recommendation to participate in CRC screening, (2) a recommendation alongside advice to make an individual decision, and (3) no recommendation but advice to make an individual decision. Other measures included trust in the NHS and preferences for information on benefits and risks.RESULTS: Most respondents (84%) preferred a recommendation (47% strong recommendation, 37% recommendation plus individual decision-making advice), but the majority also wanted full information on risks (77%) and benefits (78%). Men were more in favour of a recommendation than women (86% vs 81%). Trust in the NHS was high overall, but the minority who expressed low trust were less likely to want a recommendation.CONCLUSION: Most British adults want full information on risks and benefits of screening but they also want a recommendation from an authoritative source. An 'expert' view may be an important part of autonomous health decision-making. British Journal of Cancer (2012) 107, 1938-1943. doi:10.1038/bjc.2012.512 www.bjcancer.com Published online 22 November 2012 (C) 2012 Cancer Research UK

AIM: We sought to assess the accuracy of different search terms to identify individuals with active seasonal allergic rhinitis (SAR) in general practice. METHODS: A reference search strategy was developed to identify patients with active SAR. This was applied through inspection of electronic health records of patients aged 15–45 years in a 10% random sample of a general practice database. Searches used Read codes and medication relating to SAR. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Using the reference search strategy, 54/1092 (4.9%) of 15–45 year-old patients had current SAR. Searching for drugs used in nasal allergy had the highest sensitivity (85%) and good specificity (86%). Searching for a recorded history of SAR (H170) in the last two years was more specific (100%) but this approach only had limited sensitivity (17%). CONCLUSIONS: Electronic searches can be used to identify patients with current SAR, but the accuracy varies widely. Larger numbers of sufferers can be identified using broader search parameters, but with increasing numbers of false positives. In contrast, more focused search strategies give a smaller yield needing less cleaning of data to identify true positives, but there is an associated increase in the number of false negatives.

Objective: To determine whether oral prednisolone or aciclovir, used separately or in combination, early in the course of Bell's palsy, improves the chances of recovery at 3 and 9 months.Design: A 2 x 2 factorial randomised double-blind trial. Patients were randomly assigned to treatment by an automated telephone service using a permuted block randomisation technique with block sizes of four or eight, and no stratification.Setting: Mainland Scotland, with referrals mainly from general practice to 17 hospital trial sites.Participants: Adults (aged 16 years or older) with unilateral facial nerve weakness of no identifiable cause presenting to primary care, the emergency department or NHS24 within 72 hours of symptom onset.Interventions: Patients were randomised to receive active preparations or placebo for 10 days: (I) prednisolone (50 mg per day, 2 x 25-mg capsules) and aciclovir (2000 mg per day, 5 x 400-mg capsules); (2) prednisolone and placebo (lactose, indistinguishable); (3) aciclovir and placebo; and (4) placebo and placebo.Outcome measures: The primary outcome was recovery of facial function assessed by the House-Brackmann scale. Secondary outcomes included health status, pain, self-perceived appearance and cost-effectiveness.Results: Final outcomes were available for 496 patients, balanced for gender; mean age 44 years; initial facial paralysis moderate to severe. One half of patients initiated treatment within 24 hours of onset of symptoms, one-third within 24-48 hours and the remainder within 48-72 hours. Of the completed patients, 357 had recovered by 3 months and 80 at 9 months, leaving 59 with a residual deficit. There were significant differences in complete recovery at 3 months between the prednisolone comparison groups (83.0% for prednisolone, 63.6% for no prednisolone, a difference of + 19.4%; 95% confidence interval (CI): + 11.7% to + 27.1%, p Conclusions: This study provided robust evidence to support the early use of oral prednisolone in Bell's palsy as an effective treatment which may be considered cost-effective. Treatment with aciclovir, either alone or with steroids, had no effect on outcome.

Background The use of the private sector for health care is increasing, but it is unclear whether this will reduce demand on the NHS. The aim of this study was to examine the relationship between private and NHS outpatient referral rates accounting for their association with deprivation. Methods This is a prospective survey of general practitioner referrals to private and NHS consultant-led services between 1 January and 31 December 2001 from 10 general practices in the Trent Focus Collaborative Research Network, United Kingdom. Patient referrals were aggregated to give private and NHS referral rates for each electoral ward in each practice. Results Of 17 137 referrals, 90.4 per cent (15 495) were to the NHS and 9.6 per cent (1642) to the private sector. Private referral rates were lower in patients from the most deprived fifth of wards compared with the least deprived fifth (rate ratio 0.25, 95 per cent CI 0.15 to 0.41, p < 0.001), whereas NHS referral rates were slightly higher in patients in the most deprived fifth of wards (rate ratio 1.18, 95 per cent CI 0.98 to 1.42, p = 0.08) both after age standardisation and adjustment for practice. The NHS referral rate was significantly higher (rate ratio 1.40, 95 per cent CI 1.15 to 1.71, p = 0.001) in wards with private referral rates in the top fifth compared with the bottom fifth after adjustment for deprivation and practice. Conclusions Increased private health care activity does not reduce the demand for NHS care: NHS and private referral rates were positively associated with each other after adjusting for age, deprivation and practice.

There are large variations in reported diabetes prevalence within United Kingdom (UK) populations. Linear regression was used to investigate whether population characteristics could explain the variation in prevalence between 19 practices with relatively complete diagnostic recording. Population obesity and South Asian ethnicity largely explained observed variation in prevalence (adjusted R2 = 0.80). When adjusted for obesity and ethnicity, the deprivation score was no longer a predictor of diabetes prevalence. If true variation in prevalence between practices is largely predicted by population ethnicity and obesity, these population characteristics could be used to predict expected prevalence and to assess the completeness of practice registers.

Objectives To determine whether paperless medical records contained less information than paper based medical records and whether that information was harder to retrieve. Design Cross sectional study with review of medical records and interviews with general practitioners. Setting 25 general practices in Trent region. Participants 53 British general practitioners (25 using paperless records and 28 using paper based records) who each provided records of 10 consultations. Main outcome measures Content of a sample of records and doctor recall of consultations for which paperless or paper based records had been made. Results Compared with paper based records, more paperless records were fully understandable (89.2% v 69.9%, P=0.0001) and fully legible (100% v 64.3%, P < 0.0001). Paperless records were significantly more likely to have at least one diagnosis recorded (48.2% v 33.2%, P=0.05), to record that advice had been given (23.7% vs 10.7%, P=0.017), and, when a referral had been made, were more likely to contain details of the specialty (77.4% v 59.5%, P=0.03). When a prescription had been issued, paperless records were more likely to specify the drug dose (86.6% v 66.2%, P=0.005). Paperless records contained significantly more words, abbreviations, and symbols (P < 0.01 for all). At doctor interview, there was no difference between the groups for the proportion of patients or consultations that could be recalled. Doctors using paperless records were able to recall more advice given to patients (38.6% v 26.8%, P=0.03). Conclusion We found no evidence to support our hypotheses that paperless records would be truncated and contain more local abbreviations; and that the absence of writing would decrease subsequent recall. Conversely we found that the paperless records compared favourably with manual records.

BACKGROUND: When interpreting results of studies undertaken by research networks we need to know how representative volunteer practices and their registered patients are of the total population of practices and patients in their locality. AIM: To compare the following in research and non-research general practices in one region: practice and population demography, morbidity and mortality, selected performance indicators, and health outcomes. DESIGN OF STUDY: Cross-sectional survey. SETTING: Sixty-six Trent Focus Collaborative Research Network general practices and 749 other general practices in Trent, United Kingdom. METHOD: Practice characteristics and GP contract data were obtained from the NHS Executive, Quarry House, Leeds. The Trent Regional NHS Hospital Admission Database was searched to identify all relevant admissions to hospital from all practices between 1 April 1993 and 31 March 1997. Ward-linked data on cancer were obtained from the Trent Cancer Registry. RESULTS: Of the 815 general practices in Trent Region in the study period, 66 (8%) were in the Trent Focus network. They were more likely to be involved in training GPs and to have a female partner. They tended to be larger, with fewer single-handed doctors and younger GPs. Network practices prescribed a higher proportion of generics (median % prescribed/practice = 70%, versus 51%, Mann-Whitney U = 1615, P

Objectives: To determine whether there are important differences in performance between group practices and singlehanded general practitioners and the extent to which any differences are explained by practice characteristics such as deprivation. Design: Cross sectional survey. Setting: 206 singlehanded practices and 606 partnerships in Trent region, United Kingdom. Method: Comparison of process and outcome measures derived from routinely collected data on hospital admissions and target payments for singlehanded practices and partnerships. Multivariate analysis was used to adjust for the confounding effects of general practice characteristics—deprivation (Townsend score), percentage of Asian residents, percentage of black residents, proportion of men over 75 years, proportion of women over 75 years, rurality, presence of a female general practitioner, and vocational training status. Results: Differences in achievement of immunisation and cytology targets apparent on univariate analysis were not seen after adjustment for other general practice characteristics. Similarly, significant differences (>15%; P Conclusions: This study provides no evidence that singlehanded general practitioners are underperforming clinically. Our results offer insight into the structural difference between the two types of practice and underline the importance of the effect of other practice characteristics on process and outcome measures. What is already known on this topic Singlehanded general practitioners tend to work in areas of high deprivation and need Patients like singlehanded practices because of good communication, personal rapport, availability, and continuity of care Concerns have been expressed about professional isolation and quality standards for singlehanded practice, on the basis of little evidence What this study adds This study provides no evidence that singlehanded general practitioners are underperforming clinically The results offer insight into the structural differences between the two types of practice and underline the importance of other practice characteristics such as deprivation

Objective: To determine whether people whose marital partners have depression, diabetes, hypertension, ischaemic heart disease, stroke, hyperlipidaemia, peptic ulcer disease, or asthma or chronic obstructive pulmonary disease are at increased risk of the same disease. Design: Cross sectional study. Setting: 10 practices from the Trent Focus Collaborative Research Practice Network. Participants: 8386 married couples (16 772 individuals) from a population of 29 014 participants aged 30-74 years. Outcomes: Risk of disease in participants whose marital partner had that disease compared with those whose partner did not. Results: After both partners9 age, smoking, and obesity and which general practice they attend were adjusted for, participants whose marital partner had asthma, depression, hypertension, hyperlipidaemia, and peptic ulcer disease were at increased risk of having the same disease. The adjusted odds ratios were 1.69 (95% confidence interval 1.43 to 2.98) for asthma, 2.08 (1.71 to 2.54) for depression, 1.32 (1.04 to 1.67) for hypertension, 1.44 (1.19 to 1.75) for hyperlipidaemia, and 2.01 (1.48 to 2.73) for peptic ulcer disease. Conclusion: Partners of people with specific diseases are at increased risk of the disease themselves—at least 70% increased risk for asthma, depression, and peptic ulcer disease. This implicates shared environmental causes in some diseases in addition to any genetic or distant exposure or shared behaviours with respect to seeking health care.

Objectives: To determine whether antidepressants are a risk factor for ischaemic heart disease and to compare the risk for different subgroups of antidepressants and individual antidepressants. Design: Case-control study. Setting: Nine general practices recruited from the Trent Focus Collaborative Research Network. Participants: 933 men and women with ischaemic heart disease matched by age, sex, and practice to 5516 controls. Main outcome measure: Adjusted odds ratio for ischaemic heart disease calculated by logistic regression. Results: Odds ratios for ischaemic heart disease were significantly raised for patients who had ever received a prescription for tricyclic antidepressants even after diabetes, hypertension, smoking, body mass index, and use of selective serotonin reuptake inhibitors had been adjusted for (1.56; 95% confidence interval 1.18 to 2.05). Patients who had ever taken dosulepin (dothiepin) had a significantly raised odds ratio for ischaemic heart disease after adjustment for confounding factors and use of other antidepressants (1.67, 1.17 to 2.36). There was no significant increase in the odds ratios for amitriptyline, lofepramine, and selective serotonin reuptake inhibitors in multivariate analysis. Increasing maximum doses of dosulepin were associated with increasing odds ratios for ischaemic heart disease. Similarly, there was a significant positive trend associated with increasing numbers of prescriptions of dosulepin (adjusted odds ratio 1.52 for 1 prescription, 1.39 for 2-3, and 1.96 for ≥4, P Conclusion: There is good evidence for an association between dosulepin and subsequent ischaemic heart disease and for a dose-response relation. What is already known on this topic Over 45% of patients in hospital after myocardial infarction have depression Depression is an independent risk factor for increased mortality and morbidity after myocardial infarction What this study adds Patients who had ever taken dosulepin (dothiepin) had significantly increased risk of ischaemic heart disease after confounding factors had been adjusted for The association followed a dose-response relation The effect of other antidepressants was not significant after adjustment for confounders