Leonard Cheshire

BackgroundWorkload is probably the biggest challenge facing general practice and little is known about any modifiable factors. For GPs, both continuity and locum status are associated with differences in outcomes.AimTo determine whether practice and hospital workload after an index acute consultation depend on the type of GP consulted (locums and practice GPs with [regular] and without [non-regular] continuity, and locums).Design and settingAn observational, cross-sectional analysis of consultation-level data from English general practices from the Clinical Practice Research Datalink from 2015 to 2017.MethodAntibiotic prescription was used as a marker for acute consultations with regression models to calculate adjusted relative risks for emergency department consultations and admissions, outpatient referrals, and test ordering, as well as the patients’ GP reconsultation interval following consultations with the three types of GP.ResultsAfter adjustment, consultations with antibiotic prescriptions with regular GPs with continuity were associated with fewer subsequent hospital admissions and lower emergency department use but higher outpatient referrals relative to locums and non-regular GPs. Locums ordered tests less often (relative risk [RR] −24.3%, 95% confidence interval [CI] = −27.3 to −21.2) than regular GPs whereas non-regular GPs ordered tests more often (RR 19.1%, 95% CI = = 16.4 to 21.8). Patients seeing their regular GP had on average a 9% longer (95% CI = 8 to 10) reconsultation interval than if they saw any other GP.ConclusionThe differences in outcomes were associated more with having continuity than with GP locum status. Seeing a GP with whom the patient had continuity of care was associated with reduced workload within the practice and in hospital.

Adolescents with disabilities must have their needs prioritised in recovery and future pandemic responses to improve health, educational, and social outcomes, argue <b>Sarah Baird and colleagues</b>

Abstract BackgroundThe neurological events that follow traumatic brain injury (TBI) can include cognitive decline, personality changes, and long‐term structural and functional effects. At the microscale, the neuropathological changes following TBI overlap partially with those seen in Alzheimer’s disease (AD). Nevertheless, our understanding of how mild TBI (mTBI) can lead to AD remains inadequate. The predictive potential of acute mTBI degeneration patterns in prognosticating the risk of AD‐like structural changes is also largely unexplored.MethodIn 66 AD patients, 33 mTBI patients and 72 healthy controls (HCs), diffusion‐weighted imaging (DWI) was used to calculate the fractional anisotropy (FA) of white matter (WM) connections and T1 ‐weighted magnetic resonance imaging (MRI) was used to estimate gray matter (GM) thickness. Support vector machines (SVMs) then leveraged acute mTBI data to predict the severity of AD‐like neurodegeneration measured six months after mTBI.ResultIn both AD and mTBI, WM degeneration patterns and their extent are indistinguishable, in a statistical sense, within the fornix, corpus callosum, and corona radiata. In these structures, 78%, 35%, and 56% of their respective voxels have mean FAs which differ significantly from those of HCs for both mTBI and AD cohorts (p &lt; 0.05). The mean FAs of these same sets of voxels are statistically equivalent across the mTBI and AD groups (p &lt; 0.05, two one‐sided tests of statistical equivalence). mTBI and AD participants exhibit statistically significant similarities in their GM degeneration patterns, particularly within temporal poles (memory) and orbitofrontal cortices (executive function). 47% and 75% of voxels in these structures, respectively, exhibit statistical equivalence of mean FA across mTBI and AD (p &lt; 0.05); these sets of voxels’ mean FAs are also statistically significantly different from those of HCs. SVM predictions suggest that acute post‐traumatic cognitive assessments contain information that accurately predicts AD‐like neurodegeneration patterns and severity observed chronically after mTBI (sensitivity: 0.87±0.09, specificity: 0.93±0.09; precision: 0.88±0.2).ConclusionOur findings suggest that mTBI‐induced atrophy can relegate the brain onto AD‐like neurodegeneration trajectories and that post‐mTBI cognitive assessments may provide early indications of AD risk after TBI.

sense is precisely what has eroded the trust of our patients and opened us up to justifiable claims of professional arrogance in dismissing alternative approaches to health care. Nobody is arguing that these are not more effective when applied at a population health level, but this should not preclude GPs from applying our professional common sense in tailoring sensible and safe lifestyle interventions for our patients.

Background: Disability and caste are two different forms of oppression, however Dalits and people with disabilities commonly face similar types of marginalities. Dalit women with disabilities may experience double discrimination because of the intersectionality of disability and caste. This study examines whether the disability and caste identity of women together affects and compounds the utilization of maternal healthcare services. Methods: A cross-sectional survey was conducted using a semi-structured questionnaire among a total of 354 Dalit and non-Dalit women, with and without a disability aged between 15 &amp;ndash; 49 years. Maternal healthcare service utilization was assessed by Ante-Natal Care (ANC), health facility (HF) delivery, and Post-Natal Care (PNC) during the last pregnancy. Logistic regression was performed to detect the predictors of service utilization and identify whether disability and caste were associated with service utilization. First, disability and caste were fitted separately in models. Secondly, the intersectionality of disability and caste was tested by the inclusion of disability*caste interaction term. Finally, the confounding effect of socio-demographic factors was investigated. Results: Out of surveyed women, 73% had 4+ ANC visits, 65% had HF delivery and 29% had a PNC visit during their last pregnancy. Women with a disability had lower odds of HF delivery (OR 0.50, CI 0.30 &amp;ndash; 0.84) and PNC (OR 0.47, CI 0.25 &amp;ndash; 0.88) than women without a disability. Adjustment for women&amp;rsquo;s age and household wealth explained associations in HF delivery by women with disabilities. There was no association between caste and service utilization. Disability overrode caste and there was no other evidence of effect modification by women&amp;rsquo;s caste status in the utilization. However, a weak interaction effect in the utilization of ANC services was found in the caste group by their education (OR 0.19, 95% CI 0.05 &amp;ndash; 0.74). Conclusions: Disabled women &amp;ndash; whether Dalit or non-Dalit - had lower rates of utilizing all maternal healthcare services than non-disabled women. However, Dalit women with disabilities were more likely to receive PNC than non-Dalit women with disabilities. Increasing equity in maternal healthcare service utilization requires that traditional approaches to service development and program intervention to be re-examined and more nuanced interventions considered to ensure improved access and outcome among all vulnerable groups.

Alzheimer's disease is a progressive and fatal neurodegenerative disease affecting 50 million people worldwide, characterized by memory loss and neuronal degeneration. Current treatments have limited efficacy and there is no cure. Alzheimer's is likely caused by a combination of factors, providing several potential therapeutic targets. One area of interest is the epigenetic regulation of gene expression within the brain. Epigenetic marks, including DNA methylation and histone modifications, show consistent changes with age and in those with Alzheimer's. Some epigenetic regulation has been linked to disease pathology and progression and are the focus of current research. Epigenetic regulators might make promising therapeutic targets yet challenges need to be overcome to generate an efficacious drug lacking deleterious side effects.

Introduction: Stroke medicine has evolved over time, with changing demographics and improving outcomes. We aimed to evaluate trends in incidence, risk factors, treatment and case fatality of acute ischemic stroke (AIS) in a multiethnic population. Methods: Data was obtained from the Singapore Stroke Registry. 60,325 AIS cases that presented to Singapore’s public hospitals from 2005-16 were studied. Trends were analyzed with Poisson regression, logistic regression and Cox regression. Results: The AIS age-standardized incidence rate has decreased by 11.6% (126.5 to 111.8 per 100,000 person-years from 2005-07 to 2014-16, p &lt; 0.001). This was observed in all gender and ethnic groups except in those younger than 65, which saw a 2.5% increase (51.0 to 52.4 per 100,000 person-years, p = 0.017). In terms of risk factors, hypertension, hyperlipidemia, and atrial fibrillation have increased in prevalence, while history of stroke, ischemic heart disease, diabetes, and smoking have decreased (Figure A). Treatment-wise, thrombolysis utilization rates have increased significantly from 0.8% in 2005-2007 to 6.7% in 2014-2016 (p &lt; 0.001). While atrial fibrillation (AF) has become more prevalent (15.8% to 25.2%, p &lt; 0.001), anticoagulant prescription has not increased by the same magnitude (13.2% to 14.4%, p = 0.014). Case fatality has reduced by 25.6% (8.2% to 6.1%, p &lt; 0.001). Conclusion: In a multi-ethnic population, whilst we found that AIS age-standardized incidence rate has been declining, we demonstrate a temporal trend of changing risk factors. Further research is needed to investigate the causes and implications of these trends, so as to better strategize prevention efforts.