Long-term Conditions Research Articles

Long-term rice cultivation enhances root development and yields by improving the structural properties of soil aggregates in saline–alkaline environments

Rice cultivation has the ability to improve saline soils. However, the effects of long-term rice cultivation on saline soil chemistry, salt ions, root characteristics, and aggregate formation remain unclear. In this study, the impact of different planting durations (1, 3, 5, 8, and 10 years) on the spatial and temporal transport of soil salts, soil chemical properties, distribution and stability of aggregates, root characteristics, and yields, were assessed. Long-term rice cultivation reduced soil pH, exchangeable sodium percentage (ESP), and EC in the 0-60cm soil layer compared to 1Y (5.45%, 61.57%, and 81.87% reduction in topsoil (0-20cm) and 8.54%, 72.82%, and 71.94 in subsoil (20-60cm), respectively). However, the soil organic matter (OM), alkaline nitrogen (AN), phosphorus (AP), and potassium (AK) increased (217.09%, 90.18%, 89.23%, and 179.18% increase in topsoil and 223.72%, 81.24%, 174.28%, and 172.57% increase in subsoil, respectively). Additionally, the Cl-, K+, and Na+ in the soil gradually leached downward with the increase in the duration of rice cultivation (55.87%、36.08%、59.80%). Simultaneously, the increased duration markedly elevated the soil macroaggregate content (11.43%-20.04% by dry-sieving and 53.48%-288.09% by wet-sieving), clayey grain content (59.17%-198.33%), and soil aggregate stability, especially for 8Y and 10Y. The improved soil structure and root characteristic under long-term rice cultivation conditions increased the yield (28.89-54.81%). Partial least squares path model displayed that rice cultivation affected the aggregate stability, root characteristics, and rice yield via the corresponding chemical properties (pH, EC, and ESP), nutrient contents (AN, AP, AK, and SOM), and salt ion contents (Cl-, K+, and Na+). These findings are critical to understanding aggregate formation in saline soils.

Multimorbidity patterns in adults admitted to hospital with heart failure: an analysis of 175 million hospitalisation episodes

Abstract Background The prevalence of heart failure (HF) is increasing as a result of population ageing, improved survival following myocardial infarction and the widespread uptake of evidence-based HF treatments. Greater understanding of multimorbidity patterns in patients with HF may enable the development of treatment strategies that target multiple, related long-term conditions (LTCs), producing synergistic benefits. Purpose To characterise multimorbidity patterns in patients with HF and compare these to a matched population without HF. Methods A retrospective matched cohort study was conducted using the United States National Readmission Database (NRD), 2010–2020. International Classification of Disease (ICD) codes were used to identify HF and 92 other common LTCs. The most frequent combinations of LTCs were identified for individuals with HF and a control cohort of individuals of the same age and sex, with a non-HF-related hospital admission in the same year (matched in a 1:5 ratio). Multivariable regression analysis (adjusted for age, sex, socioeconomic status, tobacco use, year of hospitalisation, and hospital characteristics) was used to evaluate the association between multimorbidity burden, length of stay (LOS; negative binomial regression) and 30-day readmission (logistic regression). Results From a total of 175,388,410 hospitalisation episodes, 3,913,924 individuals with an HF-related hospitalisation were identified and matched to 19,552,954 controls (Figure 1a). The median (interquartile range, IQR) age of a patient admitted with HF was 74 (63–85) years; 1,856,268 (47.5%) were female. The most common comorbidities in those with HF were hypertension (87.2 vs. 72.8% in matched controls), chronic kidney disease (CKD; 55.3 vs. 34.6%), coronary artery disease (CAD; 53.7 vs. 31.0%), dyslipidaemia (46.9 vs. 39.7%), diabetes (46.6 vs. 33.9%), atrial fibrillation (AF; 43.0 vs. 23.0%) and anaemia (33.2 vs. 30.1%; p all < 0.001). Patients with HF had a greater number of LTCs compared with matched controls (median [IQR] 7 [5–9] vs. 6 [4–8]; p < 0.001). From 2010–2020, the number of LTCs in those with an HF admission increased (from 6 [4–8] in 2020, to 8 [6–10] in 2020; Figure 1b). The most common multimorbidity patterns in those with HF are presented in Figure 2. In the HF cohort, a greater multimorbidity burden was associated with a longer LOS (+6% for each additional LTC; 95% confidence interval [CI] 5–7%; p<0.001) and greater risk of 30-day readmission (adjusted odds ratio [aOR] for 6 vs. 0 LTCs: 1.15, 95% CI 1.08–1.22; aOR for ≥12 vs. 0 LTCs: 1.54, 95% CI 1.45–1.64). Conclusions Patients admitted to hospital with HF have a significant burden of multimorbidity, which has increased over time and is associated with increased length of stay and unplanned hospital re-admission. The high prevalence of multiple LTCs warrants the development of novel treatment strategies that target common multimorbidity patterns observed in HF.

Achieving integrated care through clusters of co-occurring diseases for people with multimorbidity

Abstract Background People with multimorbidity are often seen in many different specialist health services, resulting in fragmented care. Conventional services are designed around specialties based on anatomical systems, rather than diseases that occur together. We examined whether organising services around clusters of co-occurring diseases would lead to fewer interactions with unique services and so improve integrated care. Methods We used the Clinical Practice Research Datalink, a nationally representative sample of primary care data in England, including all patients registered on 1st January 2015 with multimorbidity (two or more of 212 long-term conditions (LTCs)). We used the assignment of 212 LTCs to 15 clusters of co-occurring diseases, derived from our earlier work. For each patient, we calculated the number of interactions with different specialists, under both the existing specialty-based model, and the hypothetical cluster-based model, under the assumption that a patient required review for each LTC. Results Of 6,200,973 patients with multimorbidity, the mean age was 53 years, with a median (interquartile range) of 8 (5 - 11) LTCs per person. There was considerable variation in the assignment of diseases comparing 15 clusters versus 15 specialties. Under the existing model, 409,708 (6.6%) patients interacted with only one specialty, and under the hypothetical cluster model, 584,446 (9.4%) patients interacted with only one cluster. On average, patients interacted with 3.66 specialties versus 3.30 hypothetical clusters (p < 0.001 for difference). Conclusions Health services designed around clusters of co-occurring diseases might lead patients to interact with fewer different services and so experience less fragmented care. Further work is needed to understand which specialties collaborating, and how, would have the greatest impact on improving integrated care. Key messages • Health services designed around clusters of co-occurring diseases led to a small reduction in the number of interactions with different services per year. • Designing services around clusters of co-occurring diseases might reduce fragmented care for people with multimorbidity.

Associations between general practice and outpatient care continuity in people with multimorbidity

Abstract Background Relational continuity in primary and secondary care is linked to better health outcomes for patients, but it is unclear whether metrics of continuity in each setting are associated. Our study examined the association between relational continuity in general practice (GP) and continuity of hospital outpatient specialties in people with clusters of multimorbidity. Methods We used GP records from the Clinical Practice Research Datalink, linked to Hospital Episode Statistics outpatient records. Included were patients ≥18 years, with two or more of 212 Long-Term Conditions (LTCs), registered throughout 2019 and with at least three GP and three outpatient appointments. The Continuity of Care Index (COCI) was calculated separately for visits to the same i) GP and ii) hospital specialty, where 0 represents no continuity and 1 represents all visits to the same GP or specialty. We assessed the association between the indices using univariable and multivariable fractional logit regression. We calculated expected COCI scores for each LTC and assessed variation in the COCI between LTCs assigned to one of 15 clusters of co-occurring diseases derived previously. A sensitivity analysis repeated analysis using the Sequential Continuity (SECON) score, which captures longitudinal continuity. Results Of 1,135,903 patients, 56.2% were ≥60 years. The median (IQR) COCI in GP was 0.22 (0.11-0.40) and in outpatients was 0.33 (0.20-0.52). Although statistically significant (p < 0.001) the relationship between the two measures was clinically insignificant in both univariable and multivariable models. No strong relationships were found between COCI scores and LTC clusters. Similar patterns were found using the SECON score. Conclusions We found no strong association between continuity of care in GP and outpatient settings, and no clear patterns with LTC clusters. This suggests that lack of continuity in secondary care is not compensated for by increased continuity of care in primary care. Key messages • We found no meaningful association between measures of continuity of care in general practice and hospital outpatient settings. • Our findings suggest that lack of continuity of outpatient care is not compensated for by increased continuity in primary care.

Systematic review and meta-analysis on the effects of physical activity-based interventions on frailty status and clinical outcomes in adults with long-term cardiac conditions

Abstract Introduction Frailty is common in patients with long-term cardiac conditions and is associated with poor clinical outcomes, but limited treatment options are available. Previous studies investigating interventions for frailty have shown positive results with physical activity interventions, however, these studies were largely based on general elderly populations. Aim To assess the impact of physical activity-based interventions on frailty and clinical outcomes in frail patients with long-term cardiac conditions. Methods A systematic review and meta-analysis was conducted based on the PRISMA guideline, using Medline, Embase, CENTRAL, PEDro, CINAHL electronic databases for articles published between 2000 and 2023. Studies which recruited adults >18 years with long-term cardiac conditions (including angina, acute coronary syndrome (ACS), valve disease, heart failure (HF), atrial fibrillation, cardiac surgery and congenital heart disease) who underwent physical activity-based interventions were included. The primary outcome was change in frailty (measured using a validated tool) post intervention. We also assessed the effect of interventions on mortality and hospitalisation. Results We screened 2697 records and reviewed 91 full-text articles; 12 studies (14 articles) were included, involving 1394 patients. Median age of participants ranged from 64 to 82 years. Five studies recruited participants with HF, 3 evaluated participants post transaortic valve implantation, 3 recruited cardiac surgical patients and 1 study evaluated participants post ACS. Physical activity-based interventions were multi-domain, including a mixture of aerobic, strength, balance, endurance and respiratory muscle training; the majority (N=10) had individualised exercise prescription. Meta-analysis of 8 randomised controlled trials (RCTs) showed statistically significant improvement in frailty associated with physical activity-based interventions compared to controls [pooled standardised mean difference (95% CI) = -0.34 (-0.59 to -0.08), p = 0.01, I2 = 48%]. Seven RCTs evaluated change in frailty by short physical performance battery (SPPB). Meta-analysis of these studies showed a statistically significant improvement in SPPB associated with physical activity-based interventions compared to controls [pooled mean difference (95% CI) = 0.83 (0.31-1.34), p = 0.002, I2 = 49%]. (Figure) The magnitude of improvement in SPPB exceeded the minimally clinically significant improvement of 0.5. Three studies evaluated the effect of physical activity-based intervention on clinical outcomes, all of which showed neutral effect on mortality and hospitalisation. Conclusion Physical activity-based interventions in patients with frailty and long-term cardiac conditions were associated with significant improvement in frailty status, with neutral effect on mortality and hospitalisation. Figure: Meta-analysis of 7 RCTs assessing effect of physical activity-based interventions on SPPB

Using English General Practice Patient Survey data to explore Long Covid prevalence

Abstract Background High global burden of Long Covid (LC) has significant implications for population wellbeing, health/social care and the economy. We aimed to assess prevalence of LC, the level of uncertainty general practice (GP) patients felt about whether they were experiencing it and patient characteristics associated with LC. Methods This is a secondary data analysis of GP Patient Survey 2023 data (759,149 participants aged 16+yrs in England). The outcomes included self-reported LC, and being unsure about having LC. Identity and socioeconomic characteristics were explored in relation to these outcomes using univariable and multivariable regression analyses. Results 4.8% of respondents described themselves as having LC, and 9.1% were unsure whether they had it. Patient age (highest odds at 35-54 years), sex (females more than males), ethnicity (highest odds in Gypsy or Irish Traveller), sexual orientation (increased odds in gay or lesbian or bisexual compared to heterosexual), religion, smoking, carer status, parental status, having a long-term condition, and area-level index of multiple deprivation (higher odds in more deprived areas) were all significantly associated with reporting having LC in the multivariable model compared to answering that question with ‘no’. Generally, similar patterns of association to the above were observed in those who answered the Long Covid question with ‘unsure’ compared to those answering ‘no’, except for parental status and sexual orientation which were not significantly associated with the outcome in the multivariable model. Conclusions This study quantitatively highlights the high levels of uncertainty among primary care patients around experiencing LC, and the unequal distribution of LC burden among population groups. Our findings underline the need for better public health and primary care messaging to raise awareness around LC and ensure that those needing support can access services, particularly those already disadvantaged in society. Key messages • There are high levels of uncertainty about having Long Covid among people attending primary care services. • There is unequal burden of Long Covid in England underlining the need for improved awareness and access to support, particularly for minoritised groups.

Management and outcomes of acute myocardial infarction in patients with Alzheimer's disease: a study of 2.7 million individuals with myocardial infarction, 2010 - 2020

Abstract Background As a consequence of population ageing, the prevalence of Alzheimer’s Disease (AD) is rising. Evidence-based clinical decision-making for those with AD that present with acute myocardial infarction (MI) is limited by difficulty in identifying which patients will benefit from guideline-directed invasive management versus a more conservative approach. Purpose This study aimed to assess the prevalence of AD in patients presenting with acute MI and characterise its association with patient factors, treatment utilisation and clinical outcomes. Methods A retrospective cohort study was conducted using the United States National Readmission Database (NRD), 2010–2020. International Classification of Disease (ICD; version 9 and 10, Clinical Modification) codes were used to identify patients with a principal diagnosis of MI, pre-existing AD and other comorbidities, in addition to invasive procedures (invasive coronary angiography ± percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG] surgery). Logistic and flexible parametric survival models (adjusted for age, sex, MI subtype, smoking status, comorbidities, and MI treatments) were used to evaluate the association between AD and in-hospital and 1-year clinical outcomes, respectively. Results Overall, 2,750,798 individuals were admitted with MI during the study period, of which 35,367 had Alzheimer’s disease; 1.3%; Figure 1). Patients with AD were older (median age 85 vs. 67), more likely to be female (57.6 vs. 37.9%), present with non-ST-elevation MI (77.7 vs. 69.5%), and had a greater burden of individual comorbidities (including chronic kidney disease and depression) and multimorbidity (≥2 long-term conditions; 77.4 vs. 71.0%). Patients with AD were less likely to undergo invasive management (coronary angiography ± PCI/CABG; 27.7 vs 77.6%; p < 0.001; adjusted odds ratio [aOR] 0.24, 95% confidence intervals [CI] 0.23–0.25). Patients with AD had greater mortality both in-hospital (11.9 vs. 5.2%; aOR 1.30 (95% CI: 1.26–1.35, p < 0.001) and 1-year (15.9 vs. 7.3%; adjusted hazard ratio [aHR] 1.21; 95% CI 1.18–1.25). AD was associated with a greater risk of major adverse cardiovascular events (MACE; myocardial infarction, stroke or all-cause mortality; 27.8 vs. 17.7%; aHR 1.10, 95% CI 1.08–1.12) at 1-year post-MI (figure 2). However, patients with AD that were selected to undergo invasive management experienced reduced MACE (aHR 0.74, 95% CI 0.70–0.77) and all-cause mortality (aHR 0.53, 95% CI 0.49–0.57) in comparison to those managed conservatively. Conclusions Patients with Alzheimer’s Disease presenting with acute MI face a poor prognosis marked by a high rate of MACE and all-cause mortality. Future research should seek to identify those who benefit most from invasive management. At present, individualised, shared and multidisciplinary decision-making is key to guide the management of patients with AD that present with acute MI.

Real-world effectiveness of primary care psychological therapy for depression and anxiety in patients with coronary heart disease

Abstract Background Depression and anxiety are often inadequately treated in patients with coronary heart disease (CHD), despite mental health issues being associated with poorer quality of life, higher cardiovascular morbidity, and higher mortality. Talking therapies, such as cognitive behavioural therapy, are the recommended first-line treatment for depression and anxiety symptoms in CHD patients. However, the evidence for their effectiveness was considered low in a recent Cochrane review, and trial participants may not represent patients treated in routine clinical settings. Purpose To assess the effectiveness of routinely-delivered talking therapies in patients with CHD from nationwide primary care talking therapy services in England, and to compare their treatment outcomes to patients without a CHD diagnosis. Methods Healthcare records from 1.9 million patients who completed a course of treatment (≥2 treatment sessions) via NHS Talking Therapies for anxiety and depression (NHS TTad) between 2012-2019 were linked to Hospital Episode Statistics, the Mental Health Services Data Set, and death records. Standard NHS TTad outcome indicators (recovery, reliable improvement, and reliable deterioration) were examined in three groups, with (1) any CHD (n=41,317; ICD-10=I20-I25), (2) acute coronary syndromes (ACS, n=29,991; I21, I22, I20.0), and (3) chronic CHD (n=40,524; I20.1-I20.9, I23-I25) at baseline. Effect sizes for pre-post treatment changes in depression and anxiety symptom measures (PHQ-9 and GAD-7) were calculated using the adapted Cohen’s d for within-subjects design (dav). Outcomes were also compared to those of propensity-score matched control groups without the relevant diagnoses, using logistic regression. Results After completing a course of talking therapy, 49.8% (95%CI=49.3;50.3) of patients with CHD recovered from depression or anxiety, 69.4% (95%CI=69.0;69.9) saw reliable improvement in symptoms, and 7.3% (95%CI=7.0;7.5) experienced reliable deterioration in symptoms. There were large reductions in both depression (dav=-1.02) and anxiety symptoms (dav=-1.03) on average. Compared to a control sample of patients with no diagnosis of CHD, those with a CHD diagnosis were less likely to recover (OR=0.87[95%CI=0.84;0.89]) or reliably improve (OR=0.84[95%CI=0.81;0.87]) and more likely to reliably deteriorate (OR=1.28[95%CI=1.21;1.36]), when matched on age, sex, ethnicity, deprivation, baseline depression and anxiety symptom scores, self-reported long-term health condition, and waiting times between referral, assessment, and treatment. The findings were consistent for patients with ACS and those with chronic CHD. Conclusions Nearly half of CHD patients who received primary care talking therapy recovered, in line with the UK Government target of 50% recovery for the services. Nevertheless, compared to otherwise similar patients without CHD, those with CHD at baseline had worse psychological treatment outcomes.

Educational achievement and health during adolescence in second generation immigrants in Sweden

Abstract Background Over the last decades, immigration have increased markedly in Sweden. Educational achievement is essential for successful integration; however, second generation immigrants have been shown to lag behind. There is a complex intertwinement between educational attainment and health outcomes. Thus, schooling is crucial in terms of integration but also from a public health perspective. We aim to compare school performance and health in children of immigrant parents and children of parents born in Sweden. Methods In this population-based cohort study, 1723 children were followed from birth to age 20. Of these 246 (14.3%) had at least one parent born abroad. Logistic regression was performed controlling for gender, language spoken at home and sociodemographic data obtained at 3 months, 3-, 12- and 20 years. Outcome measures were school performance at age 12 (n = 984), grades from compulsory and upper secondary school (n = 1668) and register data on psychiatric diagnoses (n = 737). Self-response questionnaires on general health, long term health problems and psychiatric conditions were administered at age 20 (n = 731). Results There were no differences in reading (p = 0.676) or mathematics (p = 0.324) at age 12, eligibility to upper secondary school (p = 0.298) or university (p = 0.232) between second generation immigrants and children of native-born parents. No differences in frequency of psychiatric diagnoses (p = 0.112), presence of long-term health problems (p = 0.267) or self-reported health (p = 0.595) were shown. Conclusions The results indicate that young adults born in Sweden in the middle of the 1990’s with immigrant parents perform similarly in school compared to children of parents born in Sweden. They are not at increased risk for mental illness, long-term health conditions and report their general health equivalently to children of native-born. The comprehensive school system and child health programs used in Sweden are likely important factors to promote education and health. Key messages • In a birth-cohort of children followed into early adulthood, no difference in educational achievement or health was shown between second generation immigrants and children of parents born in Sweden. • International comparative studies are needed to highlight the importance of underlying structural and socio-cultural factors.

Patient referral pathways to leisure providers: impacts on physical activity and falls risk

Abstract Background Physical activity aids prevention and management of noncommunicable diseases. Yet many UK adults, particularly those with long-term health conditions, do not meet recommended activity levels. In 2021, West Suffolk Foundation Trust commissioned local leisure provider Abbeycroft to offer 24 week tailored physical activity programs as part of respiratory and frailty patient pathways. Objectives Evaluation of activity and outcome data for all 1670 individuals referred between January - December 2023 to determine future commissioning decisions. Results 256 participants had completed a 24 week pathway by the time of analysis. Compared to baseline, they demonstrated statistically significant (p < 0.05) self-reported improvements on the Short Warwick Edinburgh Mental Well-being Scale (median 25 to 27) amongst 68.9% of participants; and on the self-reported International Physical Activity Questionnaire 62.1% reduced time spent sitting (average 436 to 300 minutes/ week), 75% increased metabolically active minutes (average 955 to 2632 minutes/week) and the proportion of participants with a low (inactive) score decreased by 61%. Of 40 frailty patients, 87.5% lowered their self-reported Short Falls Efficacy Scale Score (14.6 to 10.4) and observed Timed Get up and Go (13.55 to 9.53 seconds), indicative of moving from a higher risk to lower falls risk (p < 0.05). 24 week retention exceeded 80% for all ages except 16-20 years. 17.8% of participants were >75 years. Lessons Both pathways have been recommissioned and new tailored pathways for Parkinson’s disease, COPD and cancer are planned. This partnership working is a sustainable, integrated way to embed prevention in the community but needs time to build relationships and streamline data sharing. Key messages • Hospital and community referral pathways to leisure providers significantly improve patient well-being, physical activity and falls risk. • These pathways are affordable, adaptable across conditions and show high retention.

Project Health Resilience: a health literacy programme for 16–19-year-olds delivered by doctors

Abstract Background Project Health Resilience is an education-setting based health literacy pilot for Londoners aged 16-19. This is a transitional age when young people independently engage with health services. Greater health literacy levels improve use of preventive services, successful management of long-term health conditions and reduce emergency service use. Research during the COVID pandemic also demonstrated the importance of building trust with health professionals to reduce health inequalities. The impact of poor health literacy is observed universally. This intervention was developed to empower young people at a critical time. Methods 3 bespoke modules (healthcare access; medical emergencies; mental health resilience) were co-produced with young people and delivered by doctors. During 2023, 46 sessions were carried out with 712 attendances across 8 London settings. A mixed-methods approach, including questionnaires and interviews, was used for the evaluation. The study explored whether taking part resulted in increased awareness of services, knowledge, confidence and trust in health professionals. Results Participants reported that topics filled a crucial gap in their learning. Awareness and confidence increased for: awareness of different health services (increase of 18%) and mental health services (38%), confidence calling emergency services (13%), confidence dealing with medical (34%) or mental health emergencies (40%). Knowledge questions answered correctly increased across the 3 modules (46% pre vs 60% post). Trust levels increased and findings suggest that doctors delivering sessions was a key component. Conclusions Findings add to the evidence base around education-setting based health interventions improving health literacy. Providing a unique opportunity for adolescents to engage with health professionals can increase trust levels. Doctors delivering health education at this critical age is a pioneering model which can be replicated in other settings. Key messages • Health literacy education is particularly impactful at this critical age of transition; this can contribute to reducing health inequities across the life course. • Trust, collaboration, and co-production were core principles upon which this pilot thrived. Without input from young people, it is difficult to design appropriate and impactful interventions.

Investigating the patterns of air pollution exposure on major cardiovascular events by cluster analysis. Insights from the EP-PARTICLES study on a Polish smog cohort

Abstract Introduction Exposure to air pollution (AP) is a modifiable risk factor for cardiovascular diseases. Aim To analyse the short-term effects of AP on the occurrence of acute coronary syndromes (ACS). Methods The EP-PARTICLES study consists of a retrospective nationwide cohort of Eastern Poland residents (N= 8,077,671). The area is characterized by a specific type of pollution - Polish smog, featuring high concentrations of particulate matter (PM), benzo(a)pyrenes (BaP) and favourable atmospheric conditions of formation. Medical data were collected from the National Health Fund and the Central Statistical Office. The records included sex and age and the causes of hospitalization. The analysis utilized air quality modeling data from the GEM-AQ system, which allowed to provide daily pollution concentration at the level of each LAU (ie. local administrative units, at municipality level), throughout the observation period. We estimated LAU specific associations of AP concentration using quasi-Poisson generalized additive models. We controlled our models for long-term trends and weather conditions. In the second stage, we pooled LAU-specific estimates with a random-effects meta-analysis. The results are presented as % risk ratio (RR), and 95% confidence intervals (95% CIs) for the two-day moving average of AP concentration on the present day and the day after exposure (ie. LAG0-1). Cluster analysis was performed on LAU levels from 19 variables using the k-mens clustering using the Ward minimum variance method. The set of variables included demographic, ecological, socioeconomic, environmental conditions. Results Over the years 2011-20, we noted 2,141,213 hospitalizations due to CVD, including 139,697 ACS cases (45.2% STEMI). The main triggers for ACS were PM2.5 (RRLAG0-1 1.04 95%CI 1.028-1.053), BaP (RRLAG0-1 1.021 95%CI 1.01-1.032). We identified three distinct clusters: Cluster 1 was characterized by high population density and GPD per capita and highest prevalence of atrial fibrillation. Cluster 2 (40% of the entire population) exhibited significantly high variability, characterized by low population density and GPD per capita, the highest prevalence of heart failure, people drinking alcohol and smoking tobacco. Cluster 3 (7% of the entire population) was in the middle but showed the highest prevalence of hypertension, diabetes and renal failure. Cluster 2 inhabited areas with low concentrations of PMs and BaP and demonstrated increased vulnerability to the effects of PM2.5 and BaP from 3% to 5.2% (P<0.001). For details see Figure 1. Conclusions PM and BaP are important factors associated with the occurrence of MACE. AP exposure should be considered in CVD prevention models. Cluster classification helps in risk stratification and prognosis. Adverse effects of AP can be mitigated by attention to improving socio-economic status and hazardous habits.Associations between AP exposure and ACS

The impact of multimorbidity on cardiac remodelling in the UK Biobank

Abstract Background/Introduction Previous work has suggested that multimorbidity is associated with higher all-cause mortality and cardiovascular mortality in the UK Biobank (UKB). The impact of multimorbidity on cardiac remodelling as measured by cardiovascular magnetic resonance (CMR) has not been studied in large cohorts. Purpose To determine if CMR biomarkers act as surrogates for adverse cardiovascular outcomes in multimorbidity. Method We analysed 44957 UKB participants who had CMR. Self-reported cancer (UKB field ID 20001) and non-cancer illnesses (UKB field ID 20002) were used to calculate comorbidity count with multi-morbidity defined as 2 or more illnesses. The predictive value of comorbidity count (exposure counts measured in quintiles) on CMR traits (outcomes) was evaluated using a univariable and multivariable generalised linear model. Covariates included sex, age, BMI, smoking status, regular alcohol intake, and the Townsend deprivation index, a measure of socioeconomic deprivation. The first model utilised univariable regression without covariates with subsequent iterations including age and sex and then all covariates. An interaction term was included for age and sex and a quadratic term for age in the models. CMR outcome measures were indexed left ventricular mass (LVM), indexed left ventricular end diastolic volume (LVEDV), indexed left ventricular end systolic volume (LVESV), indexed left ventricular stroke volume (LVSV), left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), and indexed maximal left atrial volume (LA). The absolute value of GLS was used in the regression models. Variance inflation factor testing was used to check for collinearity. Analyses were completed using R v4.1.1. Results Median comorbidity count was 2. The burden of long-term conditions in this population of European ancestry with largely healthy individuals is lower than in other large population cohorts. Table 1 summarises multivariable analyses for comorbidity count, LVM and GLS. Due to high collinearity relating to age in the model, we centred age around the mean. LVM was higher with multimorbidity (top quintile Beta 0.63 (95% CI 0.23 to 1.04), P = 2.21x10-03). GLS was lower with multimorbidity (top quintile Beta -0.29 (95%CI -0.42 to 0.16), P = 8.10x10-6). LA volume was lower with multimorbidity (top quintile Beta -0.63(95% CI -1.22 to 0.04), P = 3.53 x 10-2). LVEF and other volume measures were not associated with multimorbidity. Conclusion Multimorbidity in this large cohort was associated with adverse cardiac structural and functional remodelling on CMR. These include a lower global longitudinal strain and higher LV mass.

Mobile health technology integrated care in atrial fibrillation patients according to polypharmacy: an analysis of the mAFA-II clinical trial

Abstract Background Polypharmacy is common in patients with multiple chronic long-term conditions and has been associated with adverse outcome in patients with Atrial Fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway has been proposed to streamline an integrated care management of AF patients, and the Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) prospective cluster randomised trial showed the efficacy of a mobile health (mHealth) implemented ‘ABC’ pathway (mAFA intervention) in improving prognosis of AF patients. Whether these benefits apply also to AF patients with polypharmacy is unclear. Purpose To evaluate the effect of mAFA intervention according to the presence of polypharmacy at baseline. Methods In the mAFA-II cluster randomised trial, between June 2018 and August 2019 adults with AF were enrolled in 40 centres in China; clusters were randomised in a 1:1 ratio to mAFA intervention or usual care. In this analysis, we defined polypharmacy as being treated with 5 or more drugs at baseline. The primary outcome was the composite of stroke, thromboembolism, all-cause death and rehospitalisation. We evaluated the interaction between the effect of mAFA intervention and the presence of polypharmacy at baseline on the risk of the primary outcome using multivariable Cox-regression analysis; results were expressed as adjusted Hazard Ratio (aHR) and 95% Confidence Intervals (95%CI). We also evaluated individual components of the primary outcomes as exploratory secondary endpoints. Results 3,324 patients were enrolled in the trial and included in this analysis; of these, 558 (16.8%) patients were polymedicated at baseline (mean age 71.9±12.6 years, females 44.3%); of these, 303 (54.3%) were allocated to mAFA intervention. 2,766 patients were not polymedicated (mean age 67.9±14.4 years, females 36.7%), of these 1,343 (48.5%) were allocated to mAFA intervention. Overall, patients in the polypharmacy group were older and with higher prevalence of most comorbidities and higher thromboembolic risk. The effect of mAFA intervention was similar among patients with vs. without polypharmacy on the reduction of the primary composite outcome, although with a diluted effect among polymedicated patients (adjusted Hazard Ratio [aHR] and 95% Confidence Interval [CI]: 0.34 [0.22-0.53] vs. 0.73 [0.27-1.99], p for interaction=0.166, Figure 1); similar results were observed for all-cause death and rehospitalizations. Conclusions A mHealth-technology implemented ABC pathway showed a similar effect on the reduction of the primary composite outcome among patients with and without polypharmacy. These findings support a broad application of the ABC pathway to improve outcomes in AF patients.Figure 1

Long COVID Prevalence and Factors Among ethnically Diverse UK Healthcare Workers

Abstract Background Long COVID (LC), characterised by persistent symptoms post-acute COVID-19 infection, presents a growing public health concern. Data on prevalence among healthcare workers (HCWs) are lacking. Our study aimed to establish the proportion of UK HCWs with symptoms lasting beyond five weeks and identify factors associated with LC in a diverse cohort. Methods We conducted a cross-sectional analysis from December 2020 to March 2021. The main outcome was LC in relation to self-reported ethnicity. Univariable and multivariable logistic regression identified associations. Odds ratios (ORs) and adjusted odds ratios (aORs) were calculated with 95% confidence intervals (95%CIs). The multivariate analysis adjusted for demographic information, job role, household factors, health status, and existing long-term conditions. Missing data were imputed via chained equations. Results From 11,513 HCWs, 2,331 (20.2%) reported COVID-19, with 525 (22.5%) experiencing LC. 80.0% of those reporting LC were female, compared to 74.3% without LC were female. Participants with LC (median age 46 [IQR 36-54)]) were slightly older than those without LC (median age 41 [IQR 31-52]). In multivariable analyses of those who reported having had COVID-19, HCWs in nursing/midwifery roles (aOR 1.76, 95% CI 1.26-2.46, p = 0.001) and allied health professions (aOR 1.42, 95% CI 1.05-1.93, p = 0.023) had higher odds of reporting LC compared to those in medical roles. Significant associations were also found with self-reported depression, anxiety, and asthma. There was no significant association between ethnicity and experiencing LC. Conclusions In this large ethnically diverse cohort study, there is a substantial burden of LC among UK HCWs. Further research and collaborative efforts are urgently needed to address these factors effectively, develop targeted public health interventions, and understand the temporal and longitudinal dynamics of the condition. Key messages • One in five UK healthcare workers reported long COVID, indicating critical needs for targeted public health interventions. • Our study highlights urgent public health responses to address long COVID among healthcare professionals.

Future patterns of health inequalities in the population of England to 2040: a microsimulation study

Abstract Introduction The existence of wide inequalities in health across England is well-documented. Our research adds to this evidence on inequalities in self-reported health by describing current patterns and projecting future patterns of inequality in diagnosed illness across multiple conditions by deprivation. Methods We used the IMPACTNCD microsimulation model that simulates a close-to-reality synthetic population of adults in England from 2019 to 2040. This model combines individual-level data on demographics, health and mortality from linked administrative data for primary and secondary care with survey responses on individual-level risk factors and epidemiological evidence on the associations between risk factors and chronic illness. This model can be adapted for other countries based on data availability. We used the Cambridge Multimorbidity Score (CMS) as our multimorbidity measure. This assigns a weight to 20 common long-term conditions based on individuals’ healthcare use and their likelihood of death. We further focus on “major illness” which corresponds to a CMS greater than 1.5. Results In preliminary results, we project that health inequalities are not projected to improve between 2019 and 2040. In 2019, the difference in the average time spent without major illness between the most and least deprived 10% of areas in England was 10.4 years. This is projected to remain largely unchanged at 10.7 years (8.8, 11.7). We also find that in 2019, the share of working age people living with major illness in the most deprived 10% of areas in England (14.6%) was more than double the rate seen in the least deprived 10% of areas (6.3%). In 2040, we project these rates to remain largely unchanged at 15.2% (13.0%, 17.6%) and 6.8% (5.4%, 9.1%) respectively. Discussion On current trends, health inequalities are projected to persist into the future. This has significant implications not just for population health but for labour supply and wider economic growth. Key messages • If current trends in risk factors continue into the future, existing wide inequalities in diagnosed illness in England are projected to persist onto 2040. • With significant disparities in major illness among the working-age population, this has implications not just for population health but for labour supply and wider economic growth.

Evolution of Microstructural and Mechanical Properties of Alloy 617B During Service on a Key-Component Test Platform at 700 °C

The evolution of the microstructural and mechanical properties of alloy 617B during long-term service on a key-component test platform at 700 °C was systematically investigated. The precipitation behavior and size changes of the M23C6 and γ′ phases were characterized by scanning electron microscopy (SEM) and transmission electron microscopy (TEM). The results showed that carbide M23C6 precipitated in the form of discontinuous particles, plates, or needles at grain boundaries and within grains, while the γ′ phase had a spherical shape and was distributed in a dispersed manner. With prolonged service time, both the M23C6 and γ′ phases gradually coarsened. After 24,000 h of service, the yield strength, tensile strength, and Brinell hardness of alloy 617B significantly increased; however, the impact toughness decreased, accompanied by intergranular embrittlement. The increase in precipitate volume fraction and its contribution to the strength of the alloy were evaluated by a precipitation strengthening model. The coarsening of M23C6 was identified as the main cause of embrittlement. The findings of this study provide important experimental data and theoretical support for the stability of 617B alloys under long-term high-temperature service conditions.

Epilepsy Demystified: Symptoms, Seizures, Types and Treatment Options

Epilepsy is a long-term neurological condition where seizures recur due to abnormal electrical signals in the brain. These seizures can vary, with focal seizures starting in one area of the brain and generalized seizures affecting the brain more broadly. Diagnosing epilepsy involves looking at your medical history, symptoms, and tests like EEG or brain scans to get a clear picture. Treatment usually includes medications to control seizures, lifestyle adjustments, and sometimes surgery. If you remain seizure-free for 2 to 4 years, your doctor might gradually lower your medication and consider stopping it altogether.

Long-Life Inoculant: Bradyrhizobium Stored in Biodegradable Beads for Four Years Shows Optimal Cell Vitality, Interacts with Peanut Roots, and Promotes Early Growth

Currently, bacterial inoculant technology focuses on improving long-term storage conditions to ensure adequate rhizobia numbers and their effectiveness as plant growth promoters. This study aimed to investigate whether storage at 4 °C for four years of alginate beads immobilizing Bradyrhizobium sp. SEMIA6144 maintains bacterial vitality, efficacy in growth promotion, and ability to establish early interactions with Arachis hypogaea L. The recovery of viable SEMIA6144 cells decreased over time (10% at six months, 1% at one year, and 0.01% at four years), while cell vitality remained high at 94.1%, 90.2%, and 93.4%, respectively. The unsaturated/saturated fatty acid ratio declined during storage, reducing membrane fluidity and metabolic activity. Mobility and root adhesion of SEMIA6144 decreased after one and four years. However, growth promotion in peanuts inoculated with SEMIA6144 beads was observed through increased biomass, total chlorophyll, leaf number, leaf area, and decreased chlorophyll fluorescence compared to non-inoculated plants. Although nodulation was low in plants inoculated with four-year-old beads, leghemoglobin levels were maintained. These results demonstrate that Bradyrhizobium sp. SEMIA6144 can be stored for four years in alginate beads at 4 °C, maintaining its vitality and ability to establish a symbiosis that stimulates early peanut growth. Understanding these physiological changes could be valuable for the future improvement of long-lasting inoculants.

What is the relationship between the volume and type of appointments in general practice and patient experience? An observational study of general practice in England.

Background Patient satisfaction is a significant dimension of quality in general practice and has notably declined post-COVID. Understanding the dynamics between practice activities, practice characteristics and patient experience is vital for improving care quality. Aim This study investigates the relationship between the volume, modality (telephone or face-to-face) and practitioner type of general practice appointments and patient experience. Design and Setting An observational study of general practices in England. Method Data from the General Practice Patient Survey (GPPS) were merged with NHS Digital's practice level appointment data, covering August 2022 to March 2023. We estimate ordinary least squares regressions of patient satisfaction with access, general satisfaction, preference for a specific GP, and support for managing long-term conditions (dependent variables) against appointment volume, modality (telephone or face-to-face), and practitioner type. Results Analysis of 5,278 practices showed that a higher volume of appointments, especially face-to-face with GPs, was significantly (p<0.001) associated with increased patient satisfaction. Practices having a greater proportion of same-day appointments was significantly correlated with lower patient satisfaction. Conclusion Patient satisfaction and ability to have health needs met is associated with face-to-face access to GPs as well as the total volume of appointments available. The results suggest that patients' perceptions of access involve more than immediate availability of appointments or that patients may struggle to get appointments at practices offering more same day appointments. Initiatives to improve access to and satisfaction with general practice should prioritise expanding face-to-face GP appointments.