Association of coexistence of frailty and depressive symptoms with mortality in community-dwelling older adults: Kashiwa Cohort Study

OBJECTIVES

This study aimed to determine the longitudinal associations of the coexistence of frailty and depressive symptoms with mortality among older adults.

METHODS

The study participants were community-dwelling older adults aged ≥65 years who participated in the baseline survey of the Kashiwa Cohort Study in Japan in 2012. We used Fried's frailty phenotype criteria to classify participants as non-frail (score = 0), pre-frail (1 or 2), or frail (≥3). Depressive symptoms were assessed using the GDS-15 (≥6 points). Cox proportional hazards models were used to evaluate the association of co-occurring frailty and depressive symptoms with all-cause mortality, after adjusting for sociodemographic and clinical characteristics.

RESULTS

The study included 1920 participants, including 810 non-frail, 921 pre-frail, and 189 frail older adults, of which 9.0 %, 15.7 %, and 36.0 %, respectively, had depressive symptoms. Ninety-one (4.7 %) participants died during the average follow-up period of 4.8 years. Compared with non-frail participants without depressive symptoms, frail participants had greater adjusted hazard ratios for mortality: 2.47 (95 % CI, 1.16 to 5.25) for frail participants without depressive symptoms and 4.34 (95 % CI, 1.95 to 9.65) for frail participants with depressive symptoms. However, no statistically significant associations were observed in non-frail or pre-frail participants irrespective of depressive symptoms.

CONCLUSION

Frail older adults with depressive symptoms have a substantially greater risk of mortality. Screening for depressive symptoms and frailty in older adults should be incorporated into health checkups and clinical practice to identify high-risk populations.

The impact of gardening on well-being, mental health, and quality of life: an umbrella review and meta-analysis

BACKGROUND

Gardening and horticultural therapy (HT) has been widely recognised as a multicomponent approach that has affected a broad range of health and well-being outcomes. The aim of this umbrella review and meta-analysis was to compare the findings of previous reviews on the impact of multiple gardening interventions and gardening attributes on different well-being constructs.

METHODS

Electronic databases including PubMed, Web of Science, Science Direct, the Cochrane Library, and Google Scholar were searched from inception to December 2022. Interventional and observational reviews were eligible for inclusion in this umbrella review. Outcome measures included mental well-being, health status and quality of life. The key exposure variables were gardening and horticultural therapy. Narrative synthesis was used to evaluate the overall impact of gardening and HT on study outcomes. For a subsample of studies with available quantitative data, a random effect meta-analysis was conducted.

RESULTS

This umbrella review included 40 studies (10 interventional studies, 2 observational studies, and 28 mixed interventional and observational studies). The reviewed studies reported an overall positive impact of gardening activities on several measures of mental well-being, quality of life, and health status. Meta-analysis showed a significant and positive effect of gardening and HT activities on well-being (effect size (ES) 0.55, 95% confidence interval (CI) 0.23, 0.87, p < 0.001).

CONCLUSIONS

Evidence from observational and interventional studies supports a positive role for gardening and HT activities on well-being and general health. Interventional studies with horticultural-based therapies were effective in improving well-being and quality of life both in the general population and vulnerable subgroups. The high degree of heterogeneity in the included studies cautions against any direct clinical implications of the study findings.

Risk of fibromyalgia following antibiotic prescriptions: A population-based case-control study

BACKGROUND

The health of the gut microbiome is now recognized to be an important component of the gut-brain axis which itself appears to be implicated in pain perception. Antibiotics are known to create dysbiosis in the microbiome, so whether fibromyalgia is more commonly diagnosed after antibiotic prescriptions provides a means of exploring the role of the microbiome in the experience of chronic pain.

METHODS

A case-control study was carried out using electronic health records collected in the UK's Clinical Practice Research Datalink (CPRD), a comprehensive database of primary care consultations. For each case of diagnosed fibromyalgia, three controls were identified and matched by age, gender and GP practice. The exposure variable was the number and timing of antibiotic prescriptions over previous years. The analysis involved adjusting for a wide range of co-variates that might be possible confounders.

RESULTS

A total of 44,674 cases of fibromyalgia were identified together with 133,513 controls. After adjusting for co-variates, it was found that both the total number of prescriptions and their timing was associated with an FM diagnosis. For example, the quartile with the highest number of prescriptions and that with the longest exposure had a greater than three-fold increase in FM diagnoses (number of prescriptions: odds ratio 3.92; 95% CIs: 3.71-4.13; exposure odds ratio 3.28; CIs: 3.13-3.43). Some antibiotics (such as tetracyclines and metronidazole) seemed to confer greater risk than others.

CONCLUSIONS

The results lend support for prior antibiotics being an important risk factor for a diagnosis of FM.

SIGNIFICANCE

This study shows an association between the volume as well as timing of prior antibiotic prescriptions and of a subsequent diagnosis of fibromyalgia in primary care.

Reconsidering the Use of Population Health Surveys for Monitoring of Mental Health

Monitoring of the mental health status of the population and assessment of its determinants are 2 of the most relevant pillars of public mental health, and data from population health surveys could be instrumental to support them. Although these surveys could be an important and suitable resource for these purposes, due to different limitations and challenges, they are often relegated to the background behind other data sources, such as electronic health records. These limitations and challenges include those related to measurement properties and cross-cultural validity of the tools used for the assessment of mental disorders, their degree of representativeness, and possible difficulties in the linkage with other data sources. Successfully addressing these limitations could significantly increase the potential of health surveys in the monitoring of mental disorders and ultimately maximize the impact of the relevant policies to reduce their burden at the population level. The widespread use of data from population health surveys, ideally linked to electronic health records data, would enhance the quality of the information available for research, public mental health decision-making, and ultimately addressing the growing burden of mental disorders.

Severe mental illness, race/ethnicity, multimorbidity and mortality following COVID-19 infection: nationally representative cohort study

BACKGROUND

The association of COVID-19 with death in people with severe mental illness (SMI), and associations with multimorbidity and ethnicity, are unclear.

AIMS

To determine all-cause mortality in people with SMI following COVID-19 infection, and assess whether excess mortality is affected by multimorbidity or ethnicity.

METHOD

This was a retrospective cohort study using primary care data from the Clinical Practice Research Database, from February 2020 to April 2021. Cox proportional hazards regression was used to estimate the effect of SMI on all-cause mortality during the first two waves of the COVID-19 pandemic.

RESULTS

Among 7146 people with SMI (56% female), there was a higher prevalence of multimorbidity compared with the non-SMI control group (n = 653 024, 55% female). Following COVID-19 infection, the SMI group experienced a greater risk of death compared with controls (adjusted hazard ratio (aHR) 1.53, 95% CI 1.39-1.68). Black Caribbean/Black African people were more likely to die from COVID-19 compared with White people (aHR = 1.22, 95% CI 1.12-1.34), with similar associations in the SMI group and non-SMI group (P for interaction = 0.73). Following infection with COVID-19, for every additional multimorbidity condition, the aHR for death was 1.06 (95% CI 1.01-1.10) in the SMI stratum and 1.16 (95% CI 1.15-1.17) in the non-SMI stratum (P for interaction = 0.001).

CONCLUSIONS

Following COVID-19 infection, patients with SMI were at an elevated risk of death, further magnified by multimorbidity. Black Caribbean/Black African people had a higher risk of death from COVID-19 than White people, and this inequity was similar for the SMI group and the control group.

Prevalence and variability of depressive symptoms in Europe: update using representative data from the second and third waves of the European Health Interview Survey (EHIS-2 and EHIS-3)

BACKGROUND

Assessing the prevalence of clinically relevant depressive symptoms and their possible variation by country and over time could be a valuable resource to inform the development of public health policies and preventive resources to reduce mental health burden. We aimed to assess cross-national differences in the point prevalence of clinically relevant depressive symptoms in Europe in 2018-20, and to evaluate point prevalence differences between countries and over time between 2013-15 and 2018-20.

METHODS

In this population-based study, data from participants in the second and third waves of the European Health Interview Survey (EHIS-2 from 2013 to 2015 and EHIS-3 from 2018 to 2020) from 30 European countries were used (n=542 580). From the total sample, 283 692 participants belonging to EHIS-3 were included in the study (52·4% women and 47·5% men). The non-response in EHIS-3 ranged by country, from 12% to 78%. Point prevalence of clinically relevant depressive symptoms was evaluated using a cutoff score of 10 or more for the 8-item version of the Patient Health Questionnaire. Crude prevalence ratios and adjusted prevalence ratios (aPRs) were obtained to assess differences in the prevalence between countries and over time within countries.

FINDINGS

The point prevalence of clinically relevant depressive symptoms in Europe in 2018-20 was 6·54% (95% CI 6·34-6·73), ranging across countries from 1·85% (1·53-2·17) in Greece to 10·72% (10·04-11·40) in Sweden. Compared with the other European countries, those with the lowest aPRs were Greece, Serbia, and Cyprus and those with the highest aPRs were Belgium, Slovenia, and Croatia. A small but significant increase in the prevalence between EHIS-2 and EHIS-3 was observed (aPR 1·11 [1·07-1·14]). A wide variability over time in the point prevalence within countries was observed, ranging from an aPR of 0·63 (0·54-0·74) in Hungary to 1·88 (1·53-2·31) in Slovenia.

INTERPRETATION

This study, based on large and representative datasets and a valid and reliable screening tool for the assessment of depression, indicates that the point prevalence of clinically relevant depressive symptoms in Europe from 2013 to 2020 remains relatively stable, with wide variability between countries. These findings could be considered a baseline for monitoring the prevalence of clinically relevant depressive symptoms in Europe, and could inform policy for the development of preventive strategies for depression both at a country and European level.

FUNDING

Center for Biomedical Research in Epidemiology and Public Health Network and AGAUR.

Ethnic differences in physical and mental multimorbidity in working age adults with a history of depression and/or anxiety

BACKGROUND

The current study used data from an ethnically diverse population from South London to examine ethnic differences in physical and mental multimorbidity among working age (18-64 years) adults in the context of depression and anxiety.

METHOD

The study included 44 506 patients who had previously attended Improving Access to Psychological Therapies services in the London Borough of Lambeth. Multinomial logistic regression examined cross-sectional associations between ethnicity with physical and mental multimorbidity. Patterns of multimorbidity were identified using hierarchical cluster analysis.

RESULTS

Within 44 056 working age adults with a history of depression or anxiety from South London there were notable ethnic differences in physical multimorbidity. Adults of Black Caribbean ethnicity were more likely to have physical multimorbidity [adjusted relative risk ratio (aRRR) = 1.25, 95% confidence interval (CI) 1.15-1.36] compared to adults of White ethnicity. Relative to adults of White ethnicity, adults of Asian ethnicity were more likely to have physical multimorbidity at higher thresholds only (e.g. 4 + conditions; aRRR = 1.53, 95% CI 1.17-2.00). Three physical (atopic, cardiometabolic, mixed) and three mental (alcohol/substance use, common/severe mental illnesses, personality disorder) multimorbidity clusters emerged. Ethnic minority groups with multimorbidity had a higher probability of belonging to the cardiometabolic cluster.

CONCLUSION

In an ethnically diverse population with a history of common mental health disorders, we found substantial between- and within-ethnicity variation in rates of physical, but not mental, multimorbidity. The findings emphasised the value of more granular definitions of ethnicity when examining the burden of physical and mental multimorbidity.

Reliability and cross-country equivalence of the 8-item version of the Patient Health Questionnaire (PHQ-8) for the assessment of depression: results from 27 countries in Europe

Background

The 8-item version of the Patient Health Questionnaire (PHQ-8) is one of the self-reported questionnaires most frequently used worldwide for the screening and severity assessment of depression. However, in some European countries its reliability is unknown, and it is unclear whether its psychometric properties vary between European countries. Therefore, the aim of this study was to assess the internal structure, reliability and cross-country equivalence of the PHQ-8 in Europe.

Methods

All participants from the 27 countries included in the second wave of the European Health Interview Survey (EHIS-2) between 2014 and 2015 with complete information on the PHQ-8 were included (n = 258,888). The internal structure of the PHQ-8 was assessed using confirmatory factor analyses (CFA) for categorical items. Additionally, the reliability of the questionnaire was assessed based on the internal consistency, Item Response Theory information functions, and item-discrimination (using Graded Response Models), and the cross-country equivalence based on multi-group CFA.

Findings

The PHQ-8 shows high internal consistency for all countries. The countries in which the PHQ-8 was more reliable were Romania, Bulgaria and Cyprus and less reliable were Iceland, Norway and Austria. The PHQ-8 item with highest discrimination was item 2 (feeling down, depressed, or hopeless) in 24 of the 27 countries. Measurement invariance between countries in Europe was observed from multigroup CFA at the configural, metric and scalar levels.

Interpretation

The results from our study, likely the largest study to the date assessing the internal structure, reliability and cross-country comparability of a self-reported mental health assessment measure, shows that the PHQ-8 has an adequate reliability and cross-country equivalence across the 27 European countries included. These results highlight the suitability of the comparisons of the PHQ-8 scores in Europe. They could be helpful to improve the screening and severity assessment of depressive symptoms at the European level.

Funding

This work was partially funded by CIBER Epidemiology and Public Health (CIBERESP) as part of the Intramural call of 2021 (ESP21PI05).

The relationship between air pollution and multimorbidity: Can two birds be killed with the same stone?

Air pollution and multimorbidity are two of the most important challenges for Public Health worldwide. Although there is a large body of evidence linking air pollution with the development of different single chronic conditions, the evidence about the relationship between air pollution and multimorbidity (the co-occurrence of multiple long-term conditions) is sparse. To obtain evidence about this relationship could be challenging and different aspects should be considered, such as its multifaceted and complex nature, the specific pollutants and their potential influence on health, their levels of exposure over time, or the data that could be used for its study. This evidence could be instrumental to inform the development of new recommendations and measures to reduce harmful levels of air pollutants, as means to prevent the development of multimorbidity and reduce its burden.

Physical multimorbidity, depressive symptoms, and social participation in adults over 50 years of age: findings from the English Longitudinal Study of Ageing

OBJECTIVES

The aim of the current study was to identify specific patterns of physical multimorbidity and examine how these patterns associated with changes in social participation over time.

METHODS

We used latent class analysis to identify clusters of physical multimorbidity in 11,391 older adults. Mixed effects regression models were used to assess associations between physical multimorbidity clusters and changes in social participation over 15 years.

RESULTS

Four clusters of physical multimorbidity were identified. All physical multimorbidity clusters were associated with a reduction in cultural engagement (e.g. visits to theatre, cinema, museums) over time, with the strongest association seen in the complex/multisystem cluster (β = -0.26, 95% CI = -0.38 to -0.15). Similar results emerged for leisure activities. Adjusting for depressive symptoms fully attenuated some associations. All physical multimorbidity clusters were associated with an increase in civic participation over time.

CONCLUSIONS

Physical multimorbidity reduced some aspects of social participation over time, with specific combinations of conditions having increased risk of reductions.

Supplemental data for this article is available online at http://dx.doi.org/10.1080/13607863.2021.2017847.

Associations between air pollution and multimorbidity in the UK Biobank: A cross-sectional study

Background

Long-term exposure to air pollution concentrations is known to be adversely associated with a broad range of single non-communicable diseases, but its role in multimorbidity has not been investigated in the UK. We aimed to assess associations between long-term air pollution exposure and multimorbidity status, severity, and patterns using the UK Biobank cohort.

Methods

Multimorbidity status was calculated based on 41 physical and mental conditions. We assessed cross-sectional associations between annual modeled particulate matter (PM)2.5, PMcoarse, PM10, and nitrogen dioxide (NO2) concentrations (μg/m3-modeled to residential address) and multimorbidity status at the baseline assessment (2006-2010) in 364,144 people (mean age: 52.2 ± 8.1 years, 52.6% female). Air pollutants were categorized into quartiles to assess dose-response associations. Among those with multimorbidity (≥2 conditions; n = 156,395) we assessed associations between air pollutant exposure levels and multimorbidity severity and multimorbidity patterns, which were identified using exploratory factor analysis. Associations were explored using generalized linear models adjusted for sociodemographic, behavioral, and environmental indicators.

Results

Higher exposures to PM2.5, and NO2 were associated with multimorbidity status in a dose-dependent manner. These associations were strongest when we compared the highest air pollution quartile (quartile 4: Q4) with the lowest quartile (Q1) [PM2.5: adjusted odds ratio (adjOR) = 1.21 (95% CI = 1.18, 1.24); NO2: adjOR = 1.19 (95 % CI = 1.16, 1.23)]. We also observed dose-response associations between air pollutant exposures and multimorbidity severity scores. We identified 11 multimorbidity patterns. Air pollution was associated with several multimorbidity patterns with strongest associations (Q4 vs. Q1) observed for neurological (stroke, epilepsy, alcohol/substance dependency) [PM2.5: adjOR = 1.31 (95% CI = 1.14, 1.51); NO2: adjOR = 1.33 (95% CI = 1.11, 1.60)] and respiratory patterns (COPD, asthma) [PM2.5: adjOR = 1.24 (95% CI = 1.16, 1.33); NO2: adjOR = 1.26 (95% CI = 1.15, 1.38)].

Conclusions

This cross-sectional study provides evidence that exposure to air pollution might be associated with having multimorbid, multi-organ conditions. Longitudinal studies are needed to further explore these associations.

COVID-19 ethnic inequalities in mental health and multimorbidities: protocol for the COVEIMM study

PURPOSE

The COVID-19 pandemic may have exacerbated ethnic health inequalities, particularly in people with multiple long-term health conditions, the interplay with mental health is unclear. This study investigates the impact of the pandemic on the association of ethnicity and multimorbidity with mortality/service use among adults, in people living with severe mental illnesses (SMI).

METHODS

This study will utilise secondary mental healthcare records via the Clinical Record Interactive Search (CRIS) and nationally representative primary care records through the Clinical Practice Interactive Research Database (CPRD). Quasi-experimental designs will be employed to quantify the impact of COVID-19 on mental health service use and excess mortality by ethnicity, in people living with severe mental health conditions. Up to 50 qualitative interviews will also be conducted, co-produced with peer researchers; findings will be synthesised with quantitative insights to provide in-depth understanding of observed associations.

RESULTS

81,483 people in CRIS with schizophrenia spectrum, bipolar or affective disorder diagnoses, were alive from 1st January 2019. Psychiatric multimorbidities in the CRIS sample were comorbid somatoform disorders (30%), substance use disorders (14%) and personality disorders (12%). In CPRD, of 678,842 individuals with a prior probable diagnosis of COVID-19, 1.1% (N = 7493) had an SMI diagnosis. People in the SMI group were more likely to die (9% versus 2% in the non-SMI sample) and were more likely to have mental and physical multimorbidities.

CONCLUSION

The effect of COVID-19 on people from minority ethnic backgrounds with SMI and multimorbidities remains under-studied. The present mixed methods study aims to address this gap.

Prior antibiotics and risk of subsequent Herpes zoster: A population-based case control study

Background

The effect of antibiotics on the human microbiome is now well established, but their indirect effect on the related immune response is less clear. The possible association of Herpes zoster, which involves a reactivation of a previous varicella zoster virus infection, with prior antibiotic exposure might indicate a potential link with the immune response.

Methods

A case-control study was carried out using a clinical database, the UK’s Clinical Practice Research Datalink. A total of 163,754 patients with varicella zoster virus infection and 331,559 age/sex matched controls were identified and their antibiotic exposure over the previous 10 years, and longer when data permitted, was identified. Conditional logistic regression was used to identify the association between antibiotic exposure and subsequent infection in terms of volume and timing.

Results

The study found an association of antibiotic prescription and subsequent risk of varicella zoster virus infection (adjusted odds ratio of 1.50; 95%CIs: 1.42–1.58). The strongest association was with a first antibiotic over 10 years ago (aOR: 1.92; 95%CIs: 1.88–1.96) which was particularly pronounced in the younger age group of 18 to 50 (aOR 2.77; 95%CIs: 1.95–3.92).

Conclusions

By finding an association between prior antibiotics and Herpes zoster this study has shown that antibiotics may be involved in the reactivation of the varicella zoster virus. That effect, moreover, may be relatively long term. This indirect effect of antibiotics on viruses, possibly mediated through their effect on the microbiome and immune system, merits further study.

Severe mental illnesses and mortality following COVID-19 infection: Data linkage study using the Clinical Practice Research Database (CPRD)

BackgroundThe association of COVID-19 infection with death in people with severe mental illnesses (SMI), and the relationship to multimorbidities/ underlying health conditions ethnicity is unclear. Health records linked to COVID-19 tests data could help to inform this knowledge gap. ObjectiveTo determine the risk of death in people with SMI following COVID-19 infection compared to reference groups and assess whether excess mortality is accounted through underlying health conditions or further elevated in minority ethnic groups. Design, setting and participantsNationally representative cohort study using primary care data from the Clinical Practice Research Database (CPRD), with participants followed from the start of the pandemic in 2020, for 1.5 years, covering England, Wales and Northern Ireland. For consenting practices, CPRD data was linked to COVID-19 data Public Health England (PHE) Second Generation Surveillance System (SGSS), PHE COVID-19 Hospitalisation in England Surveillance System (CHESS), and Intensive Care National Audit and Research Centre (ICNARC) data on COVID-10 intensive care admissions. The cohort comprised 795,836 individuals, with 7,493 individuals with SMI and a positive COVID-19 test (“SMI/COVID-19”). Comparison groups were: 2,325 individuals with SMI/ testing negative for COVID-19 (“SMI/ non COVID-19”), 657,414 individuals from a non-SMI group/ testing positive for COVID-19 (“non-SMI/ COVID-19”), and 128,604 individuals from a non-SMI group/ testing negative for COVID-19 (“non-SMI/ non-COVID-19”). ExposuresSMI defined as the presence of schizophrenia, schizoaffective disorder, bipolar disorder, or affective disorders with psychosis, according to the International Classification of Mental Disorders (ICD-10). COVID-19 diagnoses identified through confirmed laboratory tests and clinical diagnoses. OutcomesAll-cause mortality ResultsA higher proportion of SMI patients with COVID-19 were obese (37% versus 22% in the non-SMI/non-COVID-19 group), current smokers (27% versus 23% in the non-SMI/non-COVID-19 group), had underlying health conditions, and were Black Caribbean/ Black African (5% versus 1% in the non-SMI/non-COVID-19 group). Relative to the non-SMI/ non-COVID-19 group, the SMI/ COVID-19 group had an elevated risk of death (age and sex-adjusted hazard ratio (aHR) 5.03 (95%CI: 4.61-5.54)). This was elevated to a lesser extent, in the SMI/ non COVID-19 group (aHR: 1.93 (95%CI: 1.54-2.41)) and in the non-SMI/ COVID-19 group (aHR: 2.85 (95%CI: 2.72-2.98). Excess risk persisted after adjusting for tobacco use, weight and comorbidities. Mortality trends were similar across groups by ethnicity. Risk of death was highest for the SMI/ COVID-19 group during the first wave of infection in the UK, however excess mortality was still evident and substantially elevated at the second wave also. ConclusionsPeople living with SMI are at an increased risk of death compared to population controls; this excess risk is further elevated following COVID-19 infection, with similar trends by ethnicity. Underlying health conditions only partially account for deaths following COVID-19 infection in this group.

Prevalence of depression in Europe using two different PHQ-8 scoring methods

Introduction

The prevalence of depression based on the Patient Health Questionnaire-8 (PHQ-8) may vary depending on the scoring method.

Objectives

1) To describe the prevalence of depression in Europe using two PHQ-8 scoring methods. 2) To identify the countries with the highest prevalence according to each method.

Methods

Data from 27 countries included in the European Health Survey (EHIS-2) for the year 2014/2015 were used (n=258,888). All participants who completed the PHQ-8 were included. The prevalence of depression and its 95% Confidence Interval (95%CI) were calculated overall for the whole of Europe and for each country using a PHQ-8≥10 cut-off point and the PHQ-8 algorithm scoring method. Weights derived from the complex sample design were considered for their calculation.

Results

The overall prevalence of depression for all Europe was lower using the PHQ-8>=10 cut-off point (6.38%, 95%CI 6.24-6.52) than the PHQ-8 algorithm (7.01%, 95%CI, 6.86-7.16). Using the PHQ-8≥10 cut-off point, the highest prevalence was observed in Iceland (10.33%, 95%CI, 9.33-11.32), Luxembourg (9.74%, 95%CI, 8.76-10.72) and Germany (9.24%, 95%CI, 8.82-9.66). Using the PHQ-8 algorithm the highest rates were observed in Hungary (10.99%, 95%CI,10.14-11.84), Portugal (10.63%, 95%CI, 9.96-11.29) and Iceland (9.80%, 95%CI, 8.77-10.83).

Conclusions

There is variability in the prevalence of depression rates in Europe according to the PHQ-8 scoring method. These findings suggest the necessity of identify the method of choice for each country comparing with a gold standard measure (clinical diagnosis). Countries with consistent higher prevalence of depression based on PHQ-8 regardless of scoring method deserve further study.

Disclosure

This work has been funded by CIBERESP (ESP21PI05)

Multimorbidity and fit note receipt in working-age adults with long-term health conditions

BACKGROUND

Research on sickness absence has typically focussed on single diagnoses, despite increasing recognition that long-term health conditions are highly multimorbid and clusters comprising coexisting mental and physical conditions are associated with poorer clinical and functional outcomes. The digitisation of sickness certification in the UK offers an opportunity to address sickness absence in a large primary care population.

METHODS

Lambeth Datanet is a primary care database which collects individual-level data on general practitioner consultations, prescriptions, Quality and Outcomes Framework diagnostic data, sickness certification (fit note receipt) and demographic information (including age, gender, self-identified ethnicity, and truncated postcode). We analysed 326 415 people's records covering a 40-month period from January 2014 to April 2017.

RESULTS

We found significant variation in multimorbidity by demographic variables, most notably by self-defined ethnicity. Multimorbid health conditions were associated with increased fit note receipt. Comorbid depression had the largest impact on first fit note receipt, more than any other comorbid diagnoses. Highest rates of first fit note receipt after adjustment for demographics were for comorbid epilepsy and rheumatoid arthritis (HR 4.69; 95% CI 1.73-12.68), followed by epilepsy and depression (HR 4.19; 95% CI 3.60-4.87), chronic pain and depression (HR 4.14; 95% CI 3.69-4.65), cardiac condition and depression (HR 4.08; 95% CI 3.36-4.95).

CONCLUSIONS

Our results show striking variation in multimorbid conditions by gender, deprivation and ethnicity, and highlight the importance of multimorbidity, in particular comorbid depression, as a leading cause of disability among working-age adults.

All-cause and cause-specific mortality in people with mental disorders and intellectual disabilities, before and during the COVID-19 pandemic: cohort study

BACKGROUND

People with mental disorders and intellectual disabilities experience excess mortality compared with the general population. The impact of COVID-19 on exacerbating this, and in widening ethnic inequalities, is unclear.

METHODS

Prospective data (N=167,122) from a large mental healthcare provider in London, UK, with deaths from 2019 to 2020, used to assess age- and gender-standardised mortality ratios (SMRs) across nine psychiatric conditions (schizophrenia-spectrum disorders, affective disorders, somatoform/ neurotic disorders, personality disorders, learning disabilities, eating disorders, substance use disorders, pervasive developmental disorders, dementia) and by ethnicity.

FINDINGS

Prior to the World Health Organization (WHO) declaring COVID-19 a public health emergency on 30th January 2020, all-cause SMRs across all psychiatric cohorts were more than double the general population. By the second quarter of 2020, when the UK experienced substantial peaks in COVID-19 deaths, all-cause SMRs increased further, with COVID-19 SMRs elevated across all conditions (notably: learning disabilities: SMR: 9.24 (95% CI: 5.98-13.64), pervasive developmental disorders: 5.01 (95% CI: 2.40-9.20), eating disorders: 4.81 (95% CI: 1.56-11.22), schizophrenia-spectrum disorders: 3.26 (95% CI: 2.55-4.10), dementia: 3.82 (95% CI: 3.42, 4.25) personality disorders 4.58 (95% CI: 3.09-6.53)). Deaths from other causes remained at least double the population average over the whole year. Increased SMRs were similar across ethnic groups.

INTERPRETATION

People with mental disorders and intellectual disabilities were at a greater risk of deaths relative to the general population before, during and after the first peak of COVID-19 deaths, with similar risks by ethnicity. Mortality from non-COVID-19/ other causes was elevated before/ during the pandemic, with higher COVID-19 mortality during the pandemic.

FUNDING

ESRC (JD, CM), NIHR (JD, RS, MH), Health Foundation (JD), GSK, Janssen, Takeda (RS).

Depressive symptoms during early adulthood and the development of physical multimorbidity in the UK: an observational cohort study

BACKGROUND

An understanding of whether early-life depression is associated with physical multimorbidity could be instrumental for the development of preventive measures and the integrated management of depression. We therefore aimed to map out the cumulative incidence of physical multimorbidity over adulthood, and to determine the association between the presence of depressive symptoms during early adulthood and the development of physical multimorbidity in middle age.

METHODS

In this observational cohort study, we used pooled data from the 1958 National Child Development Study (NCDS) and the 1970 British Cohort Study (BCS). Cohort waves were pooled in each decade of adult life available (when cohort members were aged 26 years in the BCS and 23 years in the NCDS [baseline]; 34 years in the BCS and 33 years in the NCDS [age 34 BCS/33 NCDS]; 42 years in the BCS and NCDS [age 42 BCS/NCDS]; and 46 years in the BCS and 50 years in the NCDS [age 46 BCS/50 NCDS]). We included participants who had completed the nine-item Malaise Inventory at baseline, and did not have a history of physical multimorbidity, any physical multimorbidity at baseline, or the presence of depressive symptoms before the development of physical multimorbidity. The presence of depressive symptoms was determined using the nine-item Malaise Inventory (cutoff score ≥4). Physical multimorbidity was defined as having at least two measures of any of the following ten self-reported groups of long-term conditions: asthma or bronchitis; backache; bladder or kidney conditions; cancer; cardiovascular conditions; convulsions or epilepsy; diabetes; hearing conditions; migraine; and stomach, bowel, or gall conditions. Cumulative incidence (with 95% CI) of physical multimorbidity was calculated for each decade considered after baseline, with physical multimorbidity being assessed as both a dichotomous and categorical variable. The association between depressive symptoms and the development of physical multimorbidity was assessed using adjusted relative risk ratios (with 95% CIs).

FINDINGS

Analyses included 15 845 participants, of whom 4001 (25·25%; 95% CI 24·57-25·93) had depressive symptoms at baseline and 11 844 (74·75%; 74·07-75·42) did not. The cumulative incidence of physical multimorbidity (dichotomous) ranged over the study period from 2263 (18·44%; 95% CI 17·75-18·14) of 12 273 participants at age 34 BCS/33 NCDS, to 4496 (42·90%; 41·95-43·85) of 10 481 participants at age 46 BCS/50 NCDS, and was consistently higher in participants with depressive symptoms at baseline. The adjusted relative risk of physical multimorbidity was higher in participants with depressive symptoms than in those without and remained stable over the study period (adjusted relative rate ratio 1·67, 95% CI 1·50-1·87, at age 34 BCS/33 NCDS; 1·63, 1·48-1·79, at age 42 BCS/NCDS; and 1·58, 1·43-1·73, at age 46 BCS/50 NCDS).

INTERPRETATION

The presence of depressive symptoms during early adulthood is associated with an increased risk of the development of physical multimorbidity in middle age. Although further research about the drivers of this relationship is needed, these results could help to enhance the integrated management of individuals with depressive symptoms and the development of preventive strategies to reduce the effect and burden of physical multimorbidity.

FUNDING

UK Medical Research Council and Guy's Charity.

How do ethnicity and deprivation impact on life expectancy at birth in people with serious mental illness? Observational study in the UK

BACKGROUND

Across international contexts, people with serious mental illnesses (SMI) experience marked reductions in life expectancy at birth. The intersection of ethnicity and social deprivation on life expectancy in SMI is unclear. The aim of this study was to assess the impact of ethnicity and area-level deprivation on life expectancy at birth in SMI, defined as schizophrenia-spectrum disorders, bipolar disorders and depression, using data from London, UK.

METHODS

Abridged life tables to calculate life expectancy at birth, in a cohort with clinician-ascribed ICD-10 schizophrenia-spectrum disorders, bipolar disorders or depression, managed in secondary mental healthcare. Life expectancy in the study population with SMI was compared with life expectancy in the general population and with those residing in the most deprived areas in England.

RESULTS

Irrespective of ethnicity, people with SMI experienced marked reductions in life expectancy at birth compared with the general population; from 14.5 years loss in men with schizophrenia-spectrum and bipolar disorders, to 13.2 years in women. Similar reductions were noted for people with depression. Across all diagnoses, life expectancy at birth in people with SMI was lower than the general population residing in the most deprived areas in England.

CONCLUSIONS

Irrespective of ethnicity, reductions in life expectancy at birth among people with SMI are worse than the general population residing in the most deprived areas in England. This trend in people with SMI is similar to groups who experience extreme social exclusion and marginalisation. Evidence-based interventions to tackle this mortality gap need to take this into account.

Prevalence of Major Depressive Episode in 27 European Countries

Background

Information about the prevalence of current Major Depressive Episode (MDE) across European countries is essential for its monitoring and for the development of evidence- based mental health policies. The aims were to: 1) estimate the prevalence of MDE by country in Europe; and 2) assess variations in prevalence between countries.

Methods

Data from participants of 27 countries that completed the questionnaire of the second wave of the European Health Interview Survey (EHIS-2) were analysed (n = 258,888). The prevalence of MDE was quantified using the Patient Health Questionnaire-8 (PHQ-8) with a cut-off score of ≥ 10. Prevalence and 95% Confidence Intervals (CI) were estimated for each country. Variation in prevalence (country vs the rest) was evaluated using bivariable and multivariable negative binomial regression models considering the specific country as the main explanatory variable. From these models, crude Prevalence Ratios (PR) and adjusted Prevalence Ratios (aPR) were obtained.

Results

The overall prevalence of current MDE in Europe was 6.38% (6.24%-6.52%). The country with the lowest prevalence was the Czech Republic (2.58%, 2.14%-3.02%) and the country with highest prevalence Iceland (10.33%, 9.33%-11.32%). In all the countries (except for Finland and Croatia) prevalence was higher in women than in men. The countries with the highest aPR were Germany (aPR: 1.80, 95% CI: 1.71-1.89) and Luxembourg (aPR: 1.50, 95% CI: 1.35-1.66), while Slovakia (aPR: 0.28, 95% CI: 0.24-0.33) and the Czech Republic (aPR: 0.32, 95% CI: 0.27-0.38) exhibited the lowest aPR.

Conclusions

Considerable variability in the prevalence of MDE by country in Europe was observed without a clear pattern. These results serve as baseline for monitoring the prevalence of MDE at a European level and suggest a need for developing preventive strategies against depression, particularly in those countries identified with the highest prevalence.

Key messages

The results of this study show that the overall prevalence of MDE is high (6.38%), with important variation across countries (ranging from 2.58% in the Czech Republic to 10.33% in Iceland). The results found could serve as a reference for the monitoring of MDE in Europe and for the development of screening and preventive strategies both at European level as well as at a country level.

Prevalence and variability of current depressive disorder in 27 European countries: a population-based study

BACKGROUND

We aimed to estimate the prevalence of current depressive disorder in 27 European countries, and to explore differences in prevalence between European countries and by gender.

METHODS

In this population-based study, we analysed data from respondents living in 27 European countries who were included in the second wave of the European Health Interview Survey, collected between 2013 and 2015. We assessed the prevalence of current depressive disorder using the eight-item Patient Health Questionnaire (PHQ-8), with depressive disorder defined as a PHQ-8 score of 10 or higher. Prevalence estimates and 95% CIs were calculated for all 27 countries overall and for each country individually. We assessed variation in prevalence (country vs the rest of Europe) using crude and adjusted prevalence ratios obtained from negative binomial regression models. We did all analyses for the total sample and stratified by gender.

FINDINGS

Our analysis sample comprised 258 888 individuals, of whom 117 310 (weighted proportion 47·8%) were men and 141 578 (52·2%) were women. The overall prevalence of current depressive disorder was 6·38% (95% CI 6·24-6·52) with important variation across countries, ranging from 2·58% (2·14-3·02) in the Czech Republic to 10·33% (9·33-11·32) in Iceland. Prevalence was higher in women (7·74% [7·53-7·95]) than in men (4·89% [4·71-5·08]), with clear gender differences for all countries except Finland and Croatia. Compared with the other European countries in our sample, those with the highest adjusted prevalence ratios were Germany (1·80 [1·71-1·89]) and Luxembourg (1·50 [1·35-1·66]), and those with the lowest adjusted prevalence ratios were Slovakia (0·28 [0·24-0·33]) and the Czech Republic (0·32 [0·27-0·38]).

INTERPRETATION

Depressive disorders, although common across Europe, vary substantially in prevalence between countries. These results could be a baseline for monitoring the prevalence of current depressive disorder both at a country level in Europe and for planning health-care resources and services.

FUNDING

UK Medical Research Council and CIBER Epidemiology and Public Health (CIBERESP).

Prevalence and age patterns of depression in the United Kingdom. A population-based study

METHODS

A representative sample of the UK population (n=17,152) from the European Health Interview Survey of 2014 was included in the analyses. The Patient Health Questionnaire (PHQ-8) was used to assess the prevalence of depressive symptoms and of probable depressive disorder. Prevalence estimates (95%CI) were calculated. The association between prevalence and age was assessed using multivariable multinomial logistic and logistic regression models. All analyses were carried out for the total sample and stratified by sex.

RESULTS

The prevalence of depressive symptoms ranged from 11.3% (10.6-11.9) for mild, to 3.3% (3.0-3.7) for severe symptoms. The prevalence of probable depressive disorder was 7.5% (95%CI: 7.0-8.0). A significantly higher prevalence of probable depressive disorder was found in those aged 45 to 59 years old compared with those aged 16 to 29. For the prevalence of severe depressive symptoms those age differences were even higher: 2.55 times higher (5.38 for men and 1.75 for women).

LIMITATIONS

The cross-sectional design precludes stablishing the direction of the relationship between age and the prevalence.

CONCLUSIONS

The prevalence and age patterns of depression in the UK were described. A peak in the prevalence was identified during middle adulthood. These results could serve as a reference for the monitoring of depression in the UK and the development of preventive strategies, particularly in the high-risk population groups identified.

Associations Between Depression, Arterial Stiffness, and Metabolic Syndrome Among Adults in the UK Biobank Population Study: A Mediation Analysis

Importance

Previous research has linked a history of depression with arterial stiffness (AS) during midlife.

Objective

To assess the association of depression with elevated midlife AS and to investigate the extent to which this association is mediated via metabolic syndrome (MetS).

Design, Settings, and Participants

This population-based retrospective cohort study analyzed data collected between March 2006 and December 2010 from 124 445 participants aged 40 to 69 years from the UK Biobank. Participants without data on AS at baseline (n = 332 780) or who reported a previous diagnosis of cardiovascular disease (n = 45 374) were not eligible. Data analysis was performed from May to August 2019.

Exposures

Lifetime history of depression was assessed via verbal interview and linked hospital-based clinical depression diagnosis. Metabolic syndrome was defined as the presence of 3 or more of hypertension, dyslipidemia, hyperglycemia, hypertriglyceridemia, and unhealthy waist circumference.

Main Outcomes and Measures

Peripherally assessed AS index (ASI) using digital photoplethysmography.

Results

Of 124 445 included participants with ASI assessed, 71 799 (57.7%) were women, and the mean (SD) age was 56 (8) years. A total of 10 304 participants (8.3%) reported a history of depression. Study findings indicated a significant direct association between depression and ASI levels (β = 0.25; 95% CI, 0.17-0.32). A significant indirect association was also observed between depression and ASI levels (β = 0.10; 95% CI, 0.07-0.13), indicating that 29% of the association of depression with ASI was mediated by MetS. The proportion of mediation increased to 37% when C-reactive protein was added to the MetS criteria (direct association: β = 0.21; 95% CI, 0.15-0.28; indirect association: β = 0.13; 95% CI, 0.10-0.17). Concerning components of MetS, the strongest indirect association was for waist circumference, accounting for 25% of the association between depression and ASI levels (direct association: β = 0.26; 95% CI, 0.18-0.34; indirect association: β = 0.09; 95% CI, 0.06-0.11). Among men, hypertriglyceridemia accounted for 19% of the association between depression and ASI (direct association: β = 0.22; 95% CI, 0.05-0.40; indirect association: β = 0.05; 95% CI, 0.02-0.08).

Conclusions and Relevance

One-third of the association of depression with elevated ASI levels during midlife may be accounted for by combined MetS and inflammatory processes. Unhealthy waist circumference and hypertriglyceridemia emerged as the most important potential targets for preventive interventions within women and men, respectively.

Potential gains in life expectancy from reducing amenable mortality among people diagnosed with serious mental illness in the United Kingdom

BACKGROUND

To estimate the potential gain in life expectancy from addressing modifiable risk factors for all-cause mortality (excluding suicide and deaths from accidents or violence) across specific serious mental illness (SMI) subgroups, namely schizophrenia, schizoaffective disorders, and bipolar disorders in a Western population.

METHODS

We have used relative risks from recent meta-analyses to estimate the population attribution fraction (PAF) due to specific modifiable risk factors known to be associated with all-cause mortality within SMI. The potential gain in life expectancy at birth, age 50 and age 65 years were assessed by estimating the combined effect of modifiable risk factors from different contextual levels (behavioural, healthcare, social) and accounting for the effectiveness of existing interventions tackling these factors. Projections for annual gain in life expectancy at birth during a two-decade was estimated using the Annual Percentage Change (APC) formula. The predicted estimates were based on mortality rates for year 2014-2015.

RESULTS

Based on the effectiveness of existing interventions targeting these modifiable risk factors, we estimated potential gain in life expectancy at birth of four (bipolar disorders), six (schizoaffective disorders), or seven years (schizophrenia). The gain in life expectancy at age 50 years was three (bipolar disorders) or five (schizophrenia and schizoaffective disorders) years. The projected gain in life expectancy at age 65 years was three (bipolar disorders) or four (schizophrenia and schizoaffective disorders) years.

CONCLUSIONS

The implementation of existing interventions targeting modifiable risk factors could narrow the current mortality gap between the general and the SMI populations by 24% (men) to 28% (women). These projections represent ideal circumstances and without the limitation of overestimation which often comes with PAFs.

The association between colorectal cancer and prior antibiotic prescriptions: case control study

BACKGROUND

Antibiotic use over several decades is believed to be associated with colorectal adenomas. There is little evidence, however, for the effect of more recent antibiotic use on frequency of colorectal cancers.

METHODS

A case control study used the RCGP's Research and Surveillance Centre cohort of patients drawn from NHS England. In all, 35,214 patients with a new diagnosis of colorectal cancer between 1 January 2008 and 31 December 2018 were identified in the database and were matched with 60,348 controls. Conditional logistic regression was used to examine the association between antibiotic prescriptions and colorectal cancer.

RESULTS

A dose-response association between colorectal cancers and prior antibiotic prescriptions was observed. The risk was related to the number and recency of prescriptions with a high number of antibiotic prescriptions over a long period carrying the highest risk. For example, patients prescribed antibiotics in up to 15 years preceding diagnosis were associated with a higher risk of colorectal cancer (odds ratio (OR) = 1.90, 95% confidence intervals (CI), 1.61-2.19, p < 0.001).

CONCLUSIONS

Antibiotic use over previous years is associated with subsequent colorectal cancer. While the study design cannot determine causality, the findings suggest another reason for caution in prescribing antibiotics, especially in high volumes and over many years.

Influence of prior antibiotic use on risk of rheumatoid arthritis: case control study in general practice

Objectives

To test the hypothesis that prior antibiotics influences the risk of developing RA.

Methods

A case–control study was conducted over 15 years using the UK’s Royal College of General Practitioners Research and Surveillance Centre database. The frequency and type of antibiotic prescription for patients who subsequently developed RA were compared with antibiotic prescriptions in a control group of patients who remained free of RA. Cases, defined as patients with a new diagnosis of RA made between 2006 and 2018, were matched with up to four RA-free controls on practice, age, gender and date of diagnosis. Exposure was measured by the number and type of prescriptions for antibiotics prior to the RA diagnosis or to the index date in controls.

Results

A total of 8482 patients with a new diagnosis of RA between 2006 and 2018 were compared with 22 661 controls. There was a higher likelihood of an RA diagnosis after antibiotic prescriptions within 1 year, 5 years and ever with a strong dose–response. Patients receiving &gt;10 antibiotics in a 5 year period were more than twice as likely to receive an RA diagnosis as controls [adjusted odds ratio 2.65 (CI 2.40, 2.93)].

Conclusion

Exposure to antibiotics prior to the diagnosis was a significant risk factor for RA. This could reflect an immunological response to a compromised microbiome. Alternatively, patients with pre-symptomatic or early undiagnosed RA may have been more likely to present to their general practitioner with infections due to an unrecognized effect of RA.

Association between prior antibiotic therapy and subsequent risk of community-acquired infections: a systematic review

Background

Antibiotic use can have negative unintended consequences including disruption of the human microbiota, which is thought to protect against pathogen overgrowth. We conducted a systematic review to assess whether there is an association between exposure to antibiotics and subsequent risk of community-acquired infections.

Methods

We searched MEDLINE, EMBASE and Web of Science for studies published before 30 June 2017, examining the association between antibiotic use and subsequent community-acquired infection. Infections caused by Clostridium difficile and fungal organisms were excluded. Studies focusing exclusively on resistant organism infections were also excluded.

Results

Eighteen of 22588 retrieved studies met the inclusion criteria. From these, 16 studies reported a statistically significant association between antibiotic exposure and subsequent risk of community-acquired infection. Infections associated with prior antibiotic use included Campylobacter jejuni infection (one study), recurrent furunculosis (one study), invasive Haemophilus influenzae type b infection (one study), infectious mastitis (one study), meningitis (one study), invasive pneumococcal disease (one study), Staphylococcus aureus skin infection (one study), typhoid fever (two studies), recurrent boils and abscesses (one study), upper respiratory tract infection and urinary tract infection (one study) and Salmonella infection (five studies), although in three studies on Salmonella infection the effect was of marginal statistical significance.

Conclusions

We found an association between prior antibiotic use and subsequent risk of a diverse range of community-acquired infections. Gastrointestinal and skin and soft tissue infections were most frequently found to be associated with prior antibiotic exposure. Our findings support the hypothesis that antibiotic use may predispose to future infection risk, including infections caused by both antibiotic-resistant and non-resistant organisms.

Long-term trends in antithrombotic drug prescriptions among adults aged 80 years and over from primary care: a temporal trends analysis using electronic health records

PURPOSE

This study aimed to estimate trends in antithrombotic prescriptions from 2001 to 2015 among people aged 80 years and over within clinical indications.

METHODS

A prospective cohort study with 215,559 participants registered with the UK Clinical Practice Research Datalink from 2001 to 2015 was included in the analyses. The prevalence and incidence of antiplatelet and anticoagulant drugs were estimated for each year and by five clinical indications.

RESULTS

The prevalence rate of antithrombotic prescriptions among patients aged over 80 years and diagnosed with atrial fibrillation increased from 53% in 2001 to 77% in 2015 (P_trend <.001). Anticoagulant prescriptions rates also increased five-fold in older adults with atrial fibrillation from around 10% in 2001 to 46% in 2015 (P_trend <.001). Clopidogrel-prescribing rates in patients aged over 80 years and with venous thrombosis increased from 0.4% in 2001 to 10% in 2015 (P_trend <.001). Warfarin-prescribing rates in older patients with venous thrombosis increased from 13% in 2001 to 21% in 2015 (P_trend <.001).

CONCLUSIONS

The use of antithrombotic drugs increased from 2001 to 2015 in people aged 80 years and over across multiple clinical indications. Assessing the benefits and harms of antithrombotic drugs across different clinical indications in older people is a priority.

Incidence and mortality of fractures by frailty level over 80 years of age: cohort study using UK electronic health records

OBJECTIVE

This study aimed to estimate the association of frailty with incidence and mortality of fractures at different sites in people aged over 80 years.

DESIGN

Cohort study.

SETTING

UK family practices from 2001 to 2014.

PARTICIPANTS

265 195 registered participants aged 80 years and older.

MEASUREMENTS

Frailty status classified into 'fit', 'mild', 'moderate' and 'severe' frailty. Fractures, classified into non-fragility and fragility, including fractures of femur, pelvis, shoulder and upper arm, and forearm/wrist. Incidence of fracture, and mortality within 90 days and 1 year, were estimated.

RESULTS

There were 28 643 fractures including: non-fragility fractures, 9101; femur, 12 501; pelvis, 2172; shoulder and upper arm, 4965; and forearm/wrist, 6315. The incidence of each fracture type was higher in women and increased with frailty category (femur, severe frailty compared with 'fit', incidence rate ratio (IRR) 2.4, 95% CI 2.3 to 2.6). Fractures of the femur (95-99 years compared with 80-84 years, IRR 2.7, 95% CI 2.6 to 2.9) and pelvis (IRR 2.9, 95% CI 2.5 to 3.3) were strongly associated with age but non-fragility and forearm fractures were not. Mortality within 90 days was greatest for femur fracture (adjusted HR, compared with forearm fracture 4.3, 95% CI 3.7 to 5.1). Mortality was higher in men and increased with age (HR 5.3, 95% CI 4.3 to 6.5 in those over 100 years compared with 80-84 years) but was less strongly associated with frailty category. Similar associations with fractures were seen at 1-year mortality.

CONCLUSIONS

The incidence of fractures at all sites was higher in women and strongly associated with advancing frailty status, while the risk of mortality after a fracture was greater in men and was associated with age rather than frailty category.

Arterial stiffness association with chronic inflammatory disorders in the UK Biobank study

OBJECTIVE

The present study tested the hypothesis that arterial stiffness will be elevated across overall and specific inflammatory disorders compared with an inflammation-free comparison group.

METHODS

Adults (n=171 125) aged 40-70 years from the UK Biobank who were cardiovascular disease (CVD) free and who had their arterial stiffness assessed at the time of study recruitment between 2006 and 2010 were included. The main exposure was represented by a global measure of chronic inflammatory disorders. Two inflammatory biomarker measures (eg, leucocytes count, granulocytes count) were included as markers of inflammation severity. The arterial stiffness index assessed by a non-invasive technique represented the study primary outcome measure.

RESULTS

A total of 5976 (3%) participants diagnosed with inflammatory disorders and 165 149 participants without an inflammatory disorder had data on arterial stiffness. Adjusted linear regression analyses revealed a 14% increment in mean arterial stiffness for chronic inflammatory disorders (beta coefficient (β) 1.14, 95% CI 1.05 to 1.24, P=0.002) compared with no chronic inflammatory disorder. Arterial stiffness tended to increase (P value=0.031) with tertiles of leucocytes and granulocytes count. For instance, mean arterial stiffness values increased from 1.11 (95% CI 0.96 to 1.29) in the first tertile to 1.17 (95% CI 1.02 to 1.34) in the second tertile, and 1.21 (95% CI 1.05 to 1.39) in the third tertile of leucocytes count. There was evidence for similar associations with some of the most common individual inflammatory disorders, including psoriasis and rheumatoid arthritis.

CONCLUSION

Arterial stiffness was associated with multiple chronic inflammatory disorders. An increasing trend in mean arterial stiffness was also documented with increasing tertiles of different inflammatory biomarkers. Future studies are needed to investigate the discriminant value of arterial stiffness to predict major CVD events within various inflammatory disorders.

Cardiovascular and type 2 diabetes morbidity and all-cause mortality among diverse chronic inflammatory disorders

Objectives

The present study aimed to assess the relationship between inflammatory disorders with cardiometabolic diseases and mortality within a community-based population.

Methods

The UK Biobank data were used to conduct two investigations: a cross-sectional study to estimate cardiometabolic risk and a prospective cohort study to estimate mortality risk. Binary regression analyses were used to model the association between coronary heart disease, stroke, type 2 diabetes, venous thromboembolism and peripheral artery disease diagnoses with seven inflammatory disorders (eg, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), psoriasis, ankylosing spondylitis (AS), systemic vasculitis, Crohn’s disease and ulcerative colitis (UC)). Cox proportional hazards was used to estimate all-cause and cardiovascular-related mortality.

Results

About 4% (n=19, 082) of the study population (n=5 02 641) were diagnosed with a chronic inflammatory disorder. The most common inflammatory disorder was psoriasis (n=6286), and the least common was SLE (n=654). SLE showed the strongest association with multiple (relative risk (RR) 6.36, 95% CI 4.37 to 9.25) risk of cardiometabolic diseases, followed by the RA (RR 1.70, 95% CI 1.59 to 1.83), UC (RR 1.69, 95% CI 1.51 to 1.89), AS (RR 1.28, 95% CI 1.09 to 1.52), vasculitis (RR 1.64, 95% CI 1.42–1.90) and psoriasis (RR 1.25, 95% 1.16 to 1.35) disorders. The magnitude of the association was higher among participants prescribed non-steroidal anti-inflammatory drugs or corticosteroids drugs, with multiple cardiometabolic risk being greater within SLE (RR 12.35, 95% CI 7.18 to 21.24), followed by UC (RR 3.81, 95% CI 2.69 to 5.38), Crohn’s disease (RR 3.07, 95% CI 1.85 to 5.11), RA (RR 3.06, 95% CI 2.44 to 3.85), psoriasis (RR 2.36, 95% CI 1.88 to 2.95), AS (RR 2.25, 95% CI 1.48 to 3.41) and vasculitis (RR 1.89, 95% CI 1.28 to 2.79). Similar pattern was observed with respect to the cumulative cardiometabolic risk.

Conclusion

Inflammatory disorders are associated with heightened risk of cardiometabolic events, which may vary by anti-inflammatory therapy and duration. All-cause mortality was also higher among specific inflammatory disorders compared with the absence of inflammatory disorders.

Systolic Blood Pressure Trajectory, Frailty, and All-Cause Mortality >80 Years of Age: Cohort Study Using Electronic Health Records

BACKGROUND

Clinical trials show benefit from lowering systolic blood pressure (SBP) in people ≥80 years of age, but nonrandomized epidemiological studies suggest lower SBP may be associated with higher mortality. This study aimed to evaluate associations of SBP with all-cause mortality by frailty category >80 years of age and to evaluate SBP trajectories before death.

METHODS

A population-based cohort study was conducted using electronic health records of 144 403 participants ≥80 years of age registered with family practices in the United Kingdom from 2001 to 2014. Participants were followed for ≤5 years. Clinical records of SBP were analyzed. Frailty status was classified using the e-Frailty Index into the categories of fit, mild, moderate, and severe. All-cause mortality was evaluated by frailty status and mean SBP in Cox proportional-hazards models. SBP trajectories were evaluated using person months as observations, with mean SBP and antihypertensive treatment status estimated for each person month. Fractional polynomial models were used to estimate SBP trajectories over 5 years before death.

RESULTS

During follow-up, 51 808 deaths occurred. Mortality rates increased with frailty level and were greatest at SBP <110 mm Hg. In fit women, mortality was 7.7 per 100 person years at SBP 120 to 139 mm Hg, 15.2 at SBP 110 to 119 mm Hg, and 22.7 at SBP <110 mm Hg. For women with severe frailty, rates were 16.8, 25.2, and 39.6, respectively. SBP trajectories showed an accelerated decline in the last 2 years of life. The relative odds of SBP <120 mm Hg were higher in the last 3 months of life than 5 years previously in both treated (odds ratio, 6.06; 95% confidence interval, 5.40-6.81) and untreated (odds ratio, 6.31; 95% confidence interval, 5.30-7.52) patients. There was no evidence of intensification of antihypertensive therapy in the final 2 years of life.

CONCLUSIONS

A terminal decline of SBP in the final 2 years of life suggests that nonrandomized epidemiological associations of low SBP with higher mortality may be accounted for by reverse causation if participants with lower blood pressure values are closer, on average, to the end of life.

Cardiovascular risk assessment and treatment in chronic inflammatory disorders in primary care

Objective

To compare differences in cardiovascular (CV) risk factors assessment and management among patients with rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) with that of matched controls.

Methods

A matched cohort study was conducted using primary care electronic health records for one London borough. All patients diagnosed with RA or IBD, and matched controls registered with local general practices on 12th of January 2014 were identified. The study compared assessment and treatment of CV risk factors (blood pressure, body mass index, cholesterol and smoking) in the year before, the year after, and 5 years after RA and IBD diagnosis.

Results

A total of 1121 patients with RA and 1875 patients with IBD were identified and matched with 4282 and, respectively, 7803 controls. Patients with RA were 25% (incidence rate ratio, 1.25, 95% CI 1.12 to 1.35) more likely to have a CV risk factor measured compared with matched controls. The difference declined to 8% (1.08, 1.04 to 1.14) over 5 years of follow-up. The corresponding figures for IBD were 26% (1.26, 1.16 to 1.38) and 10% (1.10, 1.05 to 1.15). Patients with RA showed higher antihypertensive prescription rates during 5 years of follow-up (OR, 1.37, 95% CI 1.14 to 1.65) and patients with IBD showed higher statin prescription rates in the year preceding diagnosis (2.30, 1.20 to 4.42). Incomplete CV risk assessment meant that QRISK scores could be calculated for less than a fifth (17%) and clinical recording of CV disease (CVD) risk scores among patients with RA and IBD was 11% and 6%, respectively.

Conclusions

The assessment and treatment of vascular risk in patients with RA and IBD in primary care is suboptimal, particularly with reference to CVD risk score calculation.

Longitudinal Trends in Hypertension Management and Mortality Among Octogenarians: Prospective Cohort Study

The role of hypertension management among octogenarians is controversial. In this long-term follow-up (>10 years) study, we estimated trends in hypertension prevalence, awareness, treatment, and control among octogenarians, and evaluated the relationship of systolic blood pressure (SBP) ranges with mortality. Data were based on the English Longitudinal Study of Ageing (ELSA). Outcome measures were hypertension prevalence, awareness, treatment and control, and cardiovascular disease, and all-cause mortality events. Participants were separated into 8 categories of SBP values (<110, 110-119, 120-129, 130-139, 140-149, 150-159, 160-169, and >169 mm Hg). Among 2692 octogenarians, mean SBP levels declined from 147 mm Hg in 1998/2000 to 134 mm Hg in 2012/2013. The decline was of lower magnitude in the 50 to 79 years old subgroup (n=22007). Hypertension prevalence and awareness were 40% and 13%, respectively, higher among octogenarians than the 50 to 79 years of age subgroup, but hypertension treatment rates were similar (≈90%). Around 47% of the treated octogenarians achieved conventional BP targets (<140/90 mm Hg), increasing to 59% when assessed against revised targets (<150/90 mm Hg). All-cause mortality rates were higher (hazard ratio, 1.55; 95% confidence interval, 0.89-2.72) at lower extremes of SBP values (<110 mm Hg). The lowest cardiovascular disease and all-cause mortality risk among treated octogenarians was observed for an SBP range of 140 to 149 mm Hg (1.04, 0.60-1.78) and 160 to 169 mm Hg (0.78, 0.51-1.21). An increasing trend in hypertension awareness and treatment was observed in a large sample of community-dwelling octogenarians. The results do not support the view that more stringent BP targets may be associated with lower mortality.

Are Inflammation and Related Therapy Associated with All-Cause Dementia in a Primary Care Population?

BACKGROUND

There is limited primary-care based evidence for an association between chronic inflammation and related therapy with all-cause dementia.

OBJECTIVE

To estimate the association between several chronic inflammatory disorders and related drug therapy and all-cause dementia.

METHODS

The study population included a cohort of patients diagnosed with inflammatory conditions and matching controls (ratio 1:2) from the Clinical Practice Research Datalink, a database or primary care records in the UK. Inflammation patients and controls were matched on age, gender, and family practice. The study outcome measure was all-cause dementia. Chronic inflammation diagnosis and anti-inflammatory drugs represented the exposure variables of interest. Competing risks analyses were used to estimate the risk of dementia associated with exposure variables.

RESULTS

There were 1,378 (1% ) and 2,805 (1% ) dementia events recorded for chronic inflammation patients and their matched controls, respectively. Systemic vasculitis was associated with increased hazard ratios of dementia (1.75, 95% confidence interval (CI) 1.35-2.27, p <  0.001). The analyses revealed increased risk of dementia for systemic vasculitis (1.64, 95% CI 1.24-2.18), Crohn's diseases (2.08, 95% CI 1.16-3.74), bullous skin diseases (1.55, 95% CI 1.11-2.18), and inflammatory arthritis (1.33, 95% CI1.06-1.63) among treated patients. Combined glucocorticoids and NSAID therapy suggested reduced risk of dementia across most conditions, particularly systemic autoimmune disorders (0.41, 95% CI 0.18-0.95).

CONCLUSION

The association between chronic inflammation and dementia varied across inflammatory disorders, being stronger for systemic vasculitis. There was evidence that combined therapy was associated with lower risk of dementia across most disorders. These data highlight potential avenues for future mechanistic and intervention investigations.

Drug Utilization and Inappropriate Prescribing in Centenarians

OBJECTIVES

To use primary care electronic health records (EHRs) to evaluate prescriptions and inappropriate prescribing in men and women at age 100.

DESIGN

Population-based cohort study.

SETTING

Primary care database in the United Kingdom, 1990 to 2013.

PARTICIPANTS

Individuals reaching the age of 100 between 1990 and 2013 (N = 11,084; n = 8,982 women, n = 2,102 men).

MEASUREMENTS

Main drug classes prescribed and potentially inappropriate prescribing according to the 2012 American Geriatrics Society Beers Criteria.

RESULTS

At the age of 100, 73% of individuals (79% of women, 54% of men) had received one or more prescription drugs, with a median of 7 (interquartile range 0-12) prescription items. The most frequently prescribed drug classes were cardiovascular (53%), central nervous system (CNS) (53%), and gastrointestinal (47%). Overall, 32% of participants (28% of men, 32% of women) who received drug prescriptions may have received one or more potentially inappropriate prescriptions, with temazepam and amitriptyline being the most frequent. CNS prescriptions were potentially inappropriate in 23% of individuals, and anticholinergic prescriptions were potentially inappropriate in 18% of individuals.

CONCLUSION

The majority of centenarians are prescribed one or more drug therapies, and the prescription may be inappropriate for up to one-third of these individuals. Research using EHRs offers opportunities to understand prescribing trends and improve pharmacological care of the oldest adults.

The relationship between prior antimicrobial prescription and meningitis: a case-control study

BACKGROUND

Recent research into the role of the human microbiome in maintaining health has identified the potentially harmful impact of antimicrobials.

AIM

The association with bacterial and viral meningitis following antimicrobial prescription during the previous year was investigated to determine whether antimicrobials have a deleterious effect on the nasopharyngeal microbiome.

DESIGN AND SETTING

A case-control study (1:4 cases to controls) was conducted examining the rate of previous antimicrobial exposure in cases of meningitis and in a matched control group. Data from a UK primary care clinical database were analysed using conditional logistic regression.

RESULTS

A total of 7346 cases of meningitis were identified, 3307 (45%) viral, 1812 (25%) bacterial, and 2227 (30%) unspecified. The risks of viral (adjusted odds ratio [AOR] 2.45; 95% confidence interval [CI] = 2.24 to 2.68) or bacterial (AOR 1.98; 95% CI = 1.71 to 2.30) meningitis were both increased following antimicrobial prescription in the preceding year. Patients who received ≥4 antimicrobial prescriptions in the preceding year were at significantly increased risk of all types of meningitis (AOR 2.85; 95% CI = 2.44 to 3.34), bacterial meningitis (AOR 3.06; 95% CI = 2.26 to 4.15) and viral meningitis (AOR 3.23; 95% CI = 2.55 to 4.08) compared to their matched controls.

CONCLUSION

There was an increased risk of meningitis following antimicrobial prescription in the previous year. It is possible that this increase was due to an effect of antimicrobials on the microbiome or reflected an increased general susceptibility to infections in these patients.

Incidence and mortality of relapsing polychondritis in the UK: a population-based cohort study

OBJECTIVE

Relapsing polychondritis is a rare disease characterized by cartilage inflammation. Our aim was to estimate the incidence, prevalence and mortality of relapsing polychondritis and describe the clinical features of relapsing polychondritis in a large population.

METHODS

All participants diagnosed with relapsing polychondritis were sampled from the Clinical Practice Research Datalink. Prevalence and incidence rates for 1990-2012 were estimated. Relative mortality rates were estimated in a time-to-event framework using reference UK life tables. A questionnaire validation study assessed diagnostic accuracy.

RESULTS

There were 117 participants with relapsing polychondritis ever recorded. Fifty (82%) of 61 cases were validated by a physician and unconfirmed cases were excluded. The analysis included 106 participants (42 men, 64 women) diagnosed with relapsing polychondritis. The mean age (range) at diagnosis in men was 55 (range 17-81) years and in women 51 (range 11-79) years. The median interval from first symptom to diagnosis was 1.9 years. The incidence of relapsing polychondritis between 1990 and 2012 was 0.71 (95% CI 0.55, 0.91) per million population per year. There were 19 deaths from any cause. There were 16 observed deaths eligible for survival analysis and 7.4 deaths expected for the UK population of the same age, sex and period. The standardized mortality ratio was 2.16 (95% CI 1.24, 3.51), P < 0.01. Respiratory disease, cardiac conditions and cancer were the most frequent causes of death.

CONCLUSION

The incidence of relapsing polychondritis may be lower than previously estimated, and diagnostic misclassification and delay are common. Mortality in relapsing polychondritis is more than twice that of the general population.

Patterns of anti-inflammatory drug use and risk of dementia: a matched case-control study

BACKGROUND AND PURPOSE

There is limited primary-care-based evidence about a potential association between anti-inflammatory therapy and dementia subtypes. The present study addressed this limitation by using electronic health records from a large primary care database.

METHOD

A case-control study was implemented using electronic medical records. Cases had a diagnosis of dementia between 1992 and 2014. Up to four controls matched on age, gender, family practice and index date were selected for each case. Use of non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticoid drugs represented the exposure variables. Primary outcome measures included all-cause dementia and main dementia subtypes, including Alzheimer disease (AD), vascular dementia (VaD) and Lewy body dementia (LBD). Data were analysed using conditional logistic regression.

RESULTS

The study identified 31,083 patients with AD, 23,465 with VaD and 1694 with LBD. Ever-used NSAIDs were associated with a modest increase in the risk of all-cause dementia (odds ratio 1.04, 95% confidence interval 1.02-1.05, P < 0.006), whilst no association was apparent for ever-used glucocorticoids (0.98, 0.96-1.01, P = 0.152). There was no evidence for an association between NSAIDs and AD (1.03, 0.99-1.06, P = 0.07) or LBD (1.13, 0.99-1.29, P = 0.08). However, a significant increase in the risk for VaD (1.33, 1.29-1.38, P < 0.001) was observed. Similar patterns emerged for glucocorticoid therapy.

CONCLUSION

In a large primary care population, there was no robust evidence for a potential association between anti-inflammatory drugs and risk of AD or LBD. NSAIDs and glucocorticoid drugs were associated with higher risk of VaD.

Differences in Health at Age 100 According to Sex: Population-Based Cohort Study of Centenarians Using Electronic Health Records

OBJECTIVES

To use primary care electronic health records (EHRs) to evaluate the health of men and women at age 100.

DESIGN

Population-based cohort study.

SETTING

Primary care database in the United Kingdom, 1990-2013.

PARTICIPANTS

Individuals reaching the age of 100 between 1990 and 2013 (N = 11,084, n = 8,982 women, n = 2,102 men).

MEASUREMENTS

Main categories of morbidity and an index of multiple morbidities, geriatric syndromes and an index of multiple impairments, cardiovascular risk factors.

RESULTS

The number of new female centenarians per year increased from 16 per 100,000 in 1990-94 to 25 per 100,000 in 2010-13 (P < .001) and of male centenarians from four per 100,000 to six per 100,000 (P = .06). The most prevalent morbidities at the age of 100 were musculoskeletal diseases, disorders of the senses, and digestive diseases. Women had greater multiple morbidity than men (odds ratio (OR) = 1.64, 95% confidence interval (CI) = 1.42-1.89, P < .001). Geriatric syndromes, including falls, fractures, hearing and vision impairment, and dementia, were frequent; 30% of women and 49% of men had no recorded geriatric syndromes. Women had greater likelihood of having multiple geriatric syndromes (OR = 2.14, 95% CI = 1.90-2.41, P < .001).

CONCLUSION

Fewer men than women reach the age of 100, but male centenarians have lower morbidity and fewer geriatric syndromes than women. Research using EHRs offers opportunities to understand the epidemiology of aging and improve care of the oldest old.

Process evaluation of a point-of-care cluster randomised trial using a computer-delivered intervention to reduce antibiotic prescribing in primary care

BACKGROUND

The study aimed to conduct a process evaluation for a cluster randomised trial of a computer-delivered, point-of-care intervention to reduce antibiotic prescribing in primary care. The study aimed to evaluate both the intervention and implementation of the trial.

METHODS

The intervention comprised a set of electronic educational and decision support tools that were remotely installed and activated during consultations with patients with acute respiratory infections over a 12 month intervention period. A mixed method evaluation was conducted with 103 general practitioners (GPs) who participated in the trial. Semi-structured telephone interviews were conducted with 20 GPs who had been in the intervention group of the trial and 4 members of the implementation staff. Questionnaires, consisting of both intervention evaluation and theory-based measures, were self-administered to 83 GPs (56 control group and 27 intervention group).

RESULTS

Interviews suggested that a key factor influencing GPs' use of the intervention appeared to be their awareness of the implementation of the system into their practice. GPs who were aware of the implementation of the intervention reported feeling confident in using it if they chose to and understood the purpose of the intervention screens. However, GPs who were unaware that the intervention would be appearing often reported feeling confused when they saw the messages appear on the screen and not fully understanding what they were for or how they could be used. Intervention evaluation questionnaires indicated that GPs were satisfied with the usability of the prompts, and theory-based measures revealed that intervention group GPs reported higher levels of self-efficacy in managing RTI patients according to recommended guidelines compared to GPs in the control group.

CONCLUSIONS

Remote installation of a computer-delivered intervention for use at the point-of-care was feasible and acceptable. Additional measures to promote awareness of the intervention may be required to promote health care professionals' utilisation of the intervention and these might sometimes compromise the pragmatic intention of a trial.

TRIAL REGISTRATION

ISRCTN47558792 (registered on 17 March 2010).

Incidence of type 2 diabetes after bariatric surgery: population-based matched cohort study

BACKGROUND

The effect of currently used bariatric surgical procedures on the development of diabetes in obese people is not well defined. We aimed to assess the effect of bariatric surgery on development of type 2 diabetes in a large population of obese individuals.

METHODS

We did a matched cohort study of adults (age 20–100 years) identified from a UK-wide database of family practices, who were obese (BMI ≥30 kg/m2) and did not have diabetes. We enrolled 2167 patients who had undergone bariatric surgery between Jan 1, 2002, and April 30, 2014, and matched them--according to BMI, age, sex, index year, and HbA1c--with 2167 controls who had not had surgery. Procedures included laparoscopic gastric banding (n=1053), gastric bypass (795), and sleeve gastrectomy (317), with two procedures undefined. The primary outcome was development of clinical diabetes, which we extracted from electronic health records. Analyses were adjusted for matching variables, comorbidity, cardiovascular risk factors, and use of antihypertensive and lipid-lowering drugs.

FINDINGS

During a maximum of 7 years of follow-up (median 2·8 years [IQR 1·3–4·5]), 38 new diagnoses of diabetes were made in bariatric surgery patients and 177 were made in controls. By the end of 7 years of follow-up, 4·3% (95% CI 2·9–6·5) of bariatric surgery patients and 16·2% (13·3–19·6) of matched controls had developed diabetes. The incidence of diabetes diagnosis was 28·2 (95% CI 24·4–32·7) per 1000 person-years in controls and 5·7 (4·2–7·8) per 1000 person-years in bariatric surgery patients; the adjusted hazard ratio was 0·20 (95% CI 0·13–0·30, p<0·0001). This estimate was robust after varying the comparison group in sensitivity analyses, excluding gestational diabetes, or allowing for competing mortality risk.

INTERPRETATION

Bariatric surgery is associated with reduced incidence of clinical diabetes in obese participants without diabetes at baseline for up to 7 years after the procedure.

FUNDING

UK National Institute for Health Research.

Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices

OBJECTIVES

Overutilisation of antibiotics may contribute to the emergence of antimicrobial drug resistance, a growing international concern. This study aimed to analyse the performance of UK general practices with respect to antibiotic prescribing for respiratory tract infections (RTIs) among young and middle-aged adults.

SETTING

Data are reported for 568 UK general practices contributing to the Clinical Practice Research Datalink.

PARTICIPANTS

Participants were adults aged 18-59 years. Consultations were identified for acute upper RTIs including colds, cough, otitis-media, rhino-sinusitis and sore throat.

PRIMARY AND SECONDARY OUTCOME MEASURES

For each consultation, we identified whether an antibiotic was prescribed. The proportion of RTI consultations with antibiotics prescribed was estimated.

RESULTS

There were 568 general practices analysed. The median general practice prescribed antibiotics at 54% of RTI consultations. At the highest prescribing 10% of practices, antibiotics were prescribed at 69% of RTI consultations. At the lowest prescribing 10% of practices, antibiotics were prescribed at 39% RTI consultations. The median practice prescribed antibiotics at 38% of consultations for 'colds and upper RTIs', 48% for 'cough and bronchitis', 60% for 'sore throat', 60% for 'otitis-media' and 91% for 'rhino-sinusitis'. The highest prescribing 10% of practices issued antibiotic prescriptions at 72% of consultations for 'colds', 67% for 'cough', 78% for 'sore throat', 90% for 'otitis-media' and 100% for 'rhino-sinusitis'.

CONCLUSIONS

Most UK general practices prescribe antibiotics to young and middle-aged adults with respiratory infections at rates that are considerably in excess of what is clinically justified. This will fuel antibiotic resistance.