Personal historical perspective of HIV: part 11.

All animal life on earth is thought to have a common origin and have common genetic mechanisms. Evolution has enabled differentiation of species. Pathogens likewise have evolved within various species and mostly come to a settled dynamic equilibrium such that co-existence results (pathogens ideally should not kill their hosts). Problems arise when pathogens jump species because the new host had not developed any resistance. These infections from related species are known as zoonoses. COVID-19 is the latest example of a virus entering another species but HIV (and various strains of influenza) were previous examples. HIV entered the human population from monkeys in Africa. These two papers outline the underlying principle of HIV and the differing epidemiologies in Africa, the USA and in Edinburgh. The underlying immunosuppression of HIV in Africa was initially hidden behind common infections and HIV first came to world awareness in focal areas of the USA as a disease seemingly limited to gay males. The epidemic of intravenous drug abuse in Edinburgh was associated with overlapping epidemics of bloodborne viruses like hepatitis B, hepatitis C and HIV.

Nurse-led virtual interventions in managing chronic diseases: a protocol for a systematic review of randomised controlled trials.

INTRODUCTION: Technological advances are changing nursing practice; however, nurse-led virtual care for chronic disease management has not yet been adequately explored and described. This study will review and analyse the effects of nurse-led virtual services and describe the virtual intervention characteristics relevant to the scope of nursing practice in chronic disease management. METHODS AND ANALYSIS: This study will systematically review randomised controlled trials evaluating the effects of nurse-led virtual care interventions on patients with chronic conditions. Databases including PubMed, Embase, Web of Science, CINAHL, Chinese National Knowledge Infrastructure, Wanfang (Chinese) and VIP Chinese Science and Technology Periodicals will be searched. All studies will be screened and selected using the criteria described in 'population, intervention, comparison, outcome and study design' format. Relevant studies will be searched using the reference lists of eligible studies and review articles. The risk of bias will be assessed using the Joanna Briggs Institute Quality Appraisal Form. Two reviewers will independently extract data from all the included studies using a standardised data extraction form on the Covidence platform. RevMan V.5.3 software will be used to perform the meta-analysis. Data synthesis will be conducted with descriptive synthesis by summarising and tabulating the data and presenting them according to the research questions. ETHICS AND DISSEMINATION: Formal ethical approval is not required as the data used in this systematic review are abstracted from the pre-existing literature. The results of this study will be disseminated through peer-reviewed journals and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42022361260.

What is the role of primary care in the COVID-19 vaccine roll-out and the barriers and facilitators to an equitable vaccine roll-out? A rapid scoping review of nine jurisdictions.

OBJECTIVES: This study aimed to: (1) examine the experience of nine global jurisdictions that engaged primary care providers (PCPs) to administer COVID-19 vaccines during the pandemic; (2) describe how vaccine hesitancy and principles of equity were incorporated in the COVID-19 vaccine roll-out strategies and (3) identify the barriers and facilitators to the vaccine roll-out. DESIGN: Rapid scoping review. DATA SOURCES: Searches took place in MEDLINE, CINAHL, Embase, the Cochrane Library, SCOPUS and PsycINFO, Google, and the websites of national health departments. Searches and analyses took place from May 2021 to July 2021. RESULTS: Sixty-two documents met the inclusion criteria (35=grey literature; 56% and 27=peer reviewed; 44%). This review found that the vaccine distribution approach started at hospitals in almost all jurisdictions. In some jurisdictions, PCPs were engaged at the beginning, and the majority included PCPs over time. In many jurisdictions, equity was considered in the prioritisation policies for various marginalised communities. However, vaccine hesitancy was not explicitly considered in the design of vaccine distribution approaches. The barriers to the roll-out of vaccines included personal, organisational and contextual factors. The vaccine roll-out strategy was facilitated by establishing policies and processes for pandemic preparedness, well-established and coordinated information systems, primary care interventions, adequate supply of providers, education and training of providers, and effective communications strategy. CONCLUSIONS: Empirical evidence is lacking on the impact of a primary care-led vaccine distribution approach on vaccine hesitancy, adoption and equity. Future vaccine distribution approaches need to be informed by further research evaluating vaccine distribution approaches and their impact on patient and population outcomes.

Relevance of prediction scores derived from the SARS-CoV-2 first wave, in the evolving UK COVID-19 second wave, for safe early discharge and mortality: a PREDICT COVID-19 UK prospective observational cohort study.

OBJECTIVE: Prospectively validate prognostication scores, SOARS and 4C Mortality Score, derived from the COVID-19 first wave, for mortality and safe early discharge in the evolving pandemic with SARS-CoV-2 variants (B.1.1.7 replacing D614) and healthcare responses altering patient demographic and mortality. DESIGN: Protocol-based prospective observational cohort study. SETTING: Single site PREDICT and multisite ISARIC (International Severe Acute Respiratory and Emerging Infections Consortium) cohorts in UK COVID-19 second wave, October 2020 to January 2021. PARTICIPANTS: 1383 PREDICT and 20 595 ISARIC SARS-CoV-2 patients. PRIMARY OUTCOME MEASURES: Relevance of SOARS and 4C Mortality Score determining in-hospital mortality and safe early discharge in the evolving UK COVID-19 second wave. RESULTS: 1383 (median age 67 years, IQR 52-82; mortality 24.7%) PREDICT and 20 595 (mortality 19.4%) ISARIC patient cohorts showed SOARS had area under the curve (AUC) of 0.8 and 0.74, while 4C Mortality Score had AUC of 0.83 and 0.91 for hospital mortality, in the PREDICT and ISARIC cohorts respectively, therefore, effective in evaluating safe discharge and in-hospital mortality. 19.3% (231/1195, PREDICT cohort) and 16.7% (2550/14992, ISARIC cohort) with SOARS of 0-1 were candidates for safe discharge to a virtual hospital (VH) model. SOARS implementation in the VH pathway resulted in low readmission, 11.8% (27/229) and low mortality, 0.9% (2/229). Use to prevent admission is still suboptimal, as 8.1% in the PREDICT cohort and 9.5% in the ISARIC cohort were admitted despite SOARS score of 0-1. CONCLUSIONS: SOARS and 4C Mortality Score remains valid, transforming complex clinical presentations into tangible numbers, aiding objective decision making, despite SARS-CoV-2 variants and healthcare responses altering patient demographic and mortality. Both scores, easily implemented within urgent care pathways for safe early discharge, allocate hospital resources appropriately to the pandemic's needs while enabling normal healthcare services resumption.

Global evidence of gender equity in academic health research: a scoping review.

OBJECTIVES: To chart the global literature on gender equity in academic health research. DESIGN: Scoping review. PARTICIPANTS: Quantitative studies were eligible if they examined gender equity within academic institutions including health researchers. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcomes related to equity across gender and other social identities in academia: (1) faculty workforce: representation of all genders in university/faculty departments, academic rank or position and salary; (2) service: teaching obligations and administrative/non-teaching activities; (3) recruitment and hiring data: number of applicants by gender, interviews and new hires for various rank; (4) promotion: opportunities for promotion and time to progress through academic ranks; (5) academic leadership: type of leadership positions, opportunities for leadership promotion or training, opportunities to supervise/mentor and support for leadership bids; (6) scholarly output or productivity: number/type of publications and presentations, position of authorship, number/value of grants or awards and intellectual property ownership; (7) contextual factors of universities; (8) infrastructure; (9) knowledge and technology translation activities; (10) availability of maternity/paternity/parental/family leave; (11) collaboration activities/opportunities for collaboration; (12) qualitative considerations: perceptions around promotion, finances and support. RESULTS: Literature search yielded 94 798 citations; 4753 full-text articles were screened, and 562 studies were included. Most studies originated from North America (462/562, 82.2%). Few studies (27/562, 4.8%) reported race and fewer reported sex/gender (which were used interchangeably in most studies) other than male/female (11/562, 2.0%). Only one study provided data on religion. No other PROGRESS-PLUS variables were reported. A total of 2996 outcomes were reported, with most studies examining academic output (371/562, 66.0%). CONCLUSIONS: Reviewed literature suggest a lack in analytic approaches that consider genders beyond the binary categories of man and woman, additional social identities (race, religion, social capital and disability) and an intersectionality lens examining the interconnection of multiple social identities in understanding discrimination and disadvantage. All of these are necessary to tailor strategies that promote gender equity. TRIAL REGISTRATION NUMBER: Open Science Framework: https://osf.io/8wk7e/.

Relationship between COVID-19 care and burnout among postgraduate clinical residents in Japan: a nationwide cross-sectional study.

OBJECTIVE: The relationship between the care of patients with COVID-19 and mental health among resident physicians in Japan is imperative for ensuring appropriate care of patients with COVID-19 and should be clarified. We herein assessed the relationship between the care of patients with COVID-19 and mental health among postgraduate year 1 (PGY-1) and PGY-2 resident physicians and factors associated with mental health. DESIGN: This nationwide cross-sectional study analysed data obtained using the clinical training environment self-reported questionnaire. SETTING: An observational study across Japan among resident physicians (PGY-1 and PGY-2) from 583 teaching hospitals. PARTICIPANTS: Examinees who took the general medicine in-training examination of academic year 2020. PRIMARY AND SECONDARY OUTCOME MEASURES: The Patient Health Questionnaire and Mini-Z 2.0 were used to assess mental health, and experience of caring for patients with COVID-19 was divided into three groups (none, 1-10 and ≥11). The prevalence of mental conditions in the three groups was compared using the 'modified' Poisson generalised estimating equations by adjusting for prefecture-level, hospital-level and resident-level variables. RESULTS: Of the 5976 participants analysed, 50.9% were PGY-1. The prevalence of burnout was 21.4%. Moreover, 47.0% of all resident physicians had no experience in the care of patients with COVID-19. The well-experienced group accounted for only 7.9% of the total participants. A positive association was found between the number of caring patients with COVID-19 and burnout (prevalence ratio 1.25; 95% CI 1.02 to 1.53). Moreover, the shortage of personal protective equipment was identified as a major contributor to burnout (prevalence ratio 1.60; 95% CI 1.36 to 1.88). CONCLUSIONS: Resident physicians who experienced more care of patients with COVID-19 had slightly greater burnout prevalence than those who did not. Approximately half of resident physicians did not participate in the care of patients with COVID-19, which posed a challenge from an educational perspective.

Standardised treatment and monitoring protocol to assess safety and tolerability of bacteriophage therapy for adult and paediatric patients (STAMP study): protocol for an open-label, single-arm trial.

INTRODUCTION: There has been renewed interest in the therapeutic use of bacteriophages (phages); however, standardised therapeutic protocols are lacking, and there is a paucity of rigorous clinical trial data assessing efficacy. METHODS AND ANALYSIS: We propose an open-label, single-arm trial investigating a standardised treatment and monitoring protocol for phage therapy. Patients included will have exhausted other therapeutic options for control of their infection and phage therapy will be administered under Australia's Therapeutic Goods Administration Special Access Scheme. A phage product with high in vitro activity against the targeted pathogen(s) must be available in line with relevant regulatory requirements. We aim to recruit 50-100 patients over 5 years, from any public or private hospitals in Australia. The standardised protocol will specify clinical assessments and biological sampling at scheduled time points. The primary outcome is safety at day 29, assessed by the frequency of adverse events, and overseen by an independent Data Safety Monitoring Board. Secondary outcomes include long-term safety (frequency of adverse events until at least 6 months following phage therapy), and feasibility, measured as the proportion of participants with>80% of minimum data available for analysis. Additional endpoints assessed include clinical response, patient/guardian reported quality of life measures, phage pharmacokinetics, human host immune responses and microbiome analysis. All trial outcomes will be summarised and presented using standard descriptive statistics. ETHICS AND DISSEMINATION: Participant inclusion will be dependent on obtaining written informed consent from the patient or guardian. The trial protocol was approved by the Sydney Children's Hospitals Network Human Research Ethics Committee in December 2021 (Reference 2021/ETH11861). In addition to publication in a peer-reviewed scientific journal, a lay summary of study outcomes will be made available for participants and the public on the Phage Australia website (https://www.phageaustralia.org/). TRIAL REGISTRATION NUMBER: Registered on ANZCTR, 10 November 2021 (ACTRN12621001526864; WHO Universal Trial Number: U1111-1269-6000).

Protocol for a 30-day randomised, parallel-group, non-inferiority, controlled trial investigating the effects of discontinuing renin-angiotensin system inhibitors in patients with and without COVID-19: the RASCOVID-19 trial.

INTRODUCTION: The COVID-19 pandemic caused by the virus SARS-CoV has spread rapidly and caused damage worldwide. Data suggest a major overrepresentation of hypertension and diabetes among patients experiencing severe courses of COVID-19 including COVID-19-related deaths. Many of these patients receive renin-angiotensin system (RAS) inhibiting therapy, and evidence suggests that treatment with angiotensin II receptor blockers (ARBs) could attenuate SARS-CoV-induced acute respiratory distress syndrome, and ACE inhibitors and ARBs have been suggested to alleviate COVID-19 pulmonary manifestations. This randomised clinical trial will address whether RAS inhibiting therapy should be continued or discontinued in hospitalised patients with COVID-19. METHODS AND ANALYSIS: This trial is a 30-day randomised parallel-group non-inferiority clinical trial with an embedded mechanistic substudy. In the main trial, 215 patients treated with a RAS inhibitor will be included. The participants will be randomly assigned in a 1:1 ratio to either discontinue or continue their RAS inhibiting therapy in addition to standard care. The patients are included during hospitalisation and followed for a period of 30 days. The primary end point is number of days alive and out of hospital within 14 days after recruitment. In a mechanistic substudy, 40 patients treated with RAS inhibition, who are not in hospital and not infected with COVID-19 will be randomly assigned to discontinue or continue their RAS inhibiting therapy with the primary end point of serum ACE2 activity. ETHICS AND DISSEMINATION: This trial has been approved by the Scientific-Ethical Committee of the Capital Region of Denmark (identification no. H-20026484), the Danish Medicines Agency (identification no. 2020040883) and by the Danish Data Protection Agency (P-2020-366). The results of this project will be compiled into one or more manuscripts for publication in international peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: 2020-001544-26; NCT04351581.

Cardiovascular-related conditions and risk factors in primary care for deprived communities before and during the COVID-19 pandemic: an observational study in Northern England.

OBJECTIVES: The North East of England, ranked as having the highest poverty levels and the lowest health outcomes, has the highest cardiovascular disease (CVD) premature mortality. This study aimed to compare CVD-related conditions and risk factors for deprived practice populations with other general practice (GP) populations in Northern England to England overall, before and during COVID-19 to identify changes in recorded CVD-related risk factors and conditions and evidence-based lipid prescribing behaviour. DESIGN: A population-based observational study of aggregated practice-level data obtained from publicly accessible data sets. SETTING: 34 practices that fall into the 15% most deprived practice populations in England were identified as the most deprived communities in the North East and North Cumbria (Deep End). PARTICIPANTS: Patients aged ≥16 registered with GP and diagnosed with any form of CVD. PRIMARY AND SECONDARY OUTCOME MEASURES: CVD-related conditions and risk factors, statin prescribing. RESULTS: Deep End (n=263 830) had a smaller, younger and more deprived population with lower levels of employment and full-time education and higher smoking prevalence. They had some higher recorded CVD-related conditions than England but lower than the non-Deep End. Atrial fibrillation (-0.9, -0.5), hypertension (-3.7, -1.3) and stroke and transient ischaemic attack rates (-0.5, -0.1) appeared to be lower in the Deep End than in the non-Deep End but the optimal statin prescribing rate was higher (3.1, 8.2) than in England. CONCLUSION: Recorded CVD-related risk factors and conditions remained comparable before and during COVID-19. These are higher in the Deep End than in England and similar or lower than the non-Deep End, with a higher optimal statin prescribing rate. However, it was not possible to control for age and sex. More work is needed to estimate the consequences of the pandemic on disadvantaged communities and to compare whether the findings are replicated in other areas of deprivation.

Observational cross-sectional study of the association of poor broadband provision with demographic and health outcomes: the Wolverhampton Digital ENablement (WODEN) programme.

OBJECTIVES: The association between impaired digital provision, access and health outcomes has not been systematically studied. The Wolverhampton Digital ENablement programme (WODEN) is a multiagency collaborative approach to determine and address digital factors that may impact on health and social care in a single deprived multiethnic health economy. The objective of this study is to determine the association between measurable broadband provision and demographic and health outcomes in a defined population. DESIGN: An observational cross-sectional whole local population-level study with cohorts defined according to broadband provision. SETTING/PARTICIPANTS: Data for all residents of the City of Wolverhampton, totalling 269 785 residents. PRIMARY OUTCOMES: Poor broadband provision is associated with variation in demographics and with increased comorbidity and urgent care needs. RESULTS: Broadband provision was measured using the Broadband Infrastructure Index (BII) in 158 City localities housing a total of 269 785 residents. Lower broadband provision as determined by BII was associated with younger age (p<0.001), white ethnic status (p<0.001), lesser deprivation as measured by Index of Multiple Deprivation (p<0.001), a higher number of health comorbidities (p<0.001) and more non-elective urgent events over 12 months (p<0.001). CONCLUSION: Local municipal and health authorities are advised to consider the variations in broadband provision within their locality and determine equal distribution both on a geographical basis but also against demographic, health and social data to determine equitable distribution as a platform for equitable access to digital resources for their residents.

Prevalence, incidence and longevity of antibodies against SARS-CoV-2 among primary healthcare providers in Belgium: a prospective cohort study with 12 months of follow-up.

OBJECTIVES: To estimate the prevalence, incidence and longevity of antibodies against SARS-CoV-2 among primary healthcare providers (PHCPs). DESIGN: Prospective cohort study with 12 months of follow-up. SETTING: Primary care in Belgium. PARTICIPANTS: Any general practitioner (GP) working in primary care in Belgium and any other PHCP from the same GP practice who physically manages (examines, tests, treats) patients were eligible. A convenience sample of 3648 eligible PHCPs from 2001 GP practices registered for this study (3044 and 604 to start in December 2020 and January 2021, respectively). 3390 PHCPs (92,9%) participated in their first testing time point (2820 and 565, respectively) and 2557 PHCPs (70,1%) in the last testing time point (December 2021). INTERVENTIONS: Participants were asked to perform a rapid serological test targeting IgM and IgG against the receptor binding domain of SARS-CoV-2 and to complete an online questionnaire at each of maximum eight testing time points. PRIMARY AND SECONDARY OUTCOME MEASURES: The prevalence, incidence and longevity of antibodies against SARS-CoV-2 both after natural infection and after vaccination. RESULTS: Among all participants, 67% were women and 77% GPs. Median age was 43 years. The seroprevalence in December 2020 (before vaccination availability) was 15.1% (95% CI 13.5% to 16.6%), increased to 84.2% (95% CI 82.9% to 85.5%) in March 2021 (after vaccination availability) and reached 93.9% (95% CI 92.9% to 94.9%) in December 2021 (during booster vaccination availability and fourth (delta variant dominant) COVID-19 wave). Among not (yet) vaccinated participants the first monthly incidence of antibodies against SARS-CoV-2 was estimated to be 2.91% (95% CI 1.80% to 4.01%). The longevity of antibodies is higher in PHCPs with self-reported COVID-19 infection. CONCLUSIONS: This study confirms that occupational health measures provided sufficient protection when managing patients. High uptake of vaccination resulted in high seroprevalence of SARS-CoV-2 antibodies in PHCPs in Belgium. Longevity of antibodies was supported by booster vaccination and virus circulation. TRIAL REGISTRATION NUMBER: NCT04779424.

Incidence of post-COVID syndrome and associated symptoms in outpatient care in Bavaria, Germany: a retrospective cohort study using routinely collected claims data.

OBJECTIVES: To estimate the treatment incidence of post-COVID syndrome (postinfectious sequelae present at least 12 weeks following infection) in the context of ambulatory care in Bavaria, Germany, and to establish whether related diagnoses occur more frequently than in patients with no known history of COVID-19. DESIGN: Retrospective cohort analysis of routinely collected claims data. SETTING: Ambulatory care in Bavaria, Germany, observed from January 2020 to March 2022 (data accessed May 2022). PARTICIPANTS: 391 990 patients with confirmed COVID-19 diagnosis, 62 659 patients with other respiratory infection and a control group of 659 579 patients with no confirmed or suspected diagnosis of COVID-19. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome is diagnosis of post-COVID syndrome documented in ambulatory care. Secondary outcomes are: chronic fatigue syndrome, psychological disorder, fatigue, mild cognitive impairment, disturbances of taste and smell, dyspnoea, pulmonary embolism and myalgia. RESULTS: Among all patients with confirmed COVID-19, 14.2% (95% CI 14.0% to 14.5%) received a diagnosis of a post-COVID syndrome, and 6.7% (95% CI 6.5% to 6.9%) received the diagnosis in at least two quarterly periods during a 2-year follow-up. Compared with patients with other respiratory infections and with controls, patients with COVID-19 more frequently received a variety of diagnoses including chronic fatigue syndrome (1.6% vs 0.6% and 0.3%, respectively), fatigue (13.3% vs 9.2% and 6.0%), dyspnoea (9.9% vs 5.1% and 3.2%) and disturbances of taste and smell (3.2% vs 1.2% and 0.5%). The treatment incidence of post-COVID syndrome was highest among adults aged 40-59 (19.0%) and lowest among children aged below 12 years (2.6%). CONCLUSIONS: Our results demonstrate a moderately high incidence of post-COVID syndrome 2 years after COVID-19 diagnosis. There is an urgent need to find efficient and effective solutions to help patients with dyspnoea, fatigue, cognitive impairment and loss of smell. Guidelines and treatment algorithms, including referral criteria, and occupational and physical therapy, require prompt and coherent implementation.

Continuous glucose monitoring metrics for earlier identification of pre-diabetes: protocol for a systematic review and meta-analysis.

INTRODUCTION: Glycaemic variability and other metrics are not well characterised in subjects without diabetes. More comprehensive sampling as obtained with continuous glucose monitoring (CGM) may improve diagnostic accuracy of the transition from health to pre-diabetes. Our goal is to investigate the glycaemic system as it shifts from health to pre-disease in adult patients without diabetes using CGM metrics. New insights may offer therapeutic promise for reversing dysglycaemia more successfully with dietary, nutritional and lifestyle change before progression occurs to pre-diabetes and diabetes. METHODS AND ANALYSIS: This systematic review will include comprehensive searches of the PubMed, Scopus, Cochrane Library and ClinicalTrials.gov databases, with restrictions set to studies published in the last 10 years in English and planned search date 10 March 2022. Reference lists of studies that meet eligibility criteria in the screening process will subsequently be screened for the potential inclusion of additional studies. We will include studies that examine CGM use and report diagnostic criteria such as fasting glucose and/or haemoglobin A1c such that we can assess correlation between CGM metrics and established diagnostic criteria and describe how CGM metrics are altered in the transition from health to pre-diabetes. The screening and data extraction will be conducted by two independent reviewers using Covidence. All included papers will also be evaluated for quality and publication bias using Cochrane Collaboration risk of bias tools. If there are two or more studies with quantitative estimates that can be combined, we will conduct a meta-analysis after assessing heterogeneity. ETHICS AND DISSEMINATION: The systematic review methodology does not require formal ethical review due to the nature of the study design. Study findings will be publicly available and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42022308222.

Reporting of data on participant ethnicity and socioeconomic status in high-impact medical journals: a targeted literature review.

OBJECTIVES: To assess the frequency of reporting of ethnicity (or 'race') and socioeconomic status (SES) indicators in high-impact journals. DESIGN: Targeted literature review. DATA SOURCES: The 10 highest ranked general medical journals using Google scholar h5 index. ELIGIBILITY CRITERIA: Inclusion criteria were, human research, reporting participant level data. Exclusion criteria were non-research article, animal/other non-human participant/subject or no participant characteristics reported. DATA EXTRACTION AND SYNTHESIS: Working backwards from 19 April 2021 in each journal, two independent reviewers selected the 10 most recent articles meeting inclusion/exclusion criteria, to create a sample of 100 articles. Data on the frequency of reporting of ethnicity (or 'race') and SES indicators were extracted and presented using descriptive statistics. RESULTS: Of 100 research articles included, 35 reported ethnicity and 13 SES. By contrast, 99 reported age, and 97 reported sex or gender. Among the articles not reporting ethnicity, only 3 (5%) highlighted this as a limitation, and only 6 (7%) where SES data were missing. Median number of articles reporting ethnicity per journal was 2.5/10 (range 0 to 9). Only two journals explicitly requested reporting of ethnicity (or race), and one requested SES. CONCLUSIONS: The majority of research published in high-impact medical journals does not include data on the ethnicity and SES of participants, and this omission is rarely acknowledged as a limitation. This situation persists despite the well-established importance of this issue and International Committee of Medical Journal Editors recommendations to include relevant demographic variables to ensure representative samples. Standardised explicit minimum standards are required.

What can the Defence Medical Services learn from the COVID-19 pandemic in order to be ready for the future?

The COVID-19 pandemic placed significant global pressure on public health, with the demand for specialist clinical input, equipment and therapeutics often outweighing supply in many well-established healthcare systems. The UK was no exception to this burden, resulting in unprecedented demands being placed on its NHS. Throughout the pandemic, the UK Defence Medical Services (DMS) aided the civilian healthcare sector, while concurrently adapting as an organisation to meet its enduring commitment in promoting the operational output of the wider UK Armed Forces. This paper serves to provide an overview of some of these key activities while offering proposed lessons which can be learnt, in order to promote the DMS' output in times of future crises. Of note, the DMS aided to mitigate surge demands placed on the NHS' supply chain, assisting in promoting its resilience to provide key materials to civilian clinical personnel. Adaptation of military policy generation mechanisms, together with adoption of novel technological approaches to promote remote working, empowered efficient DMS operational output throughout the pandemic. Direct provision of personnel to assist in the NHS' clinical output served to foster mutually beneficial interorganisational relationships, while providing objective benefit for the UK public.This paper was selected as the BMJ Military Health Royal Society of Medicine Colt Foundation National Essay Prize Winner 2021.

Smoking in social housing among adults in England, 2015-2020: a nationally representative survey.

OBJECTIVES: To analyse associations between living in social housing and smoking in England and to evaluate progress towards reducing disparities in smoking prevalence among residents of social housing compared with other housing types. DESIGN: Cross-sectional analysis of nationally representative data collected between January 2015 and February 2020. SETTING: England. PARTICIPANTS: 105 562 adults (≥16 years). PRIMARY AND SECONDARY OUTCOME MEASURES: Linear and logistic regression were used to analyse associations between living in social housing (vs other housing types) and smoking status, cigarettes per day, time to first cigarette, exposure to others' smoking, motivation to stop smoking, quit attempts and use of cessation support. Analyses were adjusted for sex, age, social grade, region and year. RESULTS: Adults living in social housing had two times the odds of being a smoker (ORadj=2.17, 95% CI 2.08 to 2.27), and the decline in smoking prevalence between 2015 and 2020 was less pronounced in this high-risk group (-7%; ORadj=0.98, 95% CI 0.96 to 1.01) than among adults living in other housing types (-24%; ORadj=0.95, 95% CI 0.94 to 0.96; housing tenure-survey year interaction p=0.020). Smokers living in social housing were more addicted than those in other housing types (smoking within 30 min of waking: ORadj=1.50, 95% CI 1.39 to 1.61), but were no less motivated to stop smoking (ORadj=1.06, 95% CI 0.96 to 1.17) and had higher odds of having made a serious attempt to quit in the past year (ORadj=1.16, 95% CI 1.07 to 1.25). Among smokers who had tried to quit, those living in social housing had higher odds of using evidence-based cessation support (ORadj=1.22, 95% CI 1.07 to 1.39) but lower odds of remaining abstinent (ORadj=0.63, 95% CI 0.52 to 0.76). CONCLUSIONS: There remain stark inequalities in smoking and quitting behaviour by housing tenure in England, with declines in prevalence stalling between 2015 and 2020 despite progress in the rest of the population. In the absence of targeted interventions to boost quitting among social housing residents, inequalities in health are likely to worsen.

Determinants of well-being and their interconnections in Australian general practitioners: a qualitative study.

OBJECTIVES: The well-being of doctors is recognised as a major priority in healthcare, yet there is little research on how general practitioners (GPs) keep well. We aimed to address this gap by applying a positive psychology lens, and exploring what determines GPs' well-being, as opposed to burnout and mental ill health, in Australia. DESIGN: Semi-structured qualitative interviews. From March to September 2021, we interviewed GPs working in numerous settings, using snowball and purposive sampling to expand recruitment across Australia. 20 GPs participated individually via Zoom. A semi-structured interview-guide provided a framework to explore well-being from a personal, organisational and systemic perspective. Recordings were transcribed verbatim, and inductive thematic analysis was performed. RESULTS: Eleven female and nine male GPs with diverse experience, from urban and rural settings were interviewed (mean 32 min). Determinants of well-being were underpinned by GPs' sense of identity. This was strongly influenced by GPs seeing themselves as a distinct but often undervalued profession working in small organisations within a broader health system. Both personal finances, and funding structures emerged as important moderators of the interconnections between these themes. Enablers of well-being were mainly identified at a personal and practice level, whereas systemic determinants were consistently seen as barriers to well-being. A complex balancing act between all determinants of well-being was evidenced. CONCLUSIONS: GPs were able to identify targets for individual and practice level interventions to improve well-being, many of which have not been evaluated. However, few systemic aspects were suggested as being able to promote well-being, but rather seen as barriers, limiting how to develop systemic interventions to enhance well-being. Finances need to be a major consideration to prioritise, promote and support GP well-being, and a sustainable primary care workforce.

Understanding how and why quality circles improve standards of practice, enhance professional development and increase psychological well-being of general practitioners: a realist synthesis.

OBJECTIVES: To understand how and why participation in quality circles (QCs) improves general practitioners' (GPs) psychological well-being and the quality of their clinical practice. To provide evidence-informed and practical guidance to maintain QCs at local and policy levels. DESIGN: A theory-driven mixed method. SETTING: Primary healthcare. METHOD: We collected data in four stages to develop and refine the programme theory of QCs: (1) coinquiry with Swiss and European expert stakeholders to develop a preliminary programme theory; (2) realist review with systematic searches in MEDLINE, Embase, PsycINFO and CINHAL (1980-2020) to inform the preliminary programme theory; (3) programme refinement through interviews with participants, facilitators, tutors and managers of QCs and (4) consolidation of theory through interviews with QC experts across Europe and examining existing theories. SOURCES OF DATA: The coinquiry comprised 4 interviews and 3 focus groups with 50 European experts. From the literature search, we included 108 papers to develop the literature-based programme theory. In stage 3, we used data from 40 participants gathered in 6 interviews and 2 focus groups to refine the programme theory. In stage 4, five interviewees from different healthcare systems consolidated our programme theory. RESULT: Requirements for successful QCs are governmental trust in GPs' abilities to deliver quality improvement, training, access to educational material and performance data, protected time and financial resources. Group dynamics strongly influence success; facilitators should ensure participants exchange knowledge and generate new concepts in a safe environment. Peer interaction promotes professional development and psychological well-being. With repetition, participants gain confidence to put their new concepts into practice. CONCLUSION: With expert facilitation, clinical review and practice opportunities, QCs can improve the quality of standard practice, enhance professional development and increase psychological well-being in the context of adequate professional and administrative support. PROSPERO REGISTRATION NUMBER: CRD42013004826.

Comparative end-of-life communication and support in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada.

OBJECTIVE: To compare end-of-life in-person family presence, patient-family communication and healthcare team-family communication encounters in hospitalised decedents before and during the COVID-19 pandemic. DESIGN: In a regional multicentre retrospective cohort study, electronic health record data were abstracted for a prepandemic group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one COVID-19 free (COVID-ve) and one with COVID-19 infection (COVID+ve). Pre-COVID and COVID-ve groups were matched 2:1 (age, sex and care service) with the COVID+ve group. SETTING: One quaternary and two tertiary adult, acute care hospitals in Ottawa, Canada. PARTICIPANTS: Decedents (n=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170). MAIN OUTCOME MEASURES: End-of-life (last 48 hours) in-person family presence and virtual (video) patient-family communication, and end-of-life (last 5 days) virtual team-family communication encounter occurrences were examined using logistic regression with ORs and 95% CIs. End-of-life (last 5 days) rates of in-person and telephone team-family communication encounters were examined using mixed-effects negative binomial models with incidence rate ratios (IRRs) and 95% CIs. RESULTS: End-of-life in-person family presence decreased progressively across pre-COVID (90.6%), COVID-ve (79.4%) and COVID+ve (47.1%) groups: adjusted ORs=0.38 (0.2-0.73) and 0.09 (0.04-0.17) for COVID-ve and COVID+ve groups, respectively. COVID-ve and COVID+ve groups had reduced in-person but increased telephone team-family communication encounters: IRRs=0.76 (0.64-0.9) and 0.61 (0.47-0.79) for in-person, and IRRs=2.6 (2.1-3.3) and 4.8 (3.7-6.1) for telephone communications, respectively. Virtual team-family communication encounters occurred in 17/85 (20%) and 10/170 (5.9%) of the COVID+ve and COVID-ve groups, respectively: adjusted OR=3.68 (1.51-8.95). CONCLUSIONS: In hospitalised COVID-19 pandemic wave 1 decedents, in-person family presence and in-person team-family communication encounters decreased at end of life, particularly in the COVID+ve group; virtual modalities were adopted for communication, and telephone use increased in team-family communication encounters. The implications of these communication changes for the patient, family and healthcare team warrant further study.