GP views on their role in bullying disclosure by children and young people in the community:a cross-sectional qualitative study in English primary care

Background: Bullying among children and young people (CYP) is a major public health concern which can lead to physical and mental health consequences. CYP may disclose bullying, and seek help from, their general practitioner (GP). However, there is currently little research on GPs’ views and perceptions on their role in dealing with disclosures of bullying in primary care.Aim: To explore GPs’ views about their role in dealing with disclosures of bullying by CYP, especially factors that have an impact on GPs’ roles.Design & Setting: Semi-structured interviews were conducted with GPs in primary care in England. Method: Purposive sampling was used to achieve variation in GP age, professional status in practice, profile of the patients served by the practice, practice size and location, and whether the GPs considered Conclusion: GPs feel they have a role to play in managing and supporting the health of CYP who disclose bullying during consultations. However, they feel ill equipped in dealing with these disclosures due to lack of professional development opportunities and guidance on treating and managing the health consequences of bullying

The epidemiology of injuries in epilepsy and attention deficit-hyperactivity disorder (ADHD) in children and young people using the Clinical Practice Research Datalink (CPRD) and linked data

Background Injuries are a leading cause of morbidity and mortality in children and young people (CYP) throughout the world and in the UK. Detailed estimates of the risk of specific injuries, namely fractures, thermal injuries and poisonings, are not available for CYP with specific medical conditions, such as epilepsy or attention deficit-hyperactivity disorder (ADHD) in the English primary care population. To date there has been no description of the recording of ADHD by general practitioners (GPs) in English primary care according to people’s area-level social deprivation and strategic health authority (SHA) region. Objectives 1. To define a cohort of CYP with epilepsy from the UK primary care population. 2. To estimate the risk of specific injuries, namely fractures, thermal injuries and poisonings in CYP with epilepsy compared to CYP without epilepsy. 3. To define and describe the cumulative administrative prevalence of ADHD in CYP in English primary care overall and by age, sex, SHA region, deprivation and calendar time. 4. To estimate the risk of specific injuries, namely fractures, thermal injuries and poisonings in CYP with ADHD compared to CYP without ADHD. Methods This thesis describes work conducted using a large primary care dataset (the Clinical Practice Research Datalink (CPRD)) containing GP medical records and, for a proportion, linked hospital records from the hospital episodes statistics (HES) database. Firstly, the CPRD was used to define a cohort of CYP with epilepsy and CYP without epilepsy. The GP medical records for this cohort were used to estimate the risk of fractures, thermal injuries and poisonings, in CYP with epilepsy compared to CYP without epilepsy. The rates of injuries were estimated by age and sex. For a proportion of people in this study, the effect on estimates of using linked hospital medical records in addition to the GP medical records was evaluated. Secondly, the administrative prevalence of ADHD recorded by GPs was defined for CYP in England by identifying a cohort of CYP in the CPRD with GP medical records linked to hospital medical records. The cumulative administrative prevalence of ADHD was estimated overall and by age, sex, SHA region, deprivation and calendar time. Thirdly, the GP medical records and linked hospital medical records for the cohort of CYP with ADHD was used to estimate the risk of fractures, thermal injuries and poisonings, in CYP with ADHD compared to CYP without ADHD. The rates of injuries were estimated by age, sex and deprivation. Findings CYP with epilepsy are at greater risk of fractures, thermal injuries and poisonings compared to CYP without epilepsy. In CYP with epilepsy the incidence of fractures is 18% higher, thermal injuries is 50% higher and poisonings 147% higher than in CYP without epilepsy, with the increased risk being restricted to medicinal poisonings. Among young adults with epilepsy, aged 19 to 24 years, the incidence rate of medicinal poisoning is four-fold that of the general population of the same age. Using GP medical records and linked hospital medical records may improve the ascertainment of injuries. For example, if hospital medical records are used in addition to GP medical records to ascertain femur fractures, a further 33% of fractures may be ascertained compared to using GP medical records alone. In comparison, if hospital medical records were used without GP medical records, 10% of femur fractures may not be ascertained. However, this increased ascertainment of injuries is unlikely to alter the estimates of risk of injuries in people with epilepsy when compared to people without epilepsy (e.g. risk of long bone fractures: using hospital and GP medical records, hazard ratio (HR)=1.25 (95% confidence interval (95%CI) 1.07 to 1.46) vs. using GP medical records alone, HR=1.23 (95%CI 1.10 to 1.38)). The administrative prevalence of ADHD in CYP aged 3 to 17 years old in English GP medical records is 0.88% (95% confidence interval (95%CI) 0.87 to 0.89). The prevalence of ADHD recorded by GPs is around five times greater in males than in females. The administrative prevalence of ADHD appears to increase with age, with the lowest prevalence in 3 to 4 year-olds (0.02 (95%CI 0.02 to 0.03)) and the highest prevalence in 15 to 17 year olds (1.38 (95%CI 1.36 to 1.40)). The administrative prevalence of ADHD is twice as high in CYP from the most deprived areas compared to CYP from the least deprived areas (1.14% (95%CI 1.12 to 1.16) in the most deprived areas to 0.64% (95%CI 0.63 to 0.65) in the least deprived areas)). CYP with ADHD are at greater risk of fractures, thermal injuries and poisonings compared CYP without ADHD. In CYP with ADHD the incidence of fractures is 28% higher, thermal injuries is 104% higher and poisonings is 300% higher than in CYP without ADHD. Conclusions CYP with epilepsy and ADHD have an increased risk of fracture, thermal injury and poisoning compared to CYP without these conditions. For both conditions the risk of poisoning is higher than the risk of fractures or thermal injuries. The administrative prevalence of ADHD is lower than estimates of community prevalence ascertained from studies not using primary care data. The prevalence of ADHD varied with deprivation, being almost twice as high in CYP from the most deprived areas compared to CYP from the least deprived areas. Future research is required to explore the circumstances surrounding injuries in CYP with and without epilepsy and ADHD. Future research is also required to explore the effect of treating epilepsy and ADHD with medication on injury risk. Research is required to explore the effect of the severity of epilepsy and ADHD on estimated risks of injuries. Future research exploring potential under-diagnosis or under-recording of diagnosis of ADHD in CYP in primary care is needed. CYP with epilepsy and ADHD and their parents should be provided with evidence-based injury prevention interventions because work in this thesis has demonstrated they are at higher risk of injury than the general population of CYP. Health care professionals working with CYP; child and adolescent mental health services; child education or care practitioners; and other agencies and organisations with an injury prevention role, should be made aware of the increased risk of injury in CYP with epilepsy and ADHD. Commissioners of health services for CYP should ensure service specifications include injury prevention training and provision for evidence-based injury prevention interventions

Attention-deficit/hyperactivity disorder: variation by socio-economic deprivation

Background: In England, there is a discrepancy between the prevalence of Attention-deficit/hyperactivity disorder (ADHD) ascertained from medical records and community surveys. There is also a lack of data on variation in recorded prevalence by deprivation and geographical region; information that is important for service development and commissioning. Methods: Cohort study using data from the Clinical Practice Research Datalink comprising 5,196 children and young people aged 3-17 years with ADHD and 490,016 without, in 2012. Results: In 2012, the recorded prevalence (95%CI) of ADHD was 1.06 (1.03-1.09) %. Prevalence in the most deprived areas was double that of the least deprived areas (prevalence rate ratio (PRR) 2.58 (2.36-2.83)), with a linear trend from least to most deprived areas across all regions in England. Conclusions: The low prevalence of ADHD in medical records may indicate considerable under-diagnosis. Higher rates in more disadvantaged areas indicates greater need for services in those areas

Using the plan–do–study–act (PDSA) cycle to make change in general practice

As new members of the team, GP trainees can provide a fresh perspective on practice systems. They are, therefore, ideally placed to enact change within practices. However, GP trainees may feel ill-equipped to suggest and deliver change to their practices. This article will explore the concept of change management using the plan–do–study–act cycle and consider how to initiate change by providing a structure to guide the process

GPs’ views about their role when children and young people disclose a history of bullying in the community: a qualitative study

BackgroundBullying among children and young people (CYP) can lead to both physical and mental health consequences. CYP may disclose episodes of bullying and seek help from their GP. Therefore GPs have an important role in dealing with the mental and physical health consequences of bullying. However, there is currently little research on GPs’ views and perceptions on their role in dealing with bullying.AimTo explore GPs views about their role in dealing with disclosures of bullying by CYP.MethodSemi-structured interviews were conducted with GPs in England. Purposive sampling was used to achieve variation in GP demographics. Data were collected until thematic saturation was reached and analysed using the constant comparative method.ResultsData from 14 semi-structured interviews revealed three main themes: GP experience, bullying in schools and cyberbullying, and training needs. There was an encompassing feeling that dealing with disclosures of bullying came down to a GP’s clinical experience rather than guideline recommendations, which do not currently exist; and that bullying was a precipitating factor in presentations of CYP’s mental health issues. Continuing professional development opportunities are needed. Such opportunities should include both the nature and health consequences of bullying, including cyberbullying, for which GPs felt ill prepared but which was reported to affect their practice.ConclusionGPs feel they have a role to play in managing and supporting the health of CYP who disclose bullying. However, they feel ill equipped in dealing with these disclosures. There is a need for collaboration between GPs and education services to improve support

Reasons for diagnostic delays in Bipolar Disorder:Systematic review and narrative synthesis

Background: Bipolar disorder is common, affecting 1% of people. The diagnosis of bipolar disorder is often delayed, which limits access to effective treatment and increases the burden of disease on individuals, families, and society.Aim: This paper investigates the individual, social, and clinical factors that contribute to delays in diagnosis for people with bipolar disorder, including delays that occur before and after a person presents to a primary care clinician.Design and setting: Systematic review and narrative synthesis.Method: Four electronic databases - Embase, Medline, PsychInfo, and Global Health - were systematically searched. This search yielded 3078 studies, 21 of which met the inclusion criteria. The data retrieved were analysed using Braun and Clarke’s Thematic Analysis to report a summary of recent research on the delays in the diagnosis of bipolar disorder.Results: Analysis of the data from the 21 studies identified five main themes as reasons for delays in diagnosis: (1) misdiagnosis, (2) healthcare challenges, (3) mental health stigma, (4) the complex nature of bipolar disorder, and (5) individual factors.Conclusions: The review demonstrates the importance of educating individuals, families, and clinicians on the symptomology of bipolar disorder to avoid misdiagnosis. Furthermore, changes in the accessibility and delivery of mental health services are essential to ensure that people with bipolar disorder are diagnosed and treated in a timely manner. In addition, mental health stigma among individuals, families, and clinicians must be addressed to reduce diagnostic delays

Injury among children and young people with and without attention deficit-hyperactivity disorder in the community: the risk of fractures, thermal injuries and poisonings

Background: Injuries commonly cause morbidity and mortality in children and young people (CYP). Attention deficit-hyperactivity disorder (ADHD) is the commonest neurobehavioural disorder in CYP and is associated with increased injury risk. However, large, population-based estimates of the risk of specific injuries are lacking. We aimed to provide estimates of the risk of fractures, thermal injuries and poisonings in CYP with and without ADHD. Methods: In this population-based cohort study we used primary and secondary care medical records from England from the Clinical Practice Research Datalink (CPRD). There were 15,126 CYP with ADHD frequency-matched to 263,724 without, aged 3-17 years at diagnosis. The risk of: (i) fractures (ii) thermal injuries, and (iii) poisonings in CYP with ADHD was compared to those without. Results: The absolute rate of injury per thousand person years at risk in CYP with vs. without ADHD was: fracture 28.9 (95%CI 27.5 to 30.3) vs. 18.7 (95%CI 18.5 to 19.0); long bone fracture 17.7 (95%CI 16.7 to 18.8) vs. 11.8 (95%CI 11.6 to 12.0); thermal injuries 4.4 (95%CI 3.9 to 4.9) vs. 2.2 (95%CI 2.1 to 2.3); poisonings 6.3 (95%CI 5.7 to 6.9) vs. 1.9 (95%CI 1.9 to 2.0). Adjusting for age, sex, geographical region, deprivation and calendar year, CYP with ADHD had: 25% increase in risk of fracture, (hazard ratio, HR=1.25 (95% CI 1.19 to 1.31)); 21% increase in risk of long bone fracture, (HR=1.21 (95% CI 1.13 to 1.28)); double the risk of thermal injury (HR=2.00 (95% CI 1.76 to 2.27) and almost four times the risk of poisoning (HR=3.72 (95% CI 3.32 to 4.17). Conclusions: CYP with ADHD are at greater risk of fracture, thermal injury and poisoning compared to those without. Paediatricians and healthcare professionals should provide injury prevention advice at diagnosis and reviews

A multi-centre, pragmatic, three-arm, individually randomised, non-inferiority, open trial to compare immediate orally administered, immediate topically administered or delayed orally administered antibiotics for acute otitis media with discharge in children:The Runny Ear Study (REST): study protocol

Acute otitis media (AOM) is a common painful infection in children, with around 2.8 million cases presenting to primary care in England and Wales annually. Nearly all children who present to their general practitioner (GP) with AOM or AOM with discharge (AOMd) are treated with orally administered antibiotics. These can cause side effects; contribute to the growing problem of antimicrobial resistance, and more rarely, allergic reactions. Alternative treatments, such as an antibiotic eardrops, or 'delayed' orally administered antibiotics, could be at least as effective and safe as immediate orally administered antibiotics for children with AOMd. REST is a pragmatic, three-arm, individually randomised, non-inferiority trial being conducted in 175 GP practices across the United Kingdom (UK). The study aims to recruit 399 children aged (≥ 12 months and < 16 years) presenting to their GP with AOMd. Children will be randomised to one of three arms: immediate ciprofloxacin 0.3% eardrops; delayed orally administered amoxicillin (clarithromycin if penicillin allergic) or immediate orally administered amoxicillin (clarithromycin). Recruitment, including eligibility screening, randomisation and data collection, are conducted using the innovative, TRANSFoRm electronic trial management platform. Integrated within the primary care electronic medical records it provides automatic eligibility checking, part-filling of e-CRFs, study workflow management and routine NHS follow-up data collection. The primary outcome is time to resolution of all significant symptoms and will be collected by the parent using a Symptom Recovery Questionnaire (SRQ). Secondary outcomes, including cost-effectiveness, duration of moderately bad or worse symptoms and repeat AOMd episodes, will be collected at day-14 and at 3 months. It is unclear whether prescribing orally administered antibiotics to children with AOMd results in a reduction in symptoms or a shorter duration of illness. The REST trial should allow us to compare the non-inferiority of: immediate topically administered ciprofloxacin ear drops, or delayed orally administered amoxicillin (clarithromycin) against immediate orally administered amoxicillin (clarithromycin). We aim to recruit 399 patients from 175 practices in the UK. Using the TRANSFoRm software to randomise participants to the trial will enable recruitment for a relatively uncommon condition. Name of Registry: ISCRTN Registration Number: ISRCTN12873692. This contains all items required to comply with the World Health Organization Trial Registration Data Set Date of Registration: 24 April 2018 Name of Registry: EudraCT Registration Number: 2017-003635-10 Date of Registration: 6 September 2017

The association between prescription drugs and vaccines commonly prescribed to older people and bullous pemphigoid: a UK population-based study

IntroductionBullous pemphigoid (BP) is a serious skin disease that results in large painful blisters developing over the body and occurs most commonly in older people (over 70 years). Despite several comorbidities such as stroke and a threefold increase in mortality, BP remains under-researched. The cause of BP is unclear. The auto-immune process may be triggered by medicines such as diuretics, but current evidence mainly comprises case-reports and small hospital-based studies. Electronic healthcare records from the Clinical Practice Research Datalink (CPRD) provide an opportunity to conduct a large population-based study, representative of people with BP in the UK, to assess exposure to prescribed medicines. Early identification of BP and prompt withdrawal of suspect medicines may lead to BP remission and improve long-term patient outcomes, including quality of life. We aim to determine whether medicines/vaccines, prescribed for common conditions in older people, are associated with BP in the UK population. The objectives are:i.To determine the adjusted odds ratio of developing BP per therapeutic group and class, and for multiple exposure (i.e. the use of more than one therapeutic group of medicine/vaccine during the observation period), for medicines/vaccines commonly prescribed to older people in the UK.ii.To identify which of the above are less associated with risk of BP, giving clinicians/prescribers alternative treatment options.iii.To identify additional medicines associated with BP using machine learning.iv.To identify associations between combinations of medicines prescribed to BP patients using machine learning.v.To describe patient characteristics of those at risk of BP, following medicine use, using machine learning.MethodsA UK population-based nested case-control study using the CPRD to determine associations between identified medicines/vaccines and BP. BP cases will be matched to up to 4 controls (age, sex, GP practice) using incidence density sampling. Exposure: medicines/vaccines commonly prescribed for older people; antibacterial, medicine for the cardiovascular system, stroke, diabetes, dementia, and influenza vaccination in the year leading up to diagnosis. Outcome measures: the odds of BP per therapeutic group, per class, and individual medicine; (reference=no exposure). Analysis: multivariable conditional logistic regression adjusted for a priori confounders. Confounding by indication will be considered and different exposure criteria assessed. We will undertake exploratory association rule mining to identify individual and combinations of medicines prescribed prior to BP. We will conduct unsupervised machine learning cluster analysis to identify groups of patients with demographic and clinical characteristics and their associations with prescribed medicines linked to BP.DiscussionThis study will (i) provide greater awareness of the risk of drug-associated BP amongst specialist and non-specialist healthcare professionals and therefore may facilitate earlier diagnosis of BP; (ii) support withdrawal of suspect medicines and switching to alternatives, where available, to achieve earlier remission of BP