Continuity of care and consultation mode in general practice: a cross-sectional and longitudinal study using patient-level and practice-level data from before and during the COVID-19 pandemic in England.

OBJECTIVES: Investigate trends in continuity of care with a general practitioner (GP) before and during the COVID-19 pandemic. Identify whether continuity of care is associated with consultation mode, controlling for other patient and practice characteristics. DESIGN: Retrospective cross-sectional and longitudinal observational studies. SETTING: Primary care records from 389 general practices participating in Clinical Practice Research Datalink Aurum in England. PARTICIPANTS: In the descriptive analysis, 100 000+ patients were included each month between April 2018 and April 2021. Modelling of the association between continuity of care and consultation mode focused on 153 475 and 125 298 patients in index months of February 2020 (before the pandemic) and February 2021 (during the pandemic) respectively, and 76 281 patients in both index months. PRIMARY AND SECONDARY OUTCOMES MEASURES: The primary outcome measure was the Usual Provider of Care index. Secondary outcomes included the Bice-Boxerman index and count of consultations with the most frequently seen GP. RESULTS: Continuity of care was gradually declining before the pandemic but stabilised during it. There were consistent demographic, socioeconomic and regional differences in continuity of care. An average of 23% of consultations were delivered remotely in the year to February 2020 compared with 76% in February 2021. We found little evidence consultation mode was associated with continuity at the patient level, controlling for a range of covariates. In contrast, patient characteristics and practice-level supply and demand were associated with continuity. CONCLUSIONS: We set out to examine the association of consultation mode with continuity of care but found that GP supply and patient demand were much more important. To improve continuity for patients, primary care capacity needs to increase. This requires sufficient, long-term investment in clinicians, staff, facilities and digital infrastructure. General practice also needs to transform ways of working to ensure continuity for those that need it, even in a capacity-constrained environment.

Short- and Long-Term Prediction of the Post-Pubertal Mandibular Length and Y-Axis in Females Utilizing Machine Learning.

The aim of this study was to create a novel machine learning (ML) algorithm for predicting the post-pubertal mandibular length and Y-axis in females. Cephalometric data from 176 females with Angle Class I occlusion were used to train and test seven ML algorithms. For all ML methods tested, the mean absolute errors (MAEs) for the 2-year prediction ranged from 2.78 to 5.40 mm and 0.88 to 1.48 degrees, respectively. For the 4-year prediction, MAEs of mandibular length and Y-axis ranged from 3.21 to 4.00 mm and 1.19 to 5.12 degrees, respectively. The most predictive factors for post-pubertal mandibular length were mandibular length at previous timepoints, age, sagittal positions of the maxillary and mandibular skeletal bases, mandibular plane angle, and anterior and posterior face heights. The most predictive factors for post-pubertal Y-axis were Y-axis at previous timepoints, mandibular plane angle, and sagittal positions of the maxillary and mandibular skeletal bases. ML methods were identified as capable of predicting mandibular length within 3 mm and Y-axis within 1 degree. Compared to each other, all of the ML algorithms were similarly accurate, with the exception of multilayer perceptron regressor.

Ethnic inequities in the patterns of personalized care adjustments for 'informed dissent' and 'patient unsuitable': a retrospective study using Clinical Practice Research Datalink.

BACKGROUND: In England, general practitioners voluntarily take part in the Quality and Outcomes Framework, which is a program that seeks to improve care by rewarding good practice. They can make personalized care adjustments (PCAs), e.g. if patients choose not to have the treatment/intervention offered ('informed dissent') or because they are considered to be clinically 'unsuitable'. METHODS: Using data from the Clinical Practice Research Datalink (Aurum), this study examined patterns of PCA reporting for 'informed dissent' and 'patient unsuitable', how they vary across ethnic groups and whether ethnic inequities were explained by sociodemographic factors or co-morbidities. RESULTS: The odds of having a PCA record for 'informed dissent' were lower for 7 of the 10 minoritized ethnic groups studied. Indian patients were less likely than white patients to have a PCA record for 'patient unsuitable'. The higher likelihood of reporting for 'patient unsuitable' among people from Black Caribbean, Black Other, Pakistani and other ethnic groups was explained by co-morbidities and/or area-level deprivation. CONCLUSIONS: The findings counter narratives that suggest that people from minoritized ethnic groups often refuse medical intervention/treatment. The findings also illustrate ethnic inequities in PCA reporting for 'patient unsuitable', which are linked to clinical and social complexity and should be tackled to improve health outcomes for all.

Socioeconomic gradient in mortality of working age and older adults with multiple long-term conditions in England and Ontario, Canada.

BACKGROUND: There is currently mixed evidence on the influence of long-term conditions and deprivation on mortality. We aimed to explore whether number of long-term conditions contribute to socioeconomic inequalities in mortality, whether the influence of number of conditions on mortality is consistent across socioeconomic groups and whether these associations vary by working age (18-64 years) and older adults (65 + years). We provide a cross-jurisdiction comparison between England and Ontario, by replicating the analysis using comparable representative datasets. METHODS: Participants were randomly selected from Clinical Practice Research Datalink in England and health administrative data in Ontario. They were followed from 1 January 2015 to 31 December 2019 or death or deregistration. Number of conditions was counted at baseline. Deprivation was measured according to the participant's area of residence. Cox regression models were used to estimate hazards of mortality by number of conditions, deprivation and their interaction, with adjustment for age and sex and stratified between working age and older adults in England (N = 599,487) and Ontario (N = 594,546). FINDINGS: There is a deprivation gradient in mortality between those living in the most deprived areas compared to the least deprived areas in England and Ontario. Number of conditions at baseline was associated with increasing mortality. The association was stronger in working age compared with older adults respectively in England (HR = 1.60, 95% CI 1.56,1.64 and HR = 1.26, 95% CI 1.25,1.27) and Ontario (HR = 1.69, 95% CI 1.66,1.72 and HR = 1.39, 95% CI 1.38,1.40). Number of conditions moderated the socioeconomic gradient in mortality: a shallower gradient was seen for persons with more long-term conditions. CONCLUSIONS: Number of conditions contributes to higher mortality rate and socioeconomic inequalities in mortality in England and Ontario. Current health care systems are fragmented and do not compensate for socioeconomic disadvantages, contributing to poor outcomes particularly for those managing multiple long-term conditions. Further work should identify how health systems can better support patients and clinicians who are working to prevent the development and improve the management of multiple long-term conditions, especially for individuals living in socioeconomically deprived areas.

Associations between multiple long-term conditions and mortality in diverse ethnic groups.

BACKGROUND: Multiple conditions are more prevalent in some minoritised ethnic groups and are associated with higher mortality rate but studies examining differential mortality once conditions are established is US-based. Our study tested whether the association between multiple conditions and mortality varies across ethnic groups in England. METHODS AND FINDINGS: A random sample of primary care patients from Clinical Practice Research Datalink (CPRD) was followed from 1st January 2015 until 31st December 2019. Ethnicity, usually self-ascribed, was obtained from primary care records if present or from hospital records. Long-term conditions were counted from a list of 32 that have previously been associated with greater primary care, hospital admissions, or mortality risk. Cox regression models were used to estimate mortality by count of conditions, ethnicity and their interaction, with adjustment for age and sex for 532,059 patients with complete data. During five years of follow-up, 5.9% of patients died. Each additional condition at baseline was associated with increased mortality. The direction of the interaction of number of conditions with ethnicity showed a statistically higher mortality rate associated with long-term conditions in Pakistani, Black African, Black Caribbean and Other Black ethnic groups. In ethnicity-stratified models, the mortality rate per additional condition at age 50 was 1.33 (95% CI 1.31,1.35) for White ethnicity, 1.43 (95% CI 1.26,1.61) for Black Caribbean ethnicity and 1.78 (95% CI 1.41,2.24) for Other Black ethnicity. CONCLUSIONS: The higher mortality rate associated with having multiple conditions is greater in minoritised compared with White ethnic groups. Research is now needed to identify factors that contribute to these inequalities. Within the health care setting, there may be opportunities to target clinical and self-management support for people with multiple conditions from minoritised ethnic groups.

Three-dimensional analysis of the posttreatment displacements of mandibular anterior teeth with rigid and flexible lingual retainers.

INTRODUCTION: The purpose of this study was to analyze any posttreatment changes in the positions of mandibular anterior teeth retained by 2 different fixed retention methods (rigid or flexible) and their effectiveness in minimizing postorthodontic tooth movement. METHODS: Thirty patients were selected for inclusion in this retrospective study. Group I consisted of 15 patients with 0.032-in stainless steel rigid retainers bonded to canines only. Group II consisted of 15 patients with 0.0215-in twisted stainless steel flexible retainer bonded to all mandibular anterior teeth. Geomagic Control (3DS Systems, Rock Hill, SC) software was used to quantify the changes between selected points. Paired t test was used for intragroup comparisons in all 3 coordinates, and an independent-sample t test was used for intergroup comparison. RESULTS: In the transverse dimension, significant intergroup differences were found in displacements of distoincisal points of the right lateral (P <0.05) and left central incisors (P <0.01). In the sagittal dimension, significant intergroup differences were found in the displacements of mesioincisal point of the right central incisor (P <0.05) and distoincisal point of the left central incisor (P <0.01). Examining total displacement, there were significant intergroup differences in mesioincisal point on the right central incisor, distoincisal point on the left lateral incisor (P <0.05). CONCLUSIONS: Our results suggested that central incisor contacts were more likely to shift with the rigid retainers, especially in sagittal and transverse dimensions. However, no statistically or clinically significant changes were noted in the third-order or vertical positions of the teeth with either retention method.

Simultaneous depletion of serotonin and catecholamines impairs sustained attention in healthy female subjects without affecting learning and memory.

Monoamine neurotransmitters, serotonin, noradrenaline and dopamine modulate many important cognitive processes such as attention, learning and memory. While the selective effects of serotonin and catecholamine depletion on such processes have been investigated, the effects of simultaneous depletion of these monoamines on cognition remain unclear. This is of particular interest given that multiple neurotransmitter abnormalities have been implicated in many psychiatric disorders. The aim of the current study was to examine the effects of lowered brain monoamine function on cognitive performance, using the technique of amino acid precursor depletion. The study was a double-blind, placebo-controlled design in which 20 healthy female subjects were tested under a combined monoamine depletion condition (CMD) and a balanced control condition (B). Cognitive testing was conducted at baseline and 5 h post-depletion. The CMD condition relative to the B condition resulted in deficits in digit vigilance (accuracy and reaction time), a measure of sustained attention. There were no effects on measures of learning and memory or psychomotor function. These findings suggest that simultaneously depleting the availability of brain serotonin and catecholamines in healthy female subjects selectively impairs sustained attention, without affecting other cognitive domains.

Simultaneous depletion of tryptophan, tyrosine and phenylalanine as an experimental method to probe brain monoamine function in humans.

Brain monoamines are important regulators of affective and cognitive processes and are involved in the aetiology of a number of psychiatric disorders. While methods to probe serotonin and catecholamine function are established, limited methods are available to probe monoamine function as a whole in humans. In the current study, we examined if simultaneous depletion of monoamine precursors can be used as a possible probe of monoamine function. Ten healthy subjects were tested under two treatment conditions; balanced control (B) condition and combined monoamine depletion (CMD) condition. Monoamine precursor depletion was associated with significant reductions in plasma-free tryptophan (46%), tyrosine (74%) and phenylalanine (78%). Greater reductions were achieved for ratios of each precursor to other large neutral amino acids (LNAA); tryptophan/LNAA (86%), tyrosine/LNAA (94%) and phenylalanine/LNAA (94%). Findings suggest that simultaneous depletion of monoamine precursors can achieve significant plasma monoamine depletion in the range expected to affect brain monoamine function.

Selective effects of simultaneous monoamine depletion on mood and emotional responsiveness.

Monoamines play a significant role in the regulation of mood and emotion. While the selective effects of serotonin and catecholamine depletion on mood have been described, the effects of simultaneous monoamine depletion on subjective measures of mood and emotional responsiveness are yet to be examined. The current study aimed to investigate the effects of simultaneous monoamine depletion on mood and emotional responsiveness in healthy participants. Twenty female participants completed a randomized, double-blind, placebo-controlled study, under a balanced control condition (B), and a combined monoamine depletion condition (CMD; via tryptophan, tyrosine and phenylalanine depletion). Mood ratings Visual Analogue Mood Scale (VAMS) and Profile Of Mood States (POMS) and measures of emotional responsiveness (Emotional Stroop and International Affective Picture System) were examined at baseline and 5 h post-depletion. Following CMD, participants rated themselves as feeling sadder, more antagonistic, and mentally slower on three VAMS subscales. There were no significant mood changes found on the POMS or measures of emotional responsiveness. These findings suggest that simultaneous depletion of all monoamines may have selective effects on mood. The findings provide evidence that the simultaneous monoamine depletion technique may be a useful experimental method to probe central monoamine function in humans.

Proceso de Prioridades para Clasificación de Proyectos Agropecuarios

Priorización de la selección y administración de proyectos orientados al desarrollo agropecuario (Asesoramiento - FDTA Trópico Humedo)

Reingeniería, Fortalecimiento y Planificación Estratégica

Planeamiento estratégico propuesto para enfocar la orientación y el curso de las actividades propias de la Cámara Agropecuaria del Oriente (Asesoramiento - CAO)