What happens between first symptoms and first acute exacerbation of COPD - observational study of routine data and patient survey.

Background: Chronic obstructive pulmonary disease affects nearly 400 million worldwide - over a million in the United Kingdom - and is the third leading cause of death. However, there is limited understanding of what prompts a diagnosis, how long this takes from symptom onset and the different approaches to clinical management by primary care professionals. Objectives: Map out the clinical management and National Health Service contacts from symptom presentation to chronic obstructive pulmonary disease diagnosis and first acute exacerbation of chronic obstructive pulmonary disease in three time periods; construct risk prediction for first acute exacerbation of chronic obstructive pulmonary disease. Design: Retrospective cohort study and cross-sectional survey. Setting: Primary care. Participants: Patients with incident chronic obstructive pulmonary disease aged > 35 years in England. Interventions: None. Main outcome measures: First acute exacerbation of chronic obstructive pulmonary disease. Data sources: Clinical Practice Research Datalink Aurum; new online survey. Results: Forty thousand five hundred and seventy-seven patients were diagnosed between April 2006 and March 2007 (cohort 1), 48,249 between April 2016 and March 2017 (cohort 2) and 4752 between March and August 2020 (cohort 3). The mean (standard deviation) age was 68.3 years (12.0); 47.3% were female. Around three-quarters were diagnosed in primary care, with a slight fall in cohort 3. Compliance with National Institute for Health and Care Excellence diagnostic guidelines was slightly higher in cohorts 2 and 3 for all patients; 35.8% (10.0% in the year before diagnosis) had all four elements met for all cohorts combined. Multilevel modelling showed considerable between-practice variation in spirometry. The survey on the charity website had 156 responses by chronic obstructive pulmonary disease patients. Many respondents had not heard of the condition, hoped the symptoms would go away and identified various healthcare-related barriers to earlier diagnosis. Clinical Practice Research Datalink analysis showed notable changes in post-diagnosis prescribing from cohort 1 to 2, such as increases in long-acting muscarinic antagonist (21.7-46.3%). Triple therapy rose from 2.9% in cohort 2 to 11.1% in cohort 3. Documented pulmonary rehabilitation rose from just 0.8% in cohort 1 to 13.7% in cohort 2 and 20.9% in cohort 3. For all patients combined, the median time to first acute exacerbation of chronic obstructive pulmonary disease in patients who had one was 1.4 years in cohorts 1 and 2. Acute exacerbation of chronic obstructive pulmonary disease prediction models identified some consistent predictors, such as age, deprivation, severity, comorbidities, post-diagnosis spirometry and annual review. Models without post-diagnosis general practitioner actions had a c-statistic of around 0.70; the highest c-statistic was 0.81, for cohort 2 with post-diagnosis general practitioner actions and 6-month follow-up. All models had good calibration. The three most important predictors in terms of their population attributable risks were being a current smoker and offered smoking cessation advice (32.8%), disease severity (30.6%) and deprivation (15.4%). The highest population attributable risks for variables with adjusted hazard ratios < 1 were chronic obstructive pulmonary disease review (-27.3%) and flu vaccination (-26.6%). Limitations: Symptom recording and chronic obstructive pulmonary disease diagnosis vary between practice; predicted forced expiratory volume in 1 second had many missing values. Conclusions: There has been some improvement over time in chronic obstructive pulmonary disease diagnosis and management, with large changes in prescribing, though patient and system barriers to further improvement exist. Data available to general practitioners cannot generate risk prediction models with sufficient accuracy. Future work: It will be important to expand the COVID-era cohort with longer follow-up and augment general practitioner data for better prediction. Study registration: This study is registered as Researchregistry.com: researchregistry4762. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/99/72) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 43. See the NIHR Funding and Awards website for further award information.

Chronic obstructive pulmonary disease is often caused by smoking and affects over 1 million people in the United Kingdom. While there are well-established treatments, less is known on where and when patients get the diagnosis, how general practitioners investigate their symptoms and to what extent the first major flare-up ('acute exacerbation') can be predicted and prevented. Using a research database of general practitioner consultation records linked to hospital admissions and the national death register, we described patient characteristics, general practitioner actions before and following diagnosis, and, with statistical models, predictors of the first exacerbation. We looked at three time periods according to the date of diagnosis: April 2006­March 2007 (cohort 1), April 2016­March 2017 (cohort 2) and March­August 2020 (cohort 3). We sent patients a questionnaire asking about their experiences of developing symptoms, seeking medical help and getting diagnosed. We analysed records of over 70,000 patients in total. The majority were diagnosed by their general practitioner. In cohorts 2 and 3, general practitioners did the recommended tests more than in cohort 1, though in the year before diagnosis, only 10% of patients had all four done. Our survey found that many people were unaware of chronic obstructive pulmonary disease and its symptoms before their diagnosis but also that some felt they were not taken seriously by the medical team and that their diagnosis was delayed. There were improvements over time in prescribing. Most patients were offered the flu jab. Older patients, current smokers and those with other conditions such as heart failure had higher risk of an acute exacerbation. The statistical models did not perform well enough to be used to guide decision-making. Despite some improvements over time, there remain opportunities for better recognition of the condition among patients and general practitioners alike. Future work should more fully assess the impact of COVID-19.

Incidence of rectal cancer after colectomy for inflammatory bowel disease: nationwide study.

BACKGROUND: Inflammatory bowel disease increases the risk of colorectal neoplasia. A particular problem arises in patients who have undergone subtotal colectomy leaving a rectal remnant. The risk of future rectal cancer must be accurately estimated and weighed against the risks of further surgery or surveillance. The aim of this study was to estimate the 10-year cumulative incidence of rectal cancer in such patients. METHODS: A nationwide study using England's hospital administrative data was performed. A cohort of patients undergoing subtotal colectomy between April 2002 and March 2014 was identified. A competing risks survival analysis was performed to calculate the cumulative incidence of rectal cancer. The effect of the COVID-19 pandemic on endoscopic surveillance was investigated using time-trend analysis. RESULTS: A total of 8120 patients were included and 61 patients (0.8%) were diagnosed with cancer. The cumulative incidence of rectal cancer was 0.26% (95% c.i. 0.17% to 0.39%), 0.49% (95% c.i. 0.36% to 0.68%), and 0.77% (95% c.i. 0.57% to 1.02%) at 5, 10, and 15 years respectively. A previous diagnosis of colonic dysplasia (HR 3.34, 95% c.i. 1.01 to 10.97; P = 0.047), primary sclerosing cholangitis (HR 5.42, 95% c.i. 1.34 to 21.85; P = 0.018), and elective colectomy (HR 1.83, 95% c.i. 1.11 to 3.02; P = 0.018) was associated with an increased incidence of rectal cancer. Regarding endoscopic surveillance, there was a 43% decline in endoscopic procedures performed in 2020 (333 procedures) compared with 2019 (585 procedures). CONCLUSION: The incidence of rectal cancer after subtotal colectomy is low. Asymptomatic patients without evidence of rectal dysplasia should be carefully counselled on the possible benefits and risks of prophylactic proctectomy.

Can ChatGPT make surgical decisions with confidence similar to experienced knee surgeons?

BACKGROUND: Unicompartmental knee replacements (UKRs) have become an increasingly attractive option for end-stage single-compartment knee osteoarthritis (OA). However, there remains controversy in patient selection. Natural language processing (NLP) is a form of artificial intelligence (AI). We aimed to determine whether general-purpose open-source natural language programs can make decisions regarding a patient's suitability for a total knee replacement (TKR) or a UKR and how confident AI NLP programs are in surgical decision making. METHODS: We conducted a case-based cohort study using data from a separate study, where participants (73 surgeons and AI NLP programs) were presented with 32 fictitious clinical case scenarios that simulated patients with predominantly medial knee OA who would require surgery. Using the overall UKR/TKR judgments of the 73 experienced knee surgeons as the gold standard reference, we calculated the sensitivity, specificity, and positive predictive value of AI NLP programs to identify whether a patient should undergo UKR. RESULTS: There was disagreement between the surgeons and ChatGPT in only five scenarios (15.6%). With the 73 surgeons' decision as the gold standard, the sensitivity of ChatGPT in determining whether a patient should undergo UKR was 0.91 (95% confidence interval (CI): 0.71 to 0.98). The positive predictive value for ChatGPT was 0.87 (95% CI: 0.72 to 0.94). ChatGPT was more confident in its UKR decision making (surgeon mean confidence = 1.7, ChatGPT mean confidence = 2.4). CONCLUSIONS: It has been demonstrated that ChatGPT can make surgical decisions, and exceeded the confidence of experienced knee surgeons with substantial inter-rater agreement when deciding whether a patient was most appropriate for a UKR.

The Impact of COVID-19 on Acute Surgeries in England Among the Under-25s: A Retrospective Study of 61,360 Appendicitis and 15,850 Testicular Torsion Admissions.

BACKGROUND: Little is known about how COVID-19 impacted acute surgical activity for children and young people (CYP) across England. Appendicitis and testicular torsion are common surgical conditions where treatment delays can lead to avoidable complications. We undertook a retrospective national cohort study. PRIMARY AIM: To describe monthly acute surgical activity in CYP during the COVID-19 pandemic. Secondary aim: To investigate evidence of delayed diagnosis and adverse outcomes, describing variations by age and socioeconomic deprivation. METHODS: Acute hospital admissions with appendicitis or testicular pain for those under 18 were extracted using Hospital Episode Statistics. Interrupted time series modelling, Mann-Whitney and Pearson's Chi-Squared tests compared the first 14 pandemic months with the previous five years. Results were stratified by age (0-4s, 5-9s and 10-17s) and appendicitis type (all, simple and complex). RESULTS: Admissions for appendicitis and testicular torsion fell significantly early in the COVID-19 pandemic. The proportion of children with complex appendicitis also increased during this time. Orchidectomy rates rose in April 2020 for the 0-4s (+15.6% (95% CI 7.9-23.3)) and 10-17s (+11.5% (4.9-18.2)), but when the pre-pandemic period was compared with the pandemic period as a whole, there were no overall statistically significant differences in orchidectomy rates between the study periods. Overall, there was a statistically significant rise in the orchidopexy rate during the pandemic period for the 10-17s when compared with the pre-pandemic period (Pre-pandemic: 17.0% vs Pandemic: 20.9%, p < 0.0001). CONCLUSION: A consistent reduction in activity, with short-lived periods of delayed presentations during COVID-19 pandemic peaks, occurred without persisting overall increased complication rates. These results provide useful national context for smaller sized studies that reported complications due to delays in surgery. Future research could examine how reduced activity impacted other healthcare settings and treatment pathways. LEVEL OF EVIDENCE: II.

Has multimorbidity and frailty in adult hospital admissions changed over the last 15 years? A retrospective study of 107 million admissions in England.

BACKGROUND: Few studies have quantified multimorbidity and frailty trends within hospital settings, with even fewer reporting how much is attributable to the ageing population and individual patient factors. Studies to date have tended to focus on people over 65, rarely capturing older people or stratifying findings by planned and unplanned activity. As the UK's national health service (NHS) backlog worsens, and debates about productivity dominate, it is essential to understand these hospital trends so health services can meet them. METHODS: Hospital Episode Statistics inpatient admission records were extracted for adults between 2006 and 2021. Multimorbidity and frailty was measured using Elixhauser Comorbidity Index and Soong Frailty Scores. Yearly proportions of people with Elixhauser conditions (0, 1, 2, 3 +) or frailty syndromes (0, 1, 2 +) were reported, and the prevalence between 2006 and 2021 compared. Logistic regression models measured how much patient factors impacted the likelihood of having three or more Elixhauser conditions or two or more frailty syndromes. Results were stratified by age groups (18-44, 45-64 and 65 +) and admission type (emergency or elective). RESULTS: The study included 107 million adult inpatient hospital episodes. Overall, the proportion of admissions with one or more Elixhauser conditions rose for acute and elective admissions, with the trend becoming more prominent as age increased. This was most striking among acute admissions for people aged 65 and over, who saw a 35.2% absolute increase in the proportion of admissions who had three or more Elixhauser conditions. This means there were 915,221 extra hospital episodes in the last 12 months of the study, by people who had at least three Elixhauser conditions compared with 15 years ago. The findings were similar for people who had one or more frailty syndromes. Overall, year, age and socioeconomic deprivation were found to be strongly and positively associated with having three or more Elixhauser conditions or two or more frailty syndromes, with socioeconomic deprivation showing a strong dose-response relationship. CONCLUSIONS: Overall, the proportion of hospital admissions with multiple conditions or frailty syndromes has risen over the last 15 years. This matches smaller-scale and anecdotal reports from hospitals and can inform how hospitals are reimbursed.

Exploration of understanding of impactibility analysis and application through workshops to inform model design for population health management policy: a qualitative assessment.

OBJECTIVES: Assess understanding of impactibility modelling definitions, benefits, challenges and approaches. DESIGN: Qualitative assessment. SETTING: Two workshops were developed. Workshop 1 was to consider impactibility definitions and terminology through moderated open discussion, what the potential pros and cons might be, and what factors would be best to assess. In workshop 2, participants appraised five approaches to impactibility modelling identified in the literature. PARTICIPANTS: National Health Service (NHS) analysts, policy-makers, academics and members of non-governmental think tank organisations identified through existing networks and via a general announcement on social media. Interested participants could enrol after signing informed consent. OUTCOME MEASURES: Descriptive assessment of responses to gain understanding of the concept of impactibility (defining impactibility analysis), the benefits and challenges of using this type of modelling and most relevant approach to building an impactibility model for the NHS. RESULTS: 37 people attended 1 or 2 workshops in small groups (maximum 10 participants): 21 attended both workshops, 6 only workshop 1 and 10 only workshop 2. Discussions in workshop 1 illustrated that impactibility modelling is not clearly understood, with it generally being viewed as a cross-sectional way to identify patients rather than considering patients by iterative follow-up. Recurrent factors arising from workshop 2 were the shortage of benchmarks; incomplete access to/recording of primary care data and social factors (which were seen as important to understanding amenability to treatment); the need for outcome/action suggestions as well as providing the data and the risk of increasing healthcare inequality. CONCLUSIONS: Understanding of impactibility modelling was poor among our workshop attendees, but it is an emerging concept for which few studies have been published. Implementation would require formal planning and training and should be performed by groups with expertise in the procurement and handling of the most relevant health-related real-world data.

Associations between prior healthcare use, time to diagnosis, and clinical outcomes in inflammatory bowel disease: a nationally representative population-based cohort study.

BACKGROUND: Timely diagnosis and treatment of inflammatory bowel disease (IBD) may improve clinical outcomes. OBJECTIVE: Examine associations between time to diagnosis, patterns of prior healthcare use, and clinical outcomes in IBD. DESIGN: Using the Clinical Practice Research Datalink we identified incident cases of Crohn's disease (CD) and ulcerative colitis (UC), diagnosed between January 2003 and May 2016, with a first primary care gastrointestinal consultation during the 3-year period prior to IBD diagnosis. We used multivariable Cox regression to examine the association of primary care consultation frequency (n=1, 2, >2), annual consultation intensity, hospitalisations for gastrointestinal symptoms, and time to diagnosis with a range of key clinical outcomes following diagnosis. RESULTS: We identified 2645 incident IBD cases (CD: 782; UC: 1863). For CD, >2 consultations were associated with intestinal surgery (adjusted HR (aHR)=2.22, 95% CI 1.45 to 3.39) and subsequent CD-related hospitalisation (aHR=1.80, 95% CI 1.29 to 2.50). For UC, >2 consultations were associated with corticosteroid dependency (aHR=1.76, 95% CI 1.28 to 2.41), immunomodulator use (aHR=1.68, 95% CI 1.24 to 2.26), UC-related hospitalisation (aHR=1.43, 95% CI 1.05 to 1.95) and colectomy (aHR=2.01, 95% CI 1.22 to 3.27). For CD, hospitalisation prior to diagnosis was associated with CD-related hospitalisation (aHR=1.30, 95% CI 1.01 to 1.68) and intestinal surgery (aHR=1.71, 95% CI 1.13 to 2.58); for UC, it was associated with immunomodulator use (aHR=1.42, 95% CI 1.11 to 1.81), UC-related hospitalisation (aHR=1.36, 95% CI 1.06 to 1.95) and colectomy (aHR=1.54, 95% CI 1.01 to 2.34). For CD, consultation intensity in the year before diagnosis was associated with CD-related hospitalisation (aHR=1.19, 95% CI 1.12 to 1.28) and intestinal surgery (aHR=1.13, 95% CI 1.03 to 1.23); for UC, it was associated with corticosteroid use (aHR=1.08, 95% CI 1.04 to 1.13), corticosteroid dependency (aHR=1.05, 95% CI 1.00 to 1.11), and UC-related hospitalisation (aHR=1.12, 95% CI 1.03 to 1.21). For CD, time to diagnosis was associated with risk of CD-related hospitalisation (aHR=1.03, 95% CI 1.01 to 1.68); for UC, it was associated with reduced risk of UC-related hospitalisation (aHR=0.83, 95% CI 0.70 to 0.98) and colectomy (aHR=0.59, 95% CI 0.43 to 0.80). CONCLUSION: Electronic records contain valuable information about patterns of healthcare use that can be used to expedite timely diagnosis and identify aggressive forms of IBD.

The impact of the COVID-19 pandemic on 397 631 elective dental admissions among the under-25s in England: a retrospective study.

BACKGROUND: COVID-19 caused widespread disruptions to health services worldwide, including reductions in elective surgery. Tooth extractions are among the most common reasons for elective surgery among children and young people (CYP). It is unclear how COVID-19 affected elective dental surgeries in hospitals over multiple pandemic waves at a national level. METHODS: Elective dental tooth extraction admissions were selected using Hospital Episode Statistics. Admission trends for the first 14 pandemic months were compared with the previous five years and results were stratified by age (under-11s, 11-16s, 17-24s). RESULTS: The most socioeconomically deprived CYP comprised the largest proportion of elective dental tooth extraction admissions. In April 2020, admissions dropped by >95%. In absolute terms, the biggest reduction was in April (11-16s: -1339 admissions, 95% CI -1411 to -1267; 17-24s: -1600, -1678 to -1521) and May 2020 (under-11s: -2857, -2962 to -2752). Admissions differed by socioeconomic deprivation for the under-11s (P < 0.0001), driven by fewer admissions than expected by the most deprived and more by the most affluent during the pandemic. CONCLUSION: Elective tooth extractions dropped most in April 2020, remaining below pre-pandemic levels throughout the study. Despite being the most likely to be admitted, the most deprived under-11s had the largest reductions in admissions relative to other groups.

Evaluation of emergency hospital admissions for inflammatory bowel disease as a possible marker of quality of care of British IBD inflammatory bowel disease units.

Background: Key performance indicators (KPIs) are required to facilitate quality improvement for inflammatory bowel disease (IBD). Emergency admissions for IBD may represent a possible KPI. Methods: IBD emergency admissions for 2018-2019 from Hospital Episodes Statistics for England were compared per population and per IBD cases with patient-reported quality of care from the IBD Patient Survey 2019. Patient-reported accident and emergency (A&E) attendances and hospital admissions for IBD were also compared with patient-reported quality of care. Results: For 124 IBD services within England we found only a weak and not statistically significant correlation between IBD admissions per 100 000 population and patient-rated quality of care (Spearman's rho=0.171; p=0.057). Similarly, there was no significant correlation between IBD admissions per case and patient-rated quality of care (Spearman's rho=0.164; p=0.113). Patients with ≥2 A&E attendances (OR: 0.72, 95% CI: 0.57 to 0.91; p<0.001) were less likely to report quality of IBD care as good or very good compared with those without A&E attendances. Patients with ≥2 admissions were less likely to rate their care as good or very good (OR: 0.75, 95% CI: 0.65 to 0.88; p<0.0001) compared with those without hospital admissions. Conclusions: There is a clear association for individual patients with ≥2 admissions or A&E attendances with a lower perceived quality of care. In contrast we found no correlation on a per-unit basis for IBD admissions derived from Hospital Episode Statistics with patient-assessed quality of care. Further work is required to determine whether hospital admissions could be a useful KPI for IBD.

Modifiable risk factors that may be addressed in routine care to prevent progression to and extension of multimorbidity in people with COPD: a systematic literature review.

Chronic obstructive pulmonary disease (COPD) is a multisystem disease, and many patients have multiple conditions. We explored multimorbidity patterns that might inform intervention planning to reduce health-care costs while preserving quality of life for patients. Literature searches up to February 2022 revealed 4419 clinical observational and comparative studies of risk factors for multimorbidity in people with COPD, pulmonary emphysema, or chronic bronchitis at baseline. Of these, 29 met the inclusion criteria for this review. Eight studies were cluster and network analyses, five were regression analyses, and 17 (in 16 papers) were other studies of specific conditions, physical activity and treatment. People with COPD more frequently had multimorbidity and had up to ten times the number of disorders of those without COPD. Disease combinations prominently featured cardiovascular and metabolic diseases, asthma, musculoskeletal and psychiatric disorders. An important risk factor for multimorbidity was low socioeconomic status. One study showed that many patients were receiving multiple drugs and had increased risk of adverse events, and that 10% of medications prescribed were inappropriate. Many patients with COPD have mainly preventable or modifiable multimorbidity. A proactive multidisciplinary approach to prevention and management could reduce the burden of care.

Impact of the COVID-19 pandemic on the clinical management trends for acute appendicitis among the under-25s: a retrospective study.

OBJECTIVE: To describe the COVID-19 pandemic's impact on acute appendicitis management on children and young people (CYP). DESIGN: Retrospective cohort study. SETTING: All English National Health Service hospitals. PATIENTS: Acute appendicitis admissions (all, simple, complex) by CYP (under-5s, 5-9s, 10-24s). EXPOSURE: Study pandemic period: February 2020-March 2021. Comparator pre-pandemic period: February 2015-January 2020. MAIN OUTCOME MEASURES: Monthly appendicectomy and laparoscopic appendicectomy rate trends and absolute differences between pandemic month and the pre-pandemic average. Proportions of appendicitis admissions comprising complex appendicitis by hospital with or without specialist paediatric centres were compared. RESULTS: 101 462 acute appendicitis admissions were analysed. Appendicectomy rates fell most in April 2020 for the 5-9s (-18.4% (95% CI -26.8% to -10.0%)) and 10-24s (-28.4% (-38.9% to -18.0%)), driven by reductions in appendicectomies for simple appendicitis. This was equivalent to -54 procedures (-68.4 to -39.6) and -512 (-555.9 to -467.3) for the 5-9s and 10-24s, respectively. Laparoscopic appendicectomies fell in April 2020 for the 5-9s (-15.5% (-23.2% to -7.8%)) and 10-24s (-44.8% (-57.9% to -31.6%) across all types, which was equivalent to -43 (-56.1 to 30.3) and -643 (-692.5 to -593.1) procedures for the 5-9s and 10-24s, respectively. A larger proportion of complex appendicitis admissions were treated within trusts with specialist paediatric centres during the pandemic. CONCLUSIONS: For CYP across English hospitals, a sharp recovery followed a steep reduction in appendicectomy rates in April 2020, due to concerns with COVID-19 transmission. This builds on smaller-sized studies reporting the immediate short-term impacts.

Predictors of positive outcomes from 'Early Intervention in Psychosis': protocol for a national retrospective cohort study.

Background: Psychotic disorders are severe and prevalent mental health conditions associated with long-term disability, reduced quality of life, and substantial economic costs. Early Intervention in Psychosis (EIP) services aim to provide timely and comprehensive treatment for psychotic disorders, and EIP service input is associated with improved outcomes. However, there is limited understanding of the specific components of EIP care that contribute to these improvements. There is significant nationwide variability in the commissioning and delivery of EIP, with individuals receiving different packages of components from different services. In this study, we seek to explore associations between EIP components and clinically significant outcomes, in order to understand the mechanisms underlying improved psychosis care. Methods: This national retrospective cohort study will utilize data from the 2019 National Clinical Audit of Psychosis (NCAP), examining the care received by 10,560 individuals treated by EIP services in England. Exposure data from the NCAP, capturing the components of care delivered by EIP services, will be linked with outcome data from routine NHS Digital datasets over a three-year follow-up period. This will be the first study to use this method to examine this population in England. The primary outcomes will be surrogate measures of relapse of psychosis (hospital admission and referral to community-based crisis intervention services). Secondary outcomes include duration of admissions, emergency hospital attendances, episodes of detention under the Mental Health Act, and all-cause mortality. We will use multilevel regression to examine associations between exposures and outcome events. We will handle missing data using appropriate imputation techniques. Discussion: This study aims to provide valuable insights into the long-term effects of variations in EIP service delivery. The study involves a large, diverse cohort including individuals treated by every EIP service in England. While there are limitations inherent in the observational nature of the study, any associations identified will be of great relevance to clinicians, researchers, and policymakers seeking to optimize EIP care. The results will enable more targeted treatment planning, resource allocation, and potential innovations in EIP care, ultimately leading to improved prognoses for people experiencing psychosis.

Survey-identified experiences of prediagnosis and diagnosis process among patients with COPD, asthma, interstitial lung disease and bronchiectasis.

INTRODUCTION: Diagnosis of asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis and interstitial lung disease (ILD) can be convoluted, and limited data exist on understanding the experience of diagnosis from a patient perspective. AIM: To investigate a patient's 'route to diagnosis', particularly focusing on the time prior to seeking healthcare, and perceived experiences of the diagnostic pathway. METHODS: An online survey was distributed via the UK Taskforce for Lung Health and member mailing lists to patients as well as the website and social media accounts from 23 May 2022 to 5 July 2022. Analysis was descriptive; χ2 tests were performed to make comparisons across diseases. RESULTS: There were 398 valid responses (COPD=156, asthma=119, ILD=67 and bronchiectasis=56). While only 9.2% of respondents who were eventually diagnosed with asthma had not heard of their disease, the corresponding percentages for COPD, ILD and bronchiectasis were 34.0%, 74.6% and 69.6%, respectively. 33.9% of people with bronchiectasis believed their delayed diagnosis was due to the health professionals' lack of expertise or knowledge-24.4% for asthma, 19.2% for COPD and 17.9% for ILD.People with COPD were more likely (37.2%) and patients with asthma less likely (10.9%) to report they did not know the signs of potential lung disease (p<0.001). People with COPD were more likely to report that they did not appreciate the severity or urgency of the situation (58.3%) than people with asthma (32.8%), ILD (43.3%) or bronchiectasis (28.6%, p<0.001). The proportion of patients reporting that they were being initially treated for another lung condition was higher in people with bronchiectasis (44.6%) and lower in people with asthma (8.4%, p<0.001). CONCLUSIONS: Perceived reasons for diagnostic delay can help health professionals promote early diagnosis and management. Patients' limited knowledge of respiratory diseases also played a factor, indicating the necessity to promote patients' knowledge to encourage earlier help seeking.

Adherence to 5-aminosalicylic acid maintenance treatment in young people with ulcerative colitis: a retrospective cohort study in primary care.

BACKGROUND: Maintenance treatment with 5-aminosalicylic acid (5-ASA) is recommended in ulcerative colitis (UC), but accurate estimates of discontinuation and adherence in adolescents transitioning to young adulthood are lacking. AIM: To determine rates and risk factors for discontinuation and adherence to oral 5-ASA in adolescents and young adults 1 year following diagnosis of UC. DESIGN AND SETTING: Observational cohort study using the UK Clinical Practice Research Datalink among adolescents and young adults (aged 10-24 years) diagnosed with UC between 1 January 1998 and 1 May 2016. METHOD: Time to oral 5-ASA discontinuation (days) and adherence rates (proportion of days covered) were calculated during the first year of treatment using Kaplan-Meier survival analysis. Cox regression models were built to estimate the impact of sociodemographic and health-related risk factors. RESULTS: Among 607 adolescents and young adults starting oral 5-ASA maintenance treatment, one-quarter (n = 152) discontinued within 1 month and two- thirds (n = 419) within 1 year. Discontinuation was higher among those aged 18-24 years (74%) than younger age groups (61% and 56% in those aged 10-14 and 15-17 years, respectively). Adherence was lower among young adults than adolescents (69% in those aged 18-24 years versus 80% in those aged 10-14 years). Residents in deprived versus affluent postcodes were more likely to discontinue treatment (adjusted hazard ratio [aHR] 1.46, 95% confidence interval [CI] = 1.10 to 1.92). Early corticosteroid use for an acute flare lowered the likelihood of oral 5-ASA discontinuation (aHR 0.68, 95% CI = 0.51 to 0.90). CONCLUSION: The first year of starting long-term therapies in adolescents and young adults diagnosed with UC is a critical window for active follow-up of maintenance treatment, particularly in those aged 18-24 years and those living in deprived postcodes.

Predictors of positive patient-reported outcomes from 'Early Intervention in Psychosis': a national cross-sectional study.

BACKGROUND: The components of care delivered by Early Intervention in Psychosis (EIP) services vary, but the impact on patient experience is unknown. OBJECTIVE: To investigate associations between components of care provided by EIP services in England and patient-reported outcomes. METHODS: 2374 patients from EIP services in England were surveyed during the National Clinical Audit of Psychosis. Participants were asked about the care they received, and completed the 'Patient Global Impressions' Scale (rating whether their mental health had improved), and 'Friends and Family Test' (rating whether they would recommend their service). Information about service structure was obtained from service providers. We analysed associations between outcomes and components of care using multilevel regression. FINDINGS: The majority of participants were likely to recommend the treatment they had received (89.8%), and felt that their mental health had improved (89.0%). Participants from services where care coordinators had larger case loads were less likely to recommend their care. Participants were more likely to recommend their care if they had been offered cognitive behavioural therapy for psychosis, family therapy or targeted interventions for carers. Participants were more likely to report that their mental health had improved if they had been offered cognitive behavioural therapy for psychosis or targeted interventions for carers. CONCLUSIONS: Specific components of EIP care were associated with improved patient reported outcomes. Psychosocial interventions and carer support may be particularly important in optimising outcomes for patients. CLINICAL IMPLICATIONS: These findings emphasise the need for small case load sizes and comprehensive packages of treatment in EIP services.

Pediatric Hospitalizations and ICU Admissions Due to COVID-19 and Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2 in England.

Importance: Investigating how the risk of serious illness after SARS-CoV-2 infection in children and adolescents has changed as new variants have emerged is essential to inform public health interventions and clinical guidance. Objective: To examine risk factors associated with hospitalization for COVID-19 or pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) among children and adolescents during the first 2 years of the COVID-19 pandemic and change in risk factors over time. Design, Setting, and Participants: This population-level analysis of hospitalizations after SARS-CoV-2 infection in England among children and adolescents aged 0 to 17 years was conducted from February 1, 2020, to January 31, 2022. National data on hospital activity were linked with data on SARS-CoV-2 testing, SARS-CoV-2 vaccination, pediatric intensive care unit (PICU) admissions, and mortality. Children and adolescents hospitalized with COVID-19 or PIMS-TS during this time were included. Maternal, elective, and injury-related hospitalizations were excluded. Exposures: Previous medical comorbidities, sociodemographic factors, and timing of hospitalization when different SARS-CoV-2 variants (ie, wild type, Alpha, Delta, and Omicron) were dominant in England. Main Outcomes: PICU admission and death within 28 days of hospitalization with COVID-19 or PIMS-TS. Results: A total of 10 540 hospitalizations due to COVID-19 and 997 due to PIMS-TS were identified within 1 125 010 emergency hospitalizations for other causes. The number of hospitalizations due to COVID-19 and PIMS-TS per new SARS-CoV-2 infections in England declined during the second year of the COVID-19 pandemic. Among 10 540 hospitalized children and adolescents, 448 (4.3%) required PICU admission due to COVID-19, declining from 162 of 1635 (9.9%) with wild type, 98 of 1616 (6.1%) with Alpha, and 129 of 3789 (3.4%) with Delta to 59 of 3500 (1.7%) with Omicron. Forty-eight children and adolescents died within 28 days of hospitalization due to COVID-19, and no children died of PIMS-TS (PIMS-S data were limited to November 2020 onward). Risk of severe COVID-19 in children and adolescents was associated with medical comorbidities and neurodisability regardless of SARS-CoV-2 variant. Results were similar when children and adolescents with prior SARS-CoV-2 exposure or vaccination were excluded. Conclusions: In this study of data across the first 2 years of the COVID-19 pandemic, risk of severe disease from SARS-CoV-2 infection in children and adolescents in England remained low. Children and adolescents with multiple medical problems, particularly neurodisability, were at increased risk and should be central to public health measures as further variants emerge.

Multistate transition modelling of e-cigarette use and cigarette smoking among youth in the UK.

INTRODUCTION: E-cigarette use remains a controversial topic, with questions over how people transition between e-cigarette use and cigarette smoking. This paper examined transitions into and out of nicotine product use in a representative sample of UK youth. METHODS: We used Markov multistate transition probability models on data from 10 229 participants (10-25 years old) in the UK Household Longitudinal Study (2015-2021). We used four product use states ('never', 'non-current use', 'e-cigarette only' and 'smoking and dual use') and estimated likelihood of transitions according to sociodemographic characteristics. RESULTS: Among participants who had never used nicotine products, most were still non-users a year later (92.9% probability; 95% CI 92.6%, 93.2%); a small proportion transitioned to using e-cigarettes only (4.0%; 95% CI 3.7%, 4.2%) and cigarettes (2.2%; 95% CI 2.0%, 2.4%). Those aged 14-17 years were the most likely to start using a nicotine product. E-cigarette use was less persistent overtime than cigarette smoking, with a 59.1% probability (95% CI 56.9%, 61.0%) of e-cigarette users still using after 1 year compared with 73.8% (95% CI 72.1%, 75.4%) for cigarette smoking. However, there was a 14% probability (95% CI 12.8%, 16.2%) that e-cigarette users went onto smoke cigarettes after 1 year, rising to 25% (95% CI 23%, 27%) after 3 years. CONCLUSION: This study found that although overall nicotine product use was relatively rare, participants were more likely to experiment with e-cigarette use than cigarette smoking. This was mostly not persistent over time; however, approximately one in seven transitioned to cigarette smoking. Regulators should aim to deter all nicotine product use among children.