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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Exploring the Relationship between Climate Change and Antimicrobial-resistant Bacteria: To What Extent Does This Present a Current and Long-term Threat to Population Health?
Climate change and antimicrobial-resistant bacteria (AMR) have been studied as two separate problems affecting population health. Mortality attributable to AMR could reach up to 10 million people by 2050, becoming the most important challenge for global health. However, little is known about the changing environmental factors that could facilitate the spread of AMR infections. The article explores the linkage between climate change and AMR, in particular through the role of temperature, humidity, and the presence of metals in the environment. The PRISMA method was used for the systematic review based on the PubMed database. Previous research shows that warmer, more humid, and more highly polluted environments have a direct positive impact on the growth of microorganisms and most resistant bacteria. Global warming and structural changes in bacterial habitat, because of climate change, might result in new environmental conditions that facilitate the dissemination of AMR from a biological and reproductive perspective. This would have an impact on population health in the short- and long term because simple infections are becoming more aggressive as bacteria mutate constantly owing to the higher concentration of elements boosting their resistant capacity in their habitats. As a result, the morbidity and mortality of AMR could become more widespread as climate changes continue. Finally, the linkage between AMR and climate change is consistent and clear across different types of microorganisms and classes of antibiotics, and therefore the burden of AMR could be catastrophic if regulations on the environment, in the form of prevention policies, are not instituted in the future.
The impact of weight loss interventions on disordered eating symptoms in people with overweight and obesity: a systematic review & meta-analysis
Background: It is unclear whether weight loss interventions worsen disordered eating in people living with overweight/obesity. We aimed to systematically evaluate the association between weight loss interventions and disordered eating. Methods: Six databases were searched from inception until September 2024. Trials of weight loss interventions in people with overweight/obesity were included if they reported a validated score for disordered eating on either the Eating Disorder Examination Interview or the Eating Disorder Examination Questionnaire pre- and post-intervention. Interventions included behavioural weight loss programmes (BWL) and pharmacotherapy licenced for weight loss, with or without concurrent psychological support, provided for at least 4 weeks. Pooled standardised mean differences (SMD) in scores of disordered eating were calculated using random effects meta-analyses. Risk of bias (RoB) was assessed using the Cochrane RoB 2 tool and the Newcastle–Ottawa scale for randomised and single-arm trials, respectively (PROSPERO ID: CRD42023404792). Findings: Thirty-eight studies with 66 eligible arms (61 interventions: 29 BWL, 11 BWL + pharmacotherapy, 20 BWL + psychological intervention, 1 pharmacotherapy + psychological intervention) and 3364 participants in total were included. The mean weight change was −4.7 kg (95% CI: −5.7, −3.7). Compared with baseline, disordered eating scores improved by −1.47 SMD units (95% CI: −1.67, −1.27, p < 0.001, I2 = 94%) at intervention completion (median of 4 months). Seven randomised trials that directly compared a weight loss intervention to no/minimal intervention reported an improvement of −0.49 SMD units (95% CI, −0.93, −0.04, p = 0.0035, I2 = 73%). Sub-group analyses showed: (a) disordered eating scores improved more in people with an eating disorder at baseline compared with people without high scores, (b) no clear evidence that the association depended upon intervention type, and (c) disordered eating scores improved more in trials rated at low overall RoB. Interpretation: Despite heterogeneity in effect size, weight loss interventions consistently improved disordered eating scores. These findings provide reassurance that weight loss interventions might not worsen disordered eating and may improve it. Funding: Novo Nordisk UK Research Foundation Doctoral Fellowship in Clinical Diabetes.
The relative toxicity of medicines detected after poisoning suicide deaths in Australia, 2013–19: a data linkage case series study
AbstractObjectiveTo compare the toxicity (relative to population use) and lethality (relative to poisoning events) of medicines involved in poisoning suicides in Australia; to determine the proportions of cases in which the medicines had recently been dispensed to the deceased person.Study designCase series study; analysis of linked National Coronial Information System (NCIS) and Pharmaceutical Benefits Scheme (PBS) data.Setting, participantsClosed coronial cases for deaths of people aged ten years or older deemed to have been medicine poisoning suicides (including multiple cause deaths), Australia, 1 July 2013 – 10 October 2019, with recorded post mortem toxicology findings.Main outcome measuresFatal toxicity index (FTI): deaths per million years of use at the defined daily dose in Australia (2013–2015); proportion of FTI attributable to medicines dispensed to the deceased person during the twelve months preceding their death; estimated case fatality: deaths per number of calls to poisons information centres regarding the medicine (based on the number of calls to the NSW Poisons Information Centre, 2013–2017).ResultsDuring 2013–19, 2132 deaths were classified as medicine poisoning suicide deaths (median age, 51 years [interquartile range, 39–64 years]; 1036 girls or women [49%]). The 5703 detected substances deemed to have contributed to death included 140 medicines. The overall FTI was 32.0 (95% confidence interval [CI], 30.6–33.3) deaths per million years of use; overall estimated case fatality was 1.28% (95% CI, 1.23–1.34%) of poisoning events. FTI and estimated case fatality (each log10 transformed) were moderately correlated (R2 = 0.66). Both values were relatively high for most opioids, sedative psychotropics, and tricyclic antidepressants. Specific medicines with high values were phenobarbitone, oxycodone, morphine, clonazepam, nortriptyline, and propranolol; they were relatively low for risperidone and lithium. The proportions of opioids and hypnosedatives that had been recently dispensed to the deceased persons were smaller than for antidepressant, antipsychotic, and antiepileptic medicines.ConclusionsTo reduce the risk of suicide, access to medicines of greater toxicity and lethality should be restricted, including by staged supply (regular supply of medicines in limited quantities), and limiting pack sizes; real‐time prescription monitoring could detect and minimise stockpiling.
Searching Skills Toolkit: Finding the Evidence, Second Edition
Searching Skills Toolkit is an expert guide to help you find the clinical evidence you need more easily and effectively. Clearly presented with useful tips and advice, flow charts, diagrams and real-life clinical scenarios, it shows the best methods for finding quality evidence. From deciding where to start, to building a search strategy, refining results and critical appraisal, it is a step-by-step guide to the process of finding healthcare evidence, and is designed for use by all health and social care professionals. This second edition has been expanded with new chapters on searching for sources to support evidence-based management decision making and how to better enable your patients to make informed choices. It has also been fully updated to include new web sources, open source reference management software, and new training resources and exercises. Searching Skills Toolkit is an ideal reference for doctors, nurses, allied health professionals, managers and decision makers, researchers and students.
Patient and Public Involvement Toolkit
Providing information to implement a new core healthcare requirement – patient involvement Including real case scenarios to illustrate the principles of effective PPI Following the unique Toolkit series format of flowcharts and layouts that guide the reader through each section.
Use of a violence risk prediction tool (Oxford Mental Illness and Violence) in early intervention in psychosis services: mixed methods study of acceptability, feasibility and clinical role.
BACKGROUND: Scalable assessment tools for precision psychiatry are of increasing clinical interest. One clinical risk assessment that might be improved by such approaches is assessment of violence perpetration risk. This is an important adverse outcome to reduce for some people presenting to services for first-episode psychosis. A prediction tool (Oxford Mental Illness and Violence (OxMIV)) has been externally validated in these services, but clinical acceptability and role need to be examined and developed. AIMS: This study aimed to understand clinical use of the OxMIV tool to support violence risk management in early intervention in psychosis services in terms of acceptability to clinicians, patients and carers, practical feasibility, perceived utility, impact and role. METHOD: A mixed methods approach integrated quantitative data on utility and patterns of use of the OxMIV tool over 12 months in two services with qualitative data from interviews of 20 clinicians and 12 patients and carers. RESULTS: The OxMIV tool was used 141 times, mostly in new assessments. Required information was available, with only family history items scored unknown to any notable degree. The OxMIV tool was deemed helpful by clinicians in most cases, especially if there were previous risk concerns. It was acceptable practically, and broadly for the service, for which its concordance with clinical judgement was important. Patients and carers thought it could improve openness. There was some limited impact on plans for clinical support. CONCLUSIONS: The OxMIV tool met an identified clinical need to support clinical assessment for violence risk. Linkage to intervention pathways is a research priority.
Qualitative insights into planning implementation of FeNO-guided asthma management in primary care.
Fractional exhaled nitric oxide (FeNO) testing is used in primary care in some areas of the UK to aid asthma diagnosis but is used less frequently for managing asthma. A randomised controlled trial (RCT) is investigating whether an intervention, including FeNO testing and a clinical algorithm, improves outcomes for patients with asthma. This study was conducted to explore potential for implementation of the intervention. The study aim was to explore views of those with a vested interest in implementing the FeNO intervention into primary care asthma reviews. In-depth, semi-structured interviews were conducted online with individuals, including those with experience in policymaking, healthcare management, National Health Service commissioning, as healthcare professionals (HCPs) with extended roles, and patients and advocates. Inductive thematic analysis was conducted for nineteen interviews. Findings suggest complex interplay of barriers, contextual issues and facilitators. Overall, participants perceived FeNO-informed asthma management would enhance care, if used appropriately and flexibly according to context, for example planning implementation alongside remote reviews. Easier, equitable access to funded FeNO equipment would be needed for national implementation. Participants suggested motivation of all involved in future implementation may be increased by guidelines recommending FeNO, and by use of financial incentives and champions sharing best practice examples. In conclusion, financial obstacles were reiterated as a primary barrier to FeNO use. Despite barriers, facilitating implementation by harnessing prominent cost-benefits could persuade decision makers and clinicians. Findings lay early foundations for development of an implementation strategy.
Interim 2024/25 influenza vaccine effectiveness: eight European studies, September 2024 to January 2025
The 2024/25 influenza season in Europe is currently characterised by co-circulation of influenza A(H1N1) pdm09, A(H3N2) and B/Victoria viruses, with influenza A(H1N1)pdm09 predominating. Interim vaccine effectiveness (VE) estimates from eight European studies (17 countries) indicate an all-age influenza A VE of 32–53% in primary care and 33–56% in hospital settings, with some signals of lower VE by subtype and higher VE against influenza B (≥ 58% across settings). Where feasible, influenza vaccination should be encouraged and other prevention measures strengthened.
At what stage in the drinking process does drinking water affect attention and memory? Effects of mouth rinsing and mouth drying in adults
Drinking water is important for health and there is an agreement that drinking water facilitates certain cognitive processes. However, the mechanism underlying the effect of drinking water on cognition is unknown. While attention performance is improved by even a very small drink, memory performance seems to require larger drinks for performance enhancement. This suggests that attention could be affected earlier in the drinking process than memory. We aimed to elucidate further the mechanism involved by investigating the stage during the drinking process influencing performance on cognitive tasks. To this end, we compared mouth rinsing and mouth drying. Mouth rinsing was expected to result in improved attention performance and would suggest that the mechanism responsible is located in the mouth and occurs early in the drinking process, before swallowing. Eighty-seven adults participated in either a treatment (mouth rinsing or mouth drying) or control (no intervention) condition. They were assessed at baseline and 20 min later after intervention on measures of visual attention, short-term memory, subjective thirst and mood. Our results showed that mouth rinsing improved visual attention, but not short-term memory, mood or subjective thirst. Mouth drying did not affect performance. Our results support the hypothesis that different mechanisms underlie the effect of drinking water on different cognitive processes. They suggest that merely sipping water, as opposed to having a large drink, can improve attention.
Childhood trauma and being at-risk for psychosis are associated with higher peripheral endocannabinoids
Background Evidence has been accumulating regarding alterations in components of the endocannabinoid system in patients with psychosis. Of all the putative risk factors associated with psychosis, being at clinical high-risk for psychosis (CHR) has the strongest association with the onset of psychosis, and exposure to childhood trauma has been linked to an increased risk of development of psychotic disorder. We aimed to investigate whether being at-risk for psychosis and exposure to childhood trauma were associated with altered endocannabinoid levels.Method We compared 33 CHR participants with 58 healthy controls (HC) and collected information about previous exposure to childhood trauma as well as plasma samples to analyse endocannabinoid levels.Results Individuals with both CHR and experience of childhood trauma had higher N-palmitoylethanolamine (p < 0.001) and anandamide (p < 0.001) levels in peripheral blood compared to HC and those with no childhood trauma. There was also a significant correlation between N-palmitoylethanolamine levels and symptoms as well as childhood trauma.Conclusions Our results suggest an association between CHR and/or childhood maltreatment and elevated endocannabinoid levels in peripheral blood, with a greater alteration in those with both CHR status and history of childhood maltreatment compared to those with either of those risks alone. Furthermore, endocannabinoid levels increased linearly with the number of risk factors and elevated endocannabinoid levels correlated with the severity of CHR symptoms and extent of childhood maltreatment. Further studies in larger cohorts, employing longitudinal designs are needed to confirm these findings and delineate the precise role of endocannabinoid alterations in the pathophysiology of psychosis.
Effect of continued cannabis use on medication adherence in the first two years following onset of psychosis
Uncertainty exists whether the use of non-prescription psychoactive substances following onset of a first episode of psychosis (FEP), in particular cannabis use, affects medication adherence. Data from FEP patients (N=233) obtained through prospective assessments measured medication adherence and pattern of cannabis and other substance use in the first two years following onset of psychosis. Multiple logistic regression analyses were employed to compare the different substance use groups with regard to risk of medication non-adherence, while controlling for confounders. The proportion of non-adherent patients was higher in those who continued using high-potency forms of cannabis (skunk-like) following the onset (83%) when compared to never regular users (51%), corresponding to an Odds Ratio (OR) of 5.26[95% Confidence Interval (CI) 1.91–15.68]. No significant increases in risk were present in those who used cannabis more sporadically or used milder forms of cannabis (hash-like). Other substances did not make an independent contribution in this model, including cigarette use ([OR 0.88, 95% CI 0.41–1.89]), alcohol use ([OR 0.66, 95% CI 0.27–1.64]) or regular use of other illicit drugs ([OR 1.03, 95% CI 0.34–3.15]) following the onset. These results suggest that continued use of high-potency cannabis following the onset of psychosis may adversely affect medication adherence.
Poor medication adherence and risk of relapse associated with continued cannabis use in patients with first-episode psychosis: a prospective analysis
Background Cannabis use following the onset of first-episode psychosis has been linked to both increased risk of relapse and non-adherence with antipsychotic medication. Whether poor outcome associated with cannabis use is mediated through an adverse effect of cannabis on medication adherence is unclear. Methods In a prospective analysis of data acquired from four different adult inpatient and outpatient units of the South London and Maudsley Mental Health National Health Service Foundation Trust in London, UK, 245 patients were followed up for 2 years from the onset of first-episode psychosis. Cannabis use after onset of psychosis was assessed by self-reports in face-to-face follow-up interviews. Relapse data were collected from clinical notes using the WHO Life Chart Schedule. This measure was also used to assess medication adherence on the basis of both face-to-face interviews and clinical notes. Patients were included if they had a diagnosis of first-episode non-organic or affective psychosis according to ICD-10 criteria, and were aged between 18 and 65 years when referred to local psychiatric services. We used structural equation modelling analysis to estimate whether medication adherence partly mediated the effects of continued cannabis use on risk of relapse. The primary outcome variable was relapse, defined as admission to a psychiatric inpatient unit after exacerbation of symptoms within 2 years of first presentation to psychiatric services. Information on cannabis use over the first 2 years after onset of psychosis was investigated as a predictor variable for relapse. Medication adherence was assessed as a mediator variable on the basis of clinical records and self-report data. Study researchers (TS, NP, EK, and EF) rated the adherence. Findings 397 patients who presented with their first episode of psychosis between April 12, 2002, and July 26, 2013 had a follow-up assessment until September, 2015. Of the 397 patients approached for followed up, 133 refused to take part in this study and 19 could not be included because of missing data. 91 (37%) of 245 patients with first-episode psychosis had a relapse over the 2 years of follow-up. Continued cannabis use predicted poor outcome, including risk of relapse, number of relapses, length of relapse, and care intensity at follow-up. In controlled structural equation modelling analyses, medication adherence partly mediated the effect of continued cannabis use on outcome, including risk of relapse (proportion mediated=26%, β indirect effects =0·08, 95% CI 0·004 to 0·16), number of relapses (36%, β indirect effects =0·07, 0·003 to 0·14), time until relapse (28%, β indirect effects =–0·26, −0·53 to 0·001) and care intensity (20%, β indirect effects =0·06, 0·004 to 0·11) but not length of relapse (6%, β indirect effects =0·03, −0·03 to 0·09). The adjusted models explained moderate amounts of variance for outcomes defined as risk of relapse (R 2 =0·25), number of relapses (R 2 =0·21), length of relapse (R 2 =0·07), time until relapse (R 2 =0·08), and care intensity index (R 2 =0·15). Interpretation Between 20% and 36% of the adverse effects of continued cannabis use on outcome in psychosis might be mediated through the effects of cannabis use on medication adherence. Interventions directed at medication adherence could partly help mitigate the harm from cannabis use in psychosis. Funding This study is funded by the National Institute of Health Research (NIHR) Clinician Scientist award.
Cannabis use and adherence to antipsychotic medication: a systematic review and meta-analysis
BACKGROUND: Substance use may increase the risk of non-adherence to antipsychotics, resulting in negative outcomes in patients with psychosis.
Association between continued cannabis use and risk of relapse in first-episode psychosis a quasi-experimental investigation within an observational study
IMPORTANCE Cannabis use after first-episode psychosis is associated with poor outcomes, but the causal nature of this association is unclear. OBJECTIVE To examine the precise nature of the association between continued cannabis use after the onset of psychosis and risk of relapse of psychosis. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study followed up for at least 2 years after the onset of psychosis 220 patients who presented to psychiatric services in South London, England, from April 12, 2002, to July 26, 2013, with first-episode psychosis. Longitudinal modeling (fixed-effects analysis, cross-lagged path analysis) was used to examine whether the association between changes in cannabis use and risk of relapse over time is the result of shared vulnerability between psychosis and cannabis use, psychosis increasing the risk of cannabis use (reverse causation), or a causal effect of cannabis use on psychosis relapse. INTERVENTIONS Exposure to cannabis within the first and second years after onset of psychosis. MAIN OUTCOMES AND MEASURES The main outcome measurewas relapse of psychosis, defined as subsequent hospitalization for psychosis. Effect of cannabis use status in the first year (Ct1) and second year (Ct2) and pattern of cannabis use continuation in the first year and second year were modeled for risk of relapse in the first year (Rt1) and risk of relapse in the second year (Rt2) after psychosis onset. RESULTS A total of 220 patients with first-episode psychosis were included in the analysis (mean [SD] age, 28.62 [8.58] years; age range, 18-65 years; 90 women [40.9%] and 130 men [59.1%]). Fixed-effects models that adjusted for time-variant (other illicit drug use, antipsychotic medication adherence) and time-invariant (eg, genetic or premorbid environment) unobserved confounders revealed that there was an increase in the odds of experiencing a relapse of psychosis during periods of cannabis use relative to periods of no use (odds ratio, 1.13; 95%CI, 1.03-1.24). Change in the pattern of continuation significantly increased the risk (odds ratio, 1.07; 95%CI, 1.02-1.13), suggesting a dose-dependent association. Cross-lagged analysis confirmed that this association reflected an effect of cannabis use on subsequent risk of relapse (Ct1→Rt2: β = 0.44, P = .04) rather than an effect of relapse on subsequent cannabis use (Rt1→Ct2: β = -0.29, P = .59). CONCLUSIONS AND RELEVANCE These results reveal a dose-dependent association between change in cannabis use and relapse of psychosis that is unlikely to be a result of self-medication or genetic and environmental confounding.
Effects of continuation, frequency, and type of cannabis use on relapse in the first 2 years after onset of psychosis: an observational study
Background Although cannabis use after a first episode of psychosis has been associated with relapse, little is known about the determinants of this most preventable risk factor for relapse of psychosis. Here we aimed to study whether the effects on outcome vary depending on the type of cannabis consumed and usage pattern. Methods In this observational study, we prospectively recruited and followed up patients aged 18–65 years who presented with their first episode of psychosis to psychiatric services in south London, London, UK. Relapse of psychosis within 2 years after onset of psychosis was defined as risk of subsequent admission to hospital. We classified patients into different patterns of cannabis use based on continuity of use after onset of psychosis, potency of cannabis consumed, and frequency of use after the onset of their illness. We used multiple regression analyses (logistic or binominal) to compare the different cannabis use groups and propensity score analysis to validate the results. Findings Between April 12, 2002, and July 26, 2013, 256 patients presented with a first episode of psychosis. We did follow-up assessments for these patients until September, 2015. Simple analyses showed that former regular users of cannabis who stopped after the onset of psychosis had the most favourable illness course with regards to relapse. In multiple analysis, continued high-frequency users (ie, daily use in all 24 months) of high-potency (skunk-like) cannabis had the worst outcome, indexed as an increased risk for a subsequent relapse (odds ratio [OR] 3·28; 95% CI 1·22–9·18), more relapses (incidence rate ratio 1·77; 95% CI 0·96–3·25), fewer months until a relapse occurred (b −0·22; 95% CI −0·40 to −0·04), and more intense psychiatric care (OR 3·16; 95% CI 1·26–8·09) after the onset of psychosis. Interpretation Adverse effects associated with continued use of cannabis after the onset of a first episode of psychosis depend on the specific patterns of use. Possible interventions could focus on persuading cannabis-using patients with psychosis to reduce use or shift to less potent forms of cannabis. Funding National Institute for Health Research (NIHR).