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Nasir Hamid
Disparities in the care and direct-acting oral anticoagulant (DOAC) management in atrial fibrillation (AF) and chronic kidney disease (CKD) in English primary care between 2018 and 2022: Primary care sentinel network database study
Background In England, most prescribing of direct-acting oral anticoagulants (DOACs) for patients with chronic kidney disease (CKD) and atrial fibrillation (AF) takes place in primary care. The 2024 European Society of Cardiology guidelines introduced the AF-CARE ((C) comorbidities and risk factors; (A) avoid stroke and thromboembolism by appropriate prescription of oral anticoagulants; (R) rate and rhythm control; (E) evaluation and reassessment should be individualised for every patient, with a dynamic approach) framework to address this. Objective To describe any health disparities in CKD and AF, including anticoagulation management and correct dosing of DOACs. Methods Using English primary care sentinel network data from 2018 to 2022, demographics of AF and CKD including anticoagulation and appropriate DOAC dosing according to creatinine clearance and other factors were assessed. The study also examined disparities in CKD and AF in relation to socioeconomic status and ethnicity. We defined socioeconomic status by Index of Multiple Deprivation (IMD), a weighted composite index combining information from the domains of deprivation including income. Results Of 10 513 950 people registered with general practices in the sentinel network, 2.9% (n=304 678) were aged ≥18 years with a diagnosis of AF. The prevalence of CKD in AF was 26.0% (n=79 210) and 63.3% of people eligible for anticoagulation were prescribed a DOAC. Among the 54 897 people with AF and CKD 3 or 4, greater likelihood of DOAC prescribing was associated with higher socioeconomic status. Socioeconomic disparities in anticoagulation increased through the 5 years. No association was identified between ethnicity and likelihood of being anticoagulated. In terms of correct dosing, there was no association with socioeconomic status. Overdosing was more frequent than underdosing. Incorrect dosing was associated with male sex (OR 0.80 (95% CI 0.74, 0.86)), dementia (OR 0.94 (0.83, 1.07)) and frailty (OR 0.42 (0.37, 0.48)). Conclusions People in the most deprived IMD quintile were least likely to be anticoagulated. Incorrect DOAC dosing was associated with male sex, increasing frailty and dementia. Socioeconomic and health disparities are apparent in anticoagulation prescribing and should be addressed in line with the AF-CARE framework.
A comparison of sodium-glucose co-transporter 2 inhibitor kidney outcome trial participants with a real-world chronic kidney disease primary care population
Background: Observational studies suggest sodium-glucose co-transporter 2 (SGLT2) inhibitor kidney outcome trials are not representative of the broader population of people with chronic kidney disease (CKD). However, there are limited data on the generalizability to those without co-existing type 2 diabetes (T2D), and the representativeness of the Study of Heart and Kidney Protection with Empagliflozin (EMPA-KIDNEY) trial has not been adequately explored. We hypothesized that SGLT2 inhibitor kidney outcome trials are more representative of people with co-existing T2D than those without, and that EMPA-KIDNEY is more representative than previous trials. Methods: A cross-sectional analysis of adults with CKD in English primary care was conducted using the Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub. The proportions that met the eligibility criteria of SGLT2 inhibitor kidney outcome trials were determined, and their characteristics described. Logistic regression analyses were performed to identify factors associated with trial eligibility. Results: Of 6 670 829 adults, 516 491 (7.7%) with CKD were identified. In the real-world CKD population, 0.9%, 2.2% and 8.0% met the Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE), Dapagliflozin and Renal Outcomes and Cardiovascular Mortality in Patients with Chronic Kidney Disease (DAPA-CKD) and EMPA-KIDNEY eligibility criteria, respectively. All trials were more representative of people with co-existing T2D than those without T2D. Trial participants were 9-14 years younger than the real-world CKD population, and had more advanced CKD, including higher levels of albuminuria. A higher proportion of the CREDENCE (100%), DAPA-CKD (67.6%) and EMPA-KIDNEY (44.5%) trial participants had T2D compared with the real-world CKD population (32.8%). Renin-angiotensin system inhibitors were prescribed in almost all trial participants, compared with less than half of the real-world CKD population. Females were under-represented and less likely to be eligible for the trials. Conclusion: SGLT2 inhibitor kidney outcome trials represent a subgroup of people with CKD at high risk of adverse kidney events. Our study highlights the importance of complementing trials with real-world studies, exploring the effectiveness of SGLT2 inhibitors in the broader population of people with CKD.
Anti-TNF (adalimumab) injection for the treatment of adults with frozen shoulder during the pain predominant stage protocol for a multi-centre, randomised, double blind, parallel group, feasibility trial.
ObjectivesThe Anti-Freaze-F trial will assess the feasibility of conducting a large randomised controlled trial to assess whether intra-articular injection of anti-TNF (adalimumab) can reduce pain and improve function in people with pain predominant early stage frozen shoulder.Methods and analysisWe are conducting a multi-centre, randomised feasibility study, with an embedded qualitative sub-study. We will recruit adults ≥18 years with a new episode of shoulder pain attributable to early stage frozen shoulder, recruited from at least five UK NHS musculoskeletal and related physiotherapy services. Participants (n=84) will be randomised (centralised computer generated 1:1 allocation) to receive either: 1) intra-articular injection of anti-TNF (adalimumab 160mg) or 2) placebo injection (saline [0.9% sodium chloride]), both under ultrasound guidance. A second injection of the allocated treatment (adalimumab 80mg) or equivalent volume of placebo will be administered 2-3 weeks later. All participants will receive a physiotherapy advice leaflet providing education and advice about frozen shoulder and pain management. The primary feasibility objectives are: 1) the ability to screen and identify potential participants with pain predominant early stage frozen shoulder; 2) willingness of eligible participants to consent and be randomised to intervention; 3) practicalities of delivering the intervention, including time to first injection and number of participants receiving second injection; 4) standard deviation of the Shoulder Pain and Disability Index (SPADI) score and attrition rate at 3 months (i.e. 12 weeks) post-randomisation in order to estimate the sample size for a definitive trial. We will also assess follow up rates and viability of patient-reported outcome measures and range of shoulder motion for a definitive trial. Research Ethics Committee approval (REC 21/NE/0214).Trial registration numberISRCTN 27075727; EudraCT number: 2021-003509-23; ClinicalTrials.gov NCT05299242.
Assessing adherence to the UK Government’s sugar, salt, and calorie reduction targets by the highest-grossing restaurants’ menus in 2024: Dataset to support a cross-sectional study
This dataset contains per 100g and per serving nutritional information gathered from chained restaurants' online menus in 2024.
Involvement of episodic memory in language comprehension: Naturalistic comprehension pushes unrelated words closer in semantic space for at least 12 h
Recent experience with a word significantly influences its subsequent interpretation. For instance, encountering bank in a river-related context biases future interpretations toward ‘side of a river’ (vs. ‘financial bank’). To explain this effect, the episodic context account posits that episodic memory helps bind word meanings in the language input, creating a temporary, context-specific representation that can bias subsequent lexical interpretation. This account predicts that even unrelated words would be linked together in episodic memory, potentially altering their interpretation. In Experiments 1–3, participants read unrelated word pairs (e.g., sword—microwave, privacy—export) embedded in meaningful sentences, then completed a speeded relatedness judgement task after delays of 5 min, 20 min, or 12 h (including sleep). Results showed that sentence exposure increased the likelihood of the unrelated pairs being judged as related—a robust effect observed across all delay intervals. Experiment 4 showed that this exposure effect was abolished when words in a target pair were read in separate sentences, suggesting that the exposure effect may be dependent on lexical co-occurrence. Experiment 5, also with a 12-h delay (including sleep), additionally used an innovative word arrangement task to assess word relatedness without presenting the target pairs simultaneously or successively. In line with relatedness judgement, sentence exposure pushed the unrelated words closer in semantic space. Overall, our findings suggest that a context-specific representation, supported by episodic memory, is generated during language comprehension, and in turn, these representations can influence lexical interpretation for at least 12 h and across different linguistic circumstances. We argue that these representations endow the mental lexicon with the efficiency to deal with word burstiness and the dynamic nature of language.
Improving GPs' knowledge of the benefits and harms of treatment to support decision making in multimorbidity: qualitative research and co-design of a novel electronic information resource
Background General practitioners (GPs) regularly prescribe prolonged treatments for long-term conditions. However, GPs may benefit from further understanding of the absolute benefits and harms of these treatments, enhancing their ability to engage in shared decision-making and manage multimorbidity and polypharmacy. Aim To produce and evaluate a website to provide information on the benefits and harms of treatments for long-term conditions in a way that can be understood by GPs and potentially integrated into their practice. Methods The study consisted of three parts. First, a qualitative interview study and framework analysis with GPs exploring their attitudes to and understanding of the quantitative benefits and harms of treatments. Second, a participatory co-design process to design the website, coupled with a pragmatic approach to evidence collation to provide clinical content. Finally, an exploratory evaluation study of the website using online focus groups. Results The interview study reported findings on GPs’ understanding of quantitative information on the benefits and harms of treatments which informed the co-design research. The co-design research resulted in the creation of a website, www.gpevidence.org, which presents complex scientific information on treatment effect sizes and the nature and quality of the relevant clinical evidence. The evaluation study showed that participating GPs were able to understand the clinical information on GP Evidence, and that in hypothetical scenarios this might change their prescribing practice. Some participants found some information confusing. There was limited evidence that this new information could be integrated into complex decision-making for multimorbidity and polypharmacy. Conclusion The aim of producing a website able to deliver information on the benefits and harms of treatments for long-term conditions to GPs was achieved. Further research is needed to evaluate the effect of GP Evidence in real-world practice.
How, why, for whom and when do help-seeking interventions for anxiety and depression work among older adults? A realist review
BACKGROUND: A quarter of older adults (aged ≥60 years) in the UK experience a mental health problem each year. Older adults may not seek help due to limited awareness of symptoms of mental ill-health; fear of losing independence; limited access to services. Stigmatised views linked to ageism may also influence help-seeking. AIM: To understand how, why, for whom and in what circumstances interventions to facilitate help-seeking for anxiety and/or depression work among community-dwelling older adults. METHOD: A realist review to identify and synthesise existing evidence of help-seeking interventions for anxiety and/or depression. Systematic search conducted in several databases including MEDLINE, EMBASE, Cochrane Library. A patient/public advisory group (PAG) and expert advisory group contributed to the study design, analysis and conduct. RESULTS: 1095 papers reviewed against inclusion/exclusion criteria; 80 papers identified for full text review and 42 papers included. A variety of interventions were identified including cognitive behavioural therapy, bibliotherapy and befriending, delivered by a diverse range of providers. Help-seeking interventions are complex due to interactions between attitudes, intentions, behaviours but also factors linked to inequalities. Interventions perform better when they support older adults to recognise a problem exists, promote personal agency, include culturally sensitive resources, and adopt a salutogenesis perspective that builds on individual strengths. Interventions are generally under-theorised when it comes to help-seeking. CONCLUSION: The review will generate a programme theory to inform future help-seeking initiatives and suggestions for interventions that may be more accessible to older adults and service users experiencing mental health difficulties.
Addressing the Environmental Impact of Pharmaceuticals: A Call to Action
The contribution of health care to environmental and climate crises is significant, under-addressed, and with consequences for human health. This editorial is a call to action. Focusing on pharmaceuticals as a major environmental threat, we examine pharmaceutical impacts across their lifecycle, summarising greenhouse gas emissions, pollution, and biodiversity loss, and outlining challenges and opportunities to reduce this impact. We urge health care decision-makers and providers to urgently consider environmental factors in their decision-making relating to both policy, and practice, promoting actions such as rational prescribing, non-pharmaceutical interventions, and research and advocacy for sustainable production, procurement, and use.
Intervention development and optimisation of a multi-component digital intervention for the monitoring and management of hypertensive pregnancy: the My Pregnancy Care Intervention
Background: Hypertensive disorders of pregnancy affect around 10% of pregnancies and remain a major cause of maternal and foetal morbidity and mortality. Trials have shown that self-monitoring blood pressure during pregnancy is safe, but self-monitoring alone does not improve blood pressure control or pregnancy outcomes. This study aimed to develop and optimise a multicomponent intervention to support blood pressure monitoring, hypertension management and urine testing within current care pathways. Methods: Relevant literature, input from patient and public contributors (PPI) and stakeholder groups, and the researcher’s previous experience were used to develop an initial intervention. Think-aloud interviews and focus groups with women from diverse backgrounds with lived experience of hypertension in pregnancy and healthcare professionals provided feedback on the intervention prototype (n = 29). The MRC Framework for Developing Complex Interventions guided the processes to optimise the intervention’s acceptability and maximise engagement. A detailed tabulation of participants’ views and logic models was produced using the COM-B model of Behaviour Change. Results: The prototype intervention was acceptable and viable to both pregnant women with experience of hypertensive pregnancy and healthcare professionals. Emerging themes centred on how the intervention could be optimised within current National Health Service care pathways and the lives of pregnant women to support behaviour change. Key target behaviours to support the intervention included increasing understanding of blood pressure management, engagement with the intervention, monitoring blood pressure and urine and taking appropriate actions based on those readings. This informed the development of recommendations involving clear action timelines for women and evidence-based guidance to support decision-making by healthcare professionals. The findings were used to produce the multi-component My Pregnancy Care intervention, consisting of a smartphone application and an information leaflet to support blood pressure self-monitoring and proteinuria self-testing, self-management of antihypertensive medication and smartphone application use. Conclusions: This research provided comprehensive insight into the needs of pregnant women with hypertension and their healthcare teams regarding self-monitoring and management of blood pressure. This supported the development of a tailored multi-component digital intervention that addresses barriers to blood pressure self-management by being user-friendly, persuasive and acceptable. It is hoped that the intervention will support the monitoring and management process, collaboration between healthcare professionals and women, clinical action and improved clinical outcomes.
Uncertainty Quantification in Cost-effectiveness Analysis for Stochastic-based Infectious Disease Models: Insights from Surveillance on Lymphatic Filariasis.
Cost-effectiveness analyses (CEA) typically involve comparing effectiveness and costs of one or more interventions compared to standard of care, to determine which intervention should be optimally implemented to maximise population health within the constraints of the healthcare budget. Traditionally, cost-effectiveness evaluations are expressed using incremental cost-effectiveness ratios (ICERs), which are compared with a fixed willingness-to-pay (WTP) threshold. Due to the existing uncertainty in costs for interventions and the overall burden of disease, particularly with regard to diseases in populations that are difficult to study, it becomes important to consider uncertainty quantification whilst estimating ICERs. To tackle the challenges of uncertainty quantification in CEA, we propose an alternative paradigm utilizing the Linear Wasserstein framework combined with Linear Discriminant Analysis (LDA) using a demonstrative example of lymphatic filariasis (LF). This approach uses geometric embeddings of the overall costs for treatment and surveillance, disability-adjusted lifeyears (DALYs) averted for morbidity by quantifying the burden of disease due to the years lived with disability, and probabilities of local elimination over a time-horizon of 20 years to evaluate the cost-effectiveness of lowering the stopping thresholds for post-surveillance determination of LF elimination as a public health problem. Our findings suggest that reducing the stopping threshold from <1% to <0.5% microfilaria (mf) prevalence for adults aged 20 years and above, under various treatment coverages and baseline prevalences, is cost-effective. When validated on 20% of test data, for 65% treatment coverage, a government expenditure of WTP ranging from $500 to $3,000 per 1% increase in local elimination probability justifies the switch to the lower threshold as cost-effective. Stochastic model simulations often lead to parameter and structural uncertainty in CEA. Uncertainty may impact the decisions taken, and this study underscores the necessity of better uncertainty quantification techniques within CEA for making informed decisions.