The COVID-19 pandemic has rapidly changed general practice in the UK. Research is required to understand how General Practitioners (GPs) and GP trainees adjusted to these changes, so that beneficial ...changes might be sustained, and Primary Health Care (PHC) can be prepared for future challenges. This study explored the experiences and perspectives of GP and GP trainees during the pandemic.
Remote, semi-structured interviews (n = 21) were conducted with GPs (n = 11) and GP trainees (n = 10), recruited from across the UK using convenience and purposive sampling. Interviews were audio-recorded and transcribed verbatim. Interview data were analysed with an inductive thematic approach.
Five overarching themes were identified: (1) 'Thrown in at the deep end'; (2) Telemedicine: 'it needs to be a happy balance'; (3) Delayed referrals and 'holding' patients; (4) The Covid Cohort-training in Covid; (5) Suggestions and lessons for the future of general practice'. GPs reported a turbulent and uncertain time of major changes to PHC. They described the benefits of technology in general medicine, particularly telemedicine, when used in a balanced manner, highlighting the need for accompanying teaching and guidelines, and the importance of patient preferences. Key tools to help GPs manage patients with delayed referrals to Secondary Care were also identified.
Several key changes to general practice occurred as a result of the COVID-19 pandemic, including a rapid uptake of telemedicine. The pandemic exposed the strengths and limitations of normal general practice and highlighted the importance of workplace camaraderie. These findings contribute to the evidence base used to adapt PHC infrastructures as we emerge from the pandemic.
ObjectivesUK general practice has radically altered in response to COVID-19. The general practice nursing team has been central to these changes. To help learn from COVID-19 and maintain a ...sustainable nursing workforce, general practice should reflect on their support needs and perceptions of organisational strategies. This study aimed to explore primary care nurses’ and healthcare assistants’ experiences and perceptions of general practice, and the changes made to it, during the pandemic.DesignExploratory qualitative study using semistructured interviews. Interview data were analysed using Braun and Clarke’s ‘codebook’ thematic analysis.SettingGeneral practices in the Midlands, South East and South West England. Interviews were conducted in February and March 2021, as England began to unlock from its third national lockdown.ParticipantsPractice nurses (n=12), healthcare assistants (n=7), advanced nurse practitioners (n=4) and nursing associates (n=1) recruited using convenience and snowball sampling.ResultsThree themes were identified. Difficult changes describes dramatic changes made to general practice at the onset of the pandemic, creating confusion and anxiety. Dealing with change characterises how negative emotions were intensified by fear of infection, problematic government guidance, personal protective equipment (PPE) shortages and friction with doctors; but could be mitigated through effective practice communication, peer support and individual coping strategies. An opportunity for improvement highlights certain changes (eg, the increased use of telehealth) that participants believed could be adopted long term to improve efficiency.ConclusionGeneral practice should learn from the COVID-19 pandemic to nurture the clinical role and resilience of nurses and healthcare assistants in the postpandemic ‘new normal’. Robust PPE provision could enable them to undertake their patient-facing duties safely and confidently. Judicious implementation of telehealth could help preserve the practical and caring nature of nursing. Improving channels of communication and interprofessional collaboration could help realise their potential within the primary care team.
Abstract Background and objectives The majority of people with eating disorders (ED) experience high levels of comorbid anxiety and depression, yet the maintenance processes of these in ED remain ...largely unknown. Worry, a defining cognitive feature and important maintenance factor of anxiety, has not been well-studied amongst people with ED. This is the first study to explore both the process and content characteristics of catastrophic worry in ED. Methods Twenty-nine patients with anorexia nervosa (AN), 15 patients with bulimia nervosa (BN) and 37 healthy controls (HC) completed measures assessing anxiety, depression, worry and eating disorder pathology. Catastrophic worry was assessed using the Catastrophizing Interview and catastrophic worry content was explored using qualitative Thematic Analysis. Results Compared to HCs, ED groups had higher levels of anxiety, depression and worry and they generated a greater number of catastrophic worry steps. Worry was further found associated with depressive symptomatology in those with ED. Worry content for the ED groups included ED themes, but also themes reflecting broader inter and intrapersonal concerns. Limitations The degree to which worry is driven by depressive versus anxious symptomatology remains unclear. The current study does not include an anxious or depressed control group, and results should be considered in the light of relatively small samples sizes. Conclusion Findings indicate that interventions that target worry processes may be a useful adjunct to treatment for those ED patients with clinical worry levels.
Introduction
COVID‐19 has impacted people with dementia and their family carers, yet little is known about effects on overall quality of life.
Methods
In a UK cohort study, pre‐ and post‐pandemic ...data were collected from 114 carers and 93 recently diagnosed people with dementia. Latent growth curve modeling examined change in quality of life.
Results
Carers reported significant decline in quality of life, although no change was demonstrated by people with dementia. In multivariable analyses, higher levels of cognitive impairment, deprivation, study site, and lower number of memory clinic contacts were associated with greater decline in carer quality of life.
Discussion
Maintaining life quality for people with dementia during the pandemic appears to have come at the expense of their family carers. This inequity has fallen hardest on those caring for people with more severe dementia, in deprived areas, and with least support from memory services. These effects may be prevented or reversed by post‐diagnostic care.
Variation in response to biologic therapy for inflammatory diseases, such as psoriasis, is partly driven by variation in drug exposure. Real‐world psoriasis data were used to develop a ...pharmacokinetic/pharmacodynamic (PK/PD) model for the first‐line therapeutic antibody ustekinumab. The impact of differing dosing strategies on response was explored. Data were collected from a UK prospective multicenter observational cohort (491 patients on ustekinumab monotherapy, drug levels, and anti‐drug antibody measurements on 797 serum samples, 1,590 measurements of Psoriasis Area Severity Index (PASI)). Ustekinumab PKs were described with a linear one‐compartment model. A maximum effect (Emax) model inhibited progression of psoriatic skin lesions in the turnover PD mechanism describing PASI evolution while on treatment. A mixture model on half‐maximal effective concentration identified a potential nonresponder group, with simulations suggesting that, in future, the model could be incorporated into a Bayesian therapeutic drug monitoring “dashboard” to individualize dosing and improve treatment outcomes.
Targeted biologic therapies can elicit an undesirable host immune response characterized by the development of antidrug antibodies (ADA), an important cause of treatment failure. The most widely used ...biologic across immune-mediated diseases is adalimumab, a tumor necrosis factor inhibitor. This study aimed to identify genetic variants that contribute to the development of ADA against adalimumab, thereby influencing treatment failure. In patients with psoriasis on their first course of adalimumab, in whom serum ADA had been evaluated 6-36 months after starting treatment, we observed a genome-wide association with ADA against adalimumab within the major histocompatibility complex (MHC). The association signal mapped to the presence of tryptophan at position 9 and lysine at position 71 of the HLA-DR peptide-binding groove, with both residues conferring protection against ADA. Underscoring their clinical relevance, these residues were also protective against treatment failure. Our findings highlight antigenic peptide presentation via MHC class II as a critical mechanism in the development of ADA against biologic therapies and downstream treatment response.
In the last few decades, mental health research has increasingly provided evidence supporting the role of inflammation in pathogenesis, course and treatment of mental disorders. With such a steep ...incline of research, resulting in a wealth of emerged findings, it has become difficult to follow developments within the field. The present review sets out to present the recent developments and to give an overview of the inflammatory profiles of depression, psychosis and bipolar disorder, as well as variations within these disorders. Moreover, mediating factors such as social environment and childhood experience are discussed, both in terms of their potential in elucidating the complex interface between the inflammation and other closely related biological systems, as well as the possibly confounding impact of various lifestyle factors. Whilst many issues in this fascinating area of research remain to be fully understood and elaborated, all current evidence suggests that inflammation plays a key role in mental disorders and may open up novel avenues for clinical treatment.
Biologic therapies can be highly effective for the treatment of severe psoriasis, but response for individual patients can vary according to drug. Predictive biomarkers to guide treatment selection ...could improve patient outcomes and treatment cost-effectiveness.
We sought to test whether HLA-C*06:02, the primary genetic susceptibility allele for psoriasis, predisposes patients to respond differently to the 2 most commonly prescribed biologics for psoriasis: adalimumab (anti–TNF-α) and ustekinumab (anti–IL-12/23).
This study uses a national psoriasis registry that includes longitudinal treatment and response observations and detailed clinical data. HLA alleles were imputed from genome-wide genotype data for 1326 patients for whom 90% reduction in Psoriasis Area and Severity Index score (PASI90) response status was observed after 3, 6, or 12 months of treatment. We developed regression models of PASI90 response, examining the interaction between HLA-C*06:02 and drug type (adalimumab or ustekinumab) while accounting for potentially confounding clinical variables.
HLA-C*06:02–negative patients were significantly more likely to respond to adalimumab than ustekinumab at all time points (most strongly at 6 months: odds ratio OR, 2.95; P = 5.85 × 10−7), and the difference was greater in HLA-C*06:02–negative patients with psoriatic arthritis (OR, 5.98; P = 6.89 × 10−5). Biologic-naive patients who were HLA-C*06:02 positive and psoriatic arthritis negative demonstrated significantly poorer response to adalimumab at 12 months (OR, 0.31; P = 3.42 × 10−4). Results from HLA-wide analyses were consistent with HLA-C*06:02 itself being the primary effect allele. We found no evidence for genetic interaction between HLA-C*06:02 and ERAP1.
This large observational study suggests that reference to HLA-C*06:02 status could offer substantial clinical benefit when selecting treatments for severe psoriasis.
Background and Objectives
Research into people with dementia's experiences of the Covid‐19 pandemic has tended to focus on vulnerabilities and negative outcomes, with the risk of reproducing a ...discourse in which people with dementia are positioned as passive. Informed by concepts positioning people with dementia as ‘active social agents’, we aimed to identify the pandemic‐related challenges faced by people recently diagnosed with dementia and examine the ways in which they actively coped with, and adapted to, these challenges.
Research Design and Methods
In‐depth interviews with 21 people recently diagnosed with dementia, recruited through an existing national cohort. Data was analysed thematically using Framework.
Findings
Key challenges included reduced social contact, loneliness and loss of social routines; difficulties accessing and trusting health services; dementia‐unfriendly practices; and disparate experiences of being able to ‘get out’ into the physical neighbourhood. People with dementia responded to challenges by maintaining and extending their social networks and making the most of ‘nodding acquaintances’; learning new skills, for communication and hobbies; supporting others, engaging in reciprocal exchange and valuing connection with peers; seeking help and advocacy and challenging and resisting dementia‐unfriendly practices; maintaining and adapting habitual spatial practices and being determined to ‘get out’; and employing similar emotional coping strategies for the pandemic and dementia.
Conclusions
Support for people with dementia, especially during public health crises when carers and services are under pressure, should involve utilising existing capacities, appropriately supporting the acquisition of new knowledge and skills, ‘safety‐netting’ through the availability of a named professional, advocacy and support and use of ‘check‐in calls’ and creating supportive social and environmental circumstances for people with dementia to sustain their own well‐being.
Key points
Research conducted directly with people with dementia, exploring their lived experiences, is helpful for understanding the ways in which they respond as ‘active social agents’ to challenges in their lives.
People recently diagnosed with dementia reported a range of challenges and negative experiences associated with the Covid‐19 pandemic including loneliness and loss of social routines; difficulties in accessing and trusting health services; dementia‐unfriendly practices and challenges ‘getting out’ into the physical neighbourhood.
They responded to challenges by maintaining and extending social networks; learning new skills; supporting others and engaging in reciprocal exchange, including with peers; seeking help and advocacy and challenging and resisting dementia‐unfriendly practices; maintaining and adapting habitual spatial practices; and employing a range of emotional coping strategies.
Support for people with dementia during public health crises should aim to create social and environmental circumstances that enable people with dementia to help sustain their own well‐being.
PDF
