Alcohol-related liver disease mortality and missed opportunities in secondary care: A United Kingdom retrospective observational study.

INTRODUCTION: Alcohol-related liver disease (ARLD) is a preventable cause of mortality. Historical epidemiological studies on ARLD often lack a detailed linked assessment of health-related contacts prior to death which limits understanding of opportunities for intervention. We aimed to analyse retrospective population-based data of all adult residents of Nottinghamshire dying from ARLD to determine the factors associated with delayed diagnosis of ARLD and the potential missed opportunities for interventions. METHODS: We linked the Office for National Statistics and Hospital Episode Statistics databases to identify adult (≥18 years) residents of Nottinghamshire, who died of ARLD over the 5-year period (1 January 2012 to 31 December 2017). Death was used as the primary outcome, and logistic regression analysis was conducted to test the association between key variables and mortality due to ARLD. RESULTS: Over 5 years, 799 ARLD deaths were identified. More than half had no diagnosis or a diagnosis of ARLD less than 6 months before death. Emergency presentation at first ARLD diagnosis and White ethnicity were significantly associated with a delay in diagnosis. Overall, the cohort had a median of five hospital admissions, four accident and emergency attendances and 16 outpatient appointments in the 5 years before death. Treatment was provided by a range of specialities, with general medicine the most common. Alcohol was associated with most admissions. DISCUSSION AND CONCLUSIONS: This study identified deficiencies in ARLD secondary care and provides us with a powerful methodology that can be used to evaluate and improve how alcohol issues are managed and where action can be best targeted.

Exploring life with a long-term condition using asynchronous online communication.

OBJECTIVE: We describe the development and evaluation of a novel programme that uses an online patient portal system to provide medical students with early and authentic experience of patient interaction. METHODS: Focus group discussions were held with students, tutors and patients who had taken part in the first year of the programme. RESULTS: The programme provided an opportunity for early patient interaction in a safe environment. Students were able to practice communication skills learnt elsewhere in the course as well as identifying some of the different skills required for asynchronous online interactions. The approach gave opportunities to develop understanding of aspects of life with a long-term condition. CONCLUSION: Using an online patient portal system to interact with a patient enabled students to develop and apply their communication skills in a safe environment and gain a holistic view of a patient's experience. PRACTICE IMPLICATIONS: Medical students need to be equipped with the skills needed to communicate electronically with patients. Current medical curricula currently focus on more traditional models of the consultation. Further research is needed to establish best practice in this rapidly growing area.

Clinical characteristics and public health management of invasive meningococcal group W disease in the East Midlands region of England, United Kingdom, 2011 to 2013.

In England and Wales, meningococcal disease caused by group W has historically been associated with outbreaks of disease among travellers to high-risk countries. Following a large outbreak associated with travel to the Hajj in 2000, the number of cases declined and, in 2008, only 19 laboratory-confirmed cases were identified nationally. In 2013, in the East Midlands region of England, eight cases of meningococcal disease caused by this serogroup were recorded, compared with six from 2011 to 2012. To explore this further, data for all cases with a date of onset between 1 January 2011 and 31 December 2013 were collected. Data collected included geographical location, clinical presentation and outcome. Fourteen cases were identified; two died as a result of their illness and two developed long-term health problems. No commonality in terms of geographical location, shared space or activities was identified, suggesting that group W is circulating endemically with local transmission. Clinical presentation was variable. Half presented with symptoms not typical of a classical meningococcal disease, including two cases of cellulitis, which may have implications for clinicians, in terms of timely identification and treatment, and public health specialists, for offering timely antibiotic chemoprophylaxis to close contacts.

"I don't mind damaging my own body" a qualitative study of the factors that motivate smokers to quit.

BACKGROUND: Although smoking prevalence in England has declined, one in five adults smoke. Smokers are at increased risk of a number of diseases, including COPD which affects an estimated 1.5 million people in England alone. This study aimed to explore issues relating to smoking behaviour and intention to quit that might be used to inform the development of cessation interventions. Issues explored included knowledge of smoking related disease, with a particular emphasis on Chronic Obstructive Pulmonary Disease (COPD). Understanding around risk of disease, including genetic risk was explored, as were features of appropriate and accessible cessation materials and support. METHODS: Semi-structured interviews and focus groups were conducted with a total of 30 individuals of which 17 were smoking cessation clients and 13 were professionals working within health care settings relevant to supporting smokers to quit. A largely purposive approach was taken to sampling, and data were analysed using the constant comparative method. RESULTS: Knowledge of the smoking related disease COPD was limited. Smokers' concerns around risk of disease were influenced by their social context and were more focussed on how their smoking might impact on the health of their family and friends, rather than how it might impact on them as individuals. Participants felt the provision of genetic risk information may have a limited impact on motivation to quit. Genetic risk was considered to be a difficult concept to understand, particularly as increased risk does not mean an individual will definitely develop disease. In terms of cessation approaches, the use of visual media was consistently supported, as was the use of materials that linked directly with life experiences. Images of children inhaling second hand smoke for example, had a particular impact. CONCLUSIONS: Public health messages around the risks of smoking and approaches to quitting should continue to have an emphasis on the dangers that an individual's smoking has on the lives of the people around them. More work also needs to be done to raise awareness around both the risk of COPD in smokers and the impact this disease has on quality of life and life expectancy.

Collecting genetic information in primary care: evaluating a new family history tool.

BACKGROUND: The family history is a time-honoured method for identifying genetic predisposition. In specialist practice the standard approach is to draw up a family tree based on a genetic pedigree interview, but this is too time-consuming and focused on single gene disorders to be applicable in primary care. OBJECTIVES: To assess the ability of a brief self-administered Family History Questionnaire (FHQ), given to patients when they register with a GP, to identify genetic risk. METHODS: A comparative study. Informants completed an FHQ at registration, and later participated in a genetic pedigree interview. Two clinical geneticists independently scored results obtained with each instrument. Discrepancies were agreed by consensus. The genetic risks identified by the two instruments were compared. RESULTS: 326 new registrants completed the FHQ, and 121 also completed the genetic interview. 24% of FHQs and 36% of genetic interviews resulted in a score 'higher than population risk'. There was 77% agreement in the scores obtained with the two instruments, with a moderate kappa of 0.52. (95% CI 0.40-0.64). There was 90% agreement in the scores for a family history of premature coronary heart disease (Kappa 0.67; 95% CI 0.49 to 0.85). The instruments were equally effective in identifying ethnicity-related risk of common recessive disorders. CONCLUSIONS: The FHQ identified most informants with genetic risks that are appropriately addressed in primary care-those with a family history of premature coronary heart disease, those warranting specialist referral, and those who might appropriately be offered carrier testing. However, it was less effective in identifying those with a possible Mendelian disorder for whom more information was required.

GPs' perceptions of the nurse practitioner role in primary care.

The role of nurse practitioner (NP) is increasingly integrated into the primary healthcare team, yet there remains some confusion among general practitioners about what the role entails. Following on from previous work (Carr et al, 2001), this study indicates that the majority of GPs surveyed were supportive of the integration of the NP role in primary care, both to help reduce the GPs' workload and more importantly to give the patient a choice of who to consult. However, there was some difference in opinion as to what tasks were most appropriately linked to the NP role. This may be due to the GPs' lack of knowledge and experience of the role. There were also some reservations about the financial cost of training and employing NPs. If the health needs of the population are to be met and high quality, seamless care provided, the NP could provide a solution.