Background and ObjectivesTraumatic brain injuries are associated with an increased risk of suicide; the risk of suicide after other head injuries, particularly in the general population, remains unclear. We aimed to determine whether people with head injuries are at higher risk of suicide compared with people without head injuries.MethodsA 20-year population-based matched cohort study was conducted using nationally representative electronic primary health care records linked to Hospital Episode Statistics and Office for National Statistics data. Adults (>= 18 years) with a head injury were matched 1:4 with individuals without a head injury by age, sex, and geographical location. Individuals without data linkage or with a history of self-harm or suicide attempt before the head injury were excluded. The primary outcome was risk of suicide attempt (including death by suicide). Secondary outcomes were risk factors of suicide attempt and risk of death by suicide. Subgroup analysis was conducted to investigate risk of suicide attempt by age group, sex, social deprivation level, ethnicity, and history of mental health conditions. Adjusted hazard ratios (HRs) were calculated using Cox proportional hazards regression.ResultsThe mean age of people with and without head injuries was 52.4 years (SD 22.7), and 51% were female. Of 389,523 people with head injuries, 5,107 suicide attempts were recorded (incidence rate 2.4 per 1,000 person-years) compared with 9,815 among 1,489,675 adults without head injuries (incidence rate 1.6 per 1,000 person-years), resulting in an adjusted HR of 1.21 (95% CI 1.17-1.25). Risk factors of suicide attempt were first 12 months after head injury, higher deprivation, and a history of a mental health condition. The adjusted HR for death by suicide was 0.74 (95% CI 0.66-0.84); this became nonsignificant after controlling for competing risk of death (sub-HR 0.91, 95% CI 0.81-1.03). Risk of suicide attempt was higher in all subgroups investigated, including those without any baseline mental health condition.DiscussionThese findings have implications for clinical practice and health policy. The development and testing of suicide risk assessment and prevention strategies for people with head injuries should be investigated, especially within the first 12 months after head injury and irrespective of mental health history.

OBJECTIVE:The objective of this study is to co-produce a care bundle for women with multiple long-term health conditions (MLTC) that could be pilot tested and implemented in UK maternity services. DESIGN:Online co-production workshops each attended by 20-30 key interest holders. SETTING:United Kingdom, October 2023-February 2024. POPULATION:Women with experience of pregnancy with MLTC, healthcare professionals and other interest holders involved in commissioning, planning and delivering care for pregnant women with MLTC. METHODS:This study followed a three-step process: (1) a consolidated list of key components of care for pregnant women with MLTC was created through secondary analysis of prior collected qualitative data; (2) the list of care components was explored during four co-production workshops; and (3) findings from (1) and (2) were synthesised to develop a maternity care bundle of 4-5 key care components for pregnant women with MLTC. MAIN OUTCOME MEASURES:A maternity care bundle of five key care components for pregnant women with MLTC. RESULTS:A list of 25 care components was refined to develop a proposed care bundle of five components. These were provisions of early and reliable medication advice and decision support; creation of a 'goals of care summary' accessible to women and the care team; provision of continuity of midwifery care throughout pregnancy and postnatal care; provision of a named care coordinator; and a formal postnatal handover of care from the multidisciplinary care team to the General Practitioner (GP) and secondary care team involving the woman. CONCLUSIONS:This study coproduced an evidence-based care bundle for pregnant women with MLTC to enhance communication and ensure individualised care and support. Further collaborative work with women and professionals is required to refine, implement and evaluate its impact on outcomes.

Background:Small vulnerable newborn birth (SVN) encompasses infants born preterm, small for gestational age, or low birthweight, and accounts for most neonatal deaths worldwide. This maternity population-based administrative data-linkage cohort study aimed to estimate the risk of SVN associated with maternal intimate partner violence (IPV) experience. Methods:Records were included for women who accessed maternity services in Northern Ireland and had a singleton pregnancy, with liveborn or stillborn infants born 24-42 weeks' gestation, with an estimated pregnancy start date 01 January 2011-31 December 2021. Pregnancy records were linked to community-dispensed prescriptions and hospital diagnoses data. Data were provided by the Honest Broker Service. IPV, maternal characteristics, and SVN were ascertained through maternity records. Mental health conditions were ascertained via medications or ICD-10 hospital diagnosis codes. Generalised estimating equations were utilised to perform modified Poisson regression with a log link, with clustering to account for women with more than one pregnancy during the study period. The risk of SVN given exposure to IPV was estimated, adjusted for number of mental health conditions and additional maternal characteristics. Findings:From 248,645 eligible pregnancies to 157,507 individual women, IPV was disclosed in 11,388 (4.6%) pregnancies (active: n = 3713, 1.5%; historical: n = 7675, 3.1%). The group with highest prevalence of IPV was pregnant adolescents (n = 995, 12.2%). Disparate prevalence estimates were also seen between the most (8.5%) and least (1.9%) deprived areas. Risk of SVN was increased for women reporting both active IPV (RR = 1.21, 95% CI: 1.13-1.31) and historical IPV (RR = 1.18 (95% CI: 1.12-1.25) independent of the number of coexisting mental health conditions and other maternal characteristics. Interpretation:IPV, both active and historical, is associated with an increased risk of birth of babies who are small and vulnerable, and so its detection, even IPV of historical nature, and response should be prioritised through training and creation of referral pathways. Funding:UKRI's ADRC NI (ES/W010240/1) & Strategic Priority Fund "Tackling multimorbidity at scale" programme (MR/W014432/1).

INTRODUCTION:Early diagnosis and treatment of atrial fibrillation (AF) are crucial to reduce AF-related complications and associated healthcare costs. In low-resource settings, digital health technologies could help achieve this; however, costs of different screening strategies are key for policy change. METHODS:This decision-tree model representing the Sri Lankan public health system perspective used prevalence data from a community-based cross-sectional study of 10 000 individuals aged ≥50 years in Northern Province, Sri Lanka. Participants were screened for AF using AliveCor, a handheld single-lead ECG device. Three screening strategies (systematic, opportunistic and targeted) were compared against each other. The incremental cost-effectiveness ratio (ICER) is presented, representing the incremental total aggregated cost between screening strategies divided by the incremental number of new detected AF cases to generate a cost per additional new AF cases detected for a 1-year time horizon. RESULTS:Systematic screening detected 48 new AF cases, and the targeted screening detected 47. Systematic screening was more expensive (Sri Lankan rupees (Rs) 698 422; US$2123) for 10 000 screened individuals compared with targeted screening (Rs 492 002; US$1496) for 7780 screened individuals. Opportunistic screening was the cheapest strategy (Rs 360 617; US$1096) for screening 6556 individuals; however, only 30 new AF cases were identified. The ICER of targeted screening was lower compared with opportunistic screening (Rs 7729; US$23 per additional detected AF case) whereas the ICER of systematic screening compared with opportunistic screening was higher at Rs 18 767 (US$57) per detected AF case. When the systematic screening strategy was compared with targeted screening, the cost per additional detected AF case increased to Rs 206 420 ($628). CONCLUSION:Targeted screening with AliveCor was the most cost-effective strategy. Systematic screening, while having similar effectiveness, was not cost-effective due to the high additional costs to detect just one further case. These findings support integrating targeted screening into Sri Lanka's primary care pathways.

Background Early diagnosis and continuity of care is vital for atrial fibrillation (AF), to reduce stroke ; There is a lack of understanding of when and how AF is being diagnosed and managed the care pathway) in in low- and middle-income countries (LMICs). We aimed to identify the AF care pathway in Northern Province, Sri Lanka and determine how the COVID-19 pandemic impacted the care pathway. Methods This descriptive longitudinal study utilised two quantitative questionnaires to evaluate the AF pathway: The first questionnaire (baseline) was used to identify where AF was being diagnosed and the second questionnaire (3 months following baseline) was used to identify where and how often AF follow-up care was being received. How the COVID-19 pandemic impacted the care pathway was asked in the second questionnaire. We aimed to recruit 236 adults (≥18 years) with AF from Jaffna Teaching Hospital. Data were collected between October 2020 and June 2021 and analysed using descriptive statistics. Results 151 participants were recruited (median age 57 years; 70% female). Most participants were diagnosed in the accident & emergency (38%) or inpatient department (26%), followed by an outpatient department (19%) or private facility (16%). Nearly all (97%) participants received follow-up care during the study period, with an average of 1.3 AF-related healthcare visits per person for a month; most visited an outpatient department (88%). The COVID-19 pandemic negatively impacted 39% of participants’ care: healthcare visits were reduced or, delayed or medications were unattainable, and longer intervals between blood tests were experienced; however, 24% of participants were able to receive their medication by ambulance, public health staff or post during lockdowns. Conclusions Primary care was not involved in the diagnosis of AF, indicating that most diagnoses occurr after a medical emergency. The frequency of blood tests was lower than the guideline recommendations of one per month which could in-part be due to the adverse impacts of the pandemic. Strengthening primary and community-based care may enable early diagnosis and improve continuity of care during and beyond future healthcare crises.

INTRODUCTION:One in five women enters pregnancy with multiple long-term health conditions, which is associated with increased risks of adverse maternal and child outcomes. There is a lack of research exploring individuals' experiences of preconception care for these women, which is also reflected in existing guidelines that predominantly focus on single health conditions. This study aimed to explore experiences of preconception care and support among women with multiple long-term health conditions and health professionals. METHODS:This is a secondary analysis of qualitative data collected by the MuM-PreDiCT consortium. The primary study involved semi-structured interviews between March 2022 and May 2023 with pregnant (> 28 weeks) and postnatal (< 2 years) women with multiple long-term physical and/or mental health conditions in the United Kingdom, and healthcare professionals involved in their care. Data captured within the preconception coding reports were analysed thematically. RESULTS:Fifty-seven women and 51 healthcare professionals were interviewed. Six themes were identified from the thematic analysis. Women and professionals described the importance of tailored preconception care and support, incorporating condition-focused counselling (sub-theme 1) and medication planning (sub-theme 2). Sensitive and realistic care and support were considered essential, but women had mixed experiences of involvement and empathy from different professionals. The significance of optimising antenatal care by making every preconception contact count was emphasised by both women and professionals, who valued early referrals, specialist input and integration of services. Although professionals viewed the preconception period as an opportunity to empower women, many women felt they had to self-advocate and seek information due to gaps in professional awareness, knowledge and education. Professionals reported differing views on who, within the care team, should take responsibility for care delivery. Some believed that women should play an active role in managing their health, including initiating conversations around pregnancy intentions. The delivery of preconception care was complicated by a range of challenges, including a lack of service integration, availability, time and funding. CONCLUSION:Women with long-term health conditions can experience substantial gaps in preconception care, characterised by inconsistent guidance and limited access to tailored, reliable support, which frequently leads to feelings of isolation and the need to seek additional information when preparing for pregnancy. These results will inform the co-development of a care bundle for affected women. PATIENT OR PUBLIC CONTRIBUTION:Our Patient and Public Involvement group was involved in the design of the study and the analysis and interpretation of the data, and two public study investigators are part of the author group.

Background Allergic rhinitis (AR) affects approximately 10% of Indian adults, but its clinical and biological heterogeneity remains poorly defined. Objective We sought to characterize AR phenotypes in South Indian adults using clinical features, spirometry, fractional exhaled nitric oxide (Feno), skin prick tests, blood biomarkers, and cluster analysis. Methods This was a prospective observational study of 122 patients (≥18 years old) with AR with or without asthma attending a South Indian tertiary allergy clinic and 50 asymptomatic nonatopic control subjects. Participants underwent standardized symptom/exposure assessments, spirometry, Feno, blood counts, serum IgE, and skin prick tests to 10 aeroallergens. Principal component analysis, correlation networks, and unsupervised k-means clustering were applied to define phenotypes. Results Patients with AR were younger than control subjects, predominantly female, and frequently exposed to incense and mosquito repellents. Sensitization to house dust mite (>70%) and polysensitization were common. Compared with control subjects, patients with AR had elevated Feno (43 vs18 ppb; P < .01) but no significant differences in serum IgE or eosinophils. Spirometry revealed modestly lower FEV1/forced vital capacity in patients with AR (P < .01), though values remained within normal limits. Cluster analysis identified 3 subgroups: high Feno, low eosinophils, moderate-to-severe AR with less asthma; low Feno, high eosinophils, with more asthma; and impaired lung function with moderate eosinophilia and the highest asthma burden. Network analysis demonstrated strong cosensitization between house dust mite, Parthenium hysterophorus (weed pollen), Cynodon dactylon (Bermuda pollen), and cockroach. Conclusions This study showed 3 distinct AR clusters with high dust mite sensitization alongside cosensitization with cockroach, weed, and Bermuda pollens. Multicenter studies are warranted to further refine AR clusters, including tissue-level biomarker profiling and relevance to pharmacotherapy and immunomodulatory therapies.

INTRODUCTION:Childbirth-related perineal trauma (CRPT) is the most common complication of vaginal birth, yet its associations with mental health and other health outcomes remain poorly described. This study examined the annual incidence of recorded CRPT by tear degree and investigated its association with mental health and other health outcomes. MATERIAL AND METHODS:We conducted a retrospective cohort study using Clinical Practice Research Datalink Aurum primary care data linked with Hospital Episode Statistics, including women aged ≥16 years who had given birth vaginally between 1st January 2005 and 31st December 2019. Exposure was defined as recorded CRPT of any degree including episiotomy. Annual incidence of CRPT was calculated as a percentage of all births. Cox proportional hazards regression models compared short-, medium-, and long-term (<1 year, 1-5 years, and >5 years post-childbirth) outcomes between women with and without CRPT. We conducted subgroup analyses by degree of tear and in women with spontaneous vertex births, and a sensitivity analysis restricted to first birth. RESULTS:Incidence of recorded CRPT increased from 43.4% to 48.8% between 2005 and 2019. Compared to women without CRPT, those with CRPT had a higher risk of anxiety (aHR 1.19, 95%CI 1.17, 1.22) or depression (aHR 1.23, 95%CI 1.21, 1.25) within 1 year postpartum, with elevated risks persisting beyond 5 years and across all degrees of tear. Women with 1st/2nd degree tears or episiotomy had a higher hazard of post-traumatic stress disorder 1-5 years postpartum. CRPT was associated with increased hazard of urinary incontinence, dyspareunia, reduced libido, vaginal discharge, general and perineal pain, and prolapse in all follow-up periods. Fecal incontinence was increased in women with episiotomy or 3rd/4th degree tears, persisting long-term for severe tears. CRPT was associated with 32% higher risk of antibiotic prescription compared to no CRPT (OR 1.32, 95%CI 1.30, 1.33) within 6 weeks postpartum. CONCLUSIONS:Recorded CRPT was associated with increased risks of diagnosed anxiety and depression in short-, medium- and long-term post-childbirth, irrespective of tear severity, as well as higher risks of other adverse outcomes, including urinary incontinence, pain, and sexual dysfunction. Addressing CRPT should be prioritized to improve women's health and well-being.

BACKGROUND:People living with HIV have a greater prevalence of anaemia compared with people without HIV, which increases the risk of associated morbidity and premature mortality. Risk factors for anaemia among people living with HIV have changed in recent decades due to new antiretroviral therapy (ART), increased uptake of ART and increasing chronic conditions among people living with HIV; thus, anaemia prevalence may have changed over time. We aimed to identify the prevalence and trends of anaemia among people living with HIV over a 20-year period. METHODS:A series of 20 annual cross-sectional analyses were performed from 2002 to 2021. Data on people living with HIV aged ≥18 years from Clinical Practice Research Datalink (CPRD) Aurum was used, a population-based UK primary healthcare database. Overall and annual prevalence of all-cause anaemia, defined as any clinical code indicative of having anaemia, was calculated using multivariable logistic regression models and adjusted for age, sex, ethnicity, smoking status and deprivation. Trends were determined by investigating the change in prevalence across the 20 annual analyses using linear regression. Prevalence and trends of anaemia were also calculated among the following sub-groups of people living with HIV: age, sex, ethnicity, body mass index, smoking and socioeconomic deprivation. RESULTS:Data for 41 990 people living with HIV were included. Overall adjusted prevalence of anaemia was 6.89%; however, this significantly increased from 4.6% (95% CI: 4.72%, 5.06%) in 2002 to 7.42% (95% CI: 7.33%, 7.51%) in 2021. A significant positive trend for anaemia was found (adjusted coefficient + 0.123; 95% CI: 0.107, 0.139; p < 0.001) and this was consistent among all sub-groups. Females, older age (≥50 years), non-smokers, Black ethnicity, overweight/obese and higher deprivation had an increased prevalence of anaemia. CONCLUSION:Anaemia among people living with HIV is increasing, with certain groups of people living with HIV experiencing a greater burden. Efforts should be made to prevent and reduce anaemia among people living with HIV to mitigate further morbidity, premature mortality and additional inequalities.

BACKGROUND AND OBJECTIVES:Traumatic brain injuries are associated with an increased risk of suicide; the risk of suicide after other head injuries, particularly in the general population, remains unclear. We aimed to determine whether people with head injuries are at higher risk of suicide compared with people without head injuries. METHODS:A 20-year population-based matched cohort study was conducted using nationally representative electronic primary health care records linked to Hospital Episode Statistics and Office for National Statistics data. Adults (≥18 years) with a head injury were matched 1:4 with individuals without a head injury by age, sex, and geographical location. Individuals without data linkage or with a history of self-harm or suicide attempt before the head injury were excluded. The primary outcome was risk of suicide attempt (including death by suicide). Secondary outcomes were risk factors of suicide attempt and risk of death by suicide. Subgroup analysis was conducted to investigate risk of suicide attempt by age group, sex, social deprivation level, ethnicity, and history of mental health conditions. Adjusted hazard ratios (HRs) were calculated using Cox proportional hazards regression. RESULTS:The mean age of people with and without head injuries was 52.4 years (SD 22.7), and 51% were female. Of 389,523 people with head injuries, 5,107 suicide attempts were recorded (incidence rate 2.4 per 1,000 person-years) compared with 9,815 among 1,489,675 adults without head injuries (incidence rate 1.6 per 1,000 person-years), resulting in an adjusted HR of 1.21 (95% CI 1.17-1.25). Risk factors of suicide attempt were first 12 months after head injury, higher deprivation, and a history of a mental health condition. The adjusted HR for death by suicide was 0.74 (95% CI 0.66-0.84); this became nonsignificant after controlling for competing risk of death (sub-HR 0.91, 95% CI 0.81-1.03). Risk of suicide attempt was higher in all subgroups investigated, including those without any baseline mental health condition. DISCUSSION:These findings have implications for clinical practice and health policy. The development and testing of suicide risk assessment and prevention strategies for people with head injuries should be investigated, especially within the first 12 months after head injury and irrespective of mental health history.

BACKGROUND:Autoimmune diseases are increasingly prevalent worldwide and disproportionately affect women of reproductive age, including during pregnancy. Given the association between autoimmune diseases, comorbidities, and risk factors for adverse pregnancy outcomes, we aimed to estimate the burden of autoimmune disease in pregnancy. METHODS:This was a UK population-based retrospective cohort study using routinely collected data from two large databases (Clinical Practice Research Datalink Gold and Aurum) and associated pregnancy registers. Prevalence was calculated annually for 17 autoimmune diseases (Addison's disease, alopecia areata, ankylosing spondylitis, coeliac disease, inflammatory bowel disease (including Crohn's disease and ulcerative colitis), Graves' disease, Hashimoto's thyroiditis, multiple sclerosis, myasthenia gravis, psoriasis, psoriatic arthritis, rheumatoid arthritis, Sjögren's disease, SLE, systemic sclerosis, type 1 diabetes, and vitiligo) in pregnancies among women of reproductive age (15-49 years) from Jan 1, 2000, to Dec 31, 2021. Logistic regression was used to estimate odds ratios, describing the relationship between women's characteristics (age, ethnicity, deprivation, BMI, smoking status, and gravidity), comorbidities, and autoimmune diseases. Patient and public involvement and engagement representatives participated in formulating the research question. They also played key role in collaboration with clinicians and researchers to identify and consider the list of autoimmune diseases in the study, and played a key role in disseminating the results. FINDINGS:5 165 960 pregnancies in 2 831 472 women were included. In 2000-21, there were 185 208 pregnancies in 100 655 women who had a coded diagnosis of autoimmune disease. There was an increase in prevalence of the combination of 17 autoimmune diseases, from 6058 (3·5%) of 172 430 in 2000 to 8429 (4·7%) of 181 532 in 2021. Of the 17 autoimmune diseases studied, psoriasis had the highest prevalence throughout the study period. The prevalence of most of the autoimmune diseases increased from 2000 to 2021. The steepest rise was Hashimoto's thyroiditis, followed by coeliac disease, Grave's disease, and type 1 diabetes. Women in less deprived areas had higher odds of an autoimmune disease during pregnancy (adjusted odds ratio 1·10 [95% CI 1·07-1·14]), whereas minority ethnic groups had lower prevalence rates compared with White women (Black women 0·48 [0·45-0·51]; Asian women 0·81 [0·77-0·85]). Ex-smokers had significantly higher odds of autoimmune disease than non-smokers (1·20 [1·18-1·23]). When compared with women with a single pregnancy, the odds of having an autoimmune disease were significantly higher for women with five or more pregnancies (1·12 [1·10-1·15]). Women with metabolic and mental health conditions had significantly higher odds of having an autoimmune disease during pregnancy (type 2 diabetes, 1·41 [1·30-1·53]; hypertension, 1·07 [1·01-1·13]; anxiety, 1·15 [1·12-1·19]; depression, 1·17 [1·14-1·20]). INTERPRETATION:The growing burden of autoimmune diseases in pregnancy calls for research into their impact on outcomes. Health policy should address gaps in specialised care to ensure individuals receive evidence-based care to prevent deterioration of the autoimmune disease and development of adverse pregnancy outcomes. FUNDING:Strategic Priority Fund, Medical Research Council, National Institute for Health and Care Research, Economic and Social Research Council, and Engineering and Physical Sciences Research Council.

Background: Allergic rhinoconjunctivitis (ARC), asthma and eczema carry a substantial morbidity. These conditions often co-exist within the same individual and prevalence can differ based on age, ethnicity and gender. Objectives: Using a UK primary care database, we estimated the trends in prevalence over the last decade for ARC, asthma and eczema and associated risk factors. Methods: Longitudinal cohort analysis of the health improvement (THIN) database between 1 Jan 2010 and 1 Jan 2019. Logistic regression analysis was used to explore risk factors for diagnosis of these conditions. Results: An average of 4.17 million records per year were analysed, 19.4% were children and 49.75% were male. There was an increase in prevalence of ARC, asthma and eczema amongst adults during the study period, whereas ARC and asthma prevalence amongst children has fallen. By 2018, 1:8 adults and 1:14 children had ARC; asthma was diagnosed in 1:7 adults and 1:10 children whereas eczema was diagnosed in 1:6 adults and 1:4 children respectively. Ethnicity and gender modify the risk of being diagnosed with these conditions. Having other allergies substantially increases the odds of having asthma, eczema and ARC. Conclusion: The population burden of ARC, asthma and eczema in the UK is substantial. These conditions are often associated with other allergies and can, therefore, be complex to manage. These data support calls for improvement of pathways of care for allergy patients in the UK.

Background Artificial intelligence (AI)-based clinical decision support systems (CDSSs) are currently being developed to aid prescribing in primary care. There is a lack of research on how these systems will be perceived and used by healthcare professionals and subsequently on how to optimise the implementation process of AI-based CDSSs (AICDSSs).Objectives To explore healthcare professionals’ perspectives on the use of an AICDSS for prescribing in co-existing multiple long-term conditions (MLTC), and the relevance to shared decision making (SDM).Design Qualitative study using template analysis of semistructured interviews, based on a case vignette and a mock-up of an AICDSS.Setting Healthcare professionals prescribing for patients working in the English National Health Service (NHS) primary care in the West Midlands region.Participants A purposive sample of general practitioners/resident doctors (10), nurse prescribers (3) and prescribing pharmacists (2) working in the English NHS primary care.Results The proposed tool generated interest among the participants. Findings included the perception of the tool as user friendly and as a valuable complement to existing clinical guidelines, particularly in a patient population with multiple long-term conditions and polypharmacy, where existing guidelines may be inadequate. Concerns were raised about integration into existing clinical documentation systems, medicolegal aspects, how to interpret findings that were inconsistent with clinical guidelines, and the impact on patient-prescriber relationships. Views differed on whether the tool would aid SDM.Conclusion AICDSSs such as the OPTIMAL tool hold potential for optimising pharmaceutical treatment in patients with MLTC. However, specific issues related to the tool need to be addressed and careful implementation into the existing clinical practice is necessary to realise the potential benefits.

AIM:To evaluate the association between the presence or absence of comorbid mental health disorders and the risk of asthma exacerbations in adults with prevalent asthma. METHODS:This was a cohort study of adults in England with prevalent asthma and mental health disorders (depression, anxiety, bipolar disorder and schizophrenia) between 2017 and 2019 using primary care electronic healthcare records.Adult asthma patients with mental health disorders (exposed) were matched by age, sex, ethnicity and general practice to asthma patients without a mental health disorder (unexposed) in a 1:1 ratio. The primary outcome was an exacerbation of asthma documented in primary care records. Poisson regression was used to estimate adjusted incidence rate ratios (IRR). RESULTS:873 482 adults with asthma were followed up for a total of 1 580 157 years.Mean age was 49 years; 66% were female, and 78% were white. Adults with asthma and any mental health disorder had an asthma exacerbation incidence rate of 56 per 1000 person years compared with 34 per 1000 person years for those without a mental health disorder.Adults with asthma and any mental health disorder had an adjusted IRR of 1.46 (95% CI 1.44 to 1.48) compared with matched controls. The highest IRR was in those with depression (IRR 1.34, 95% CI 1.32 to 1.37), followed by those with anxiety (IRR 1.20, 95% CI 1.18 to 1.22). There were no significant differences in patients with bipolar disorder or schizophrenia compared with matched controls (IRR 1.00, 95%CI 0.93 to 1.07; and 1.03, 95% CI 0.95 to 1.11, respectively). CONCLUSION:This study shows a significant increased risk of asthma exacerbations in asthma patients with depression or anxiety compared with those with asthma without comorbid mental health disorders.

OBJECTIVE:This study examines the risk of fragility fractures in patients with type 2 diabetes (T2D) who have obstructive sleep apnoea (OSA) compared to those without OSA. METHOD:This retrospective cohort study uses UK primary care data from 2000 to 2022. T2D patients without prior fragility fractures were included. Patients with OSA were matched with up to 4 non-OSA patients based on age, sex, BMI and T2D duration. Two cohorts were analysed based on whether OSA was diagnosed before (cohort 1) or after (cohort 2) the T2D diagnosis. Hazard ratios were calculated using a Cox proportional hazards model. RESULTS:Cohort 1 included 19,795 patients with OSA and 64,124 without OSA. Cohort 2 included 21,769 patients with OSA and 66,350 without OSA. OSA was associated with an increased risk of incident fragility fractures in both cohorts [aHR (95% CI): 1.12 (1.00-1.25); p = 0.04, and 1.15 (1.05-1.26; p = 0.002), respectively]. The point estimates of the subgroup analysis by age and gender of cohort 1 suggest an association between OSA and the risk of fractures in men and in those above 50 years old. In cohort 2, the subgroup analysis point estimate suggests an association between OSA and fragility fractures in men and women and those above and below 50 years old. CONCLUSION:OSA is associated with an increased fragility fracture risk in T2D patients. Further studies are needed to determine if treating OSA reduces this risk. Clinicians should consider bone health and fracture risk, particularly for older patients.

Hereditary Spastic Paraplegia (HSP) is a rare genetic neurological disorder that causes progressive spasticity and weakness in the lower limbs. This study aims to describe the prevalence and incidence of HSP and examine common mental health outcomes (depression and anxiety) in HSP patients in England and Northern Ireland. This retrospective cohort study used CPRD Aurum primary care data from 1 January 2000 to 31 December 2021. Annual cross-sectional and cohort studies were conducted for yearly prevalence and incidence of HSP. Common mental health outcomes were examined with a 1:4 matched cohort (age+/−1 year, sex, general practice). Descriptive analysis and logistic regression assessed the characteristics of the HSP cohort and baseline depression and anxiety. Cox regression assessed the hazard of new diagnosis of depression and anxiety. The overall cohort included 31,302,579 patients; the matched cohort included 1455 HSP patients and 5726 control non-HSP patients. Patients who were male (adjusted odds ratio [aOR] 1.45, 95

Multimorbidity in pregnancy increases health risks to women and babies, and creates challenges for services. The aim of this study was to explore the prevalence and patterns of maternal multimorbidity in a UK population. This population-based, retrospective study used individual-level, linked, routinely collected health data accessed via The Health and Social Care Northern Ireland Business Service Organisation Honest Broker Service within a Trusted Research Environment following the Five Safes Framework. Pregnancy episodes were ascertained from the Northern Ireland Regional Maternity Service Database and linked via unique Health and Care Number to secondary care diagnoses and primary care medications. Yearly prevalence (2012–2020) of multimorbidity (≥ 2 physical or mental health conditions) and complex multimorbidity (involvement of ≥ 3 organ systems) were calculated for the full cohort and stratified by age, deprivation, body mass index (BMI) and gravida. Cross-sectional analyses of prevalence and exploration of unique combinations of conditions and organ system involvement across strata were performed during a period of stability in detection rates (2014–2019). The annual number of pregnancies ranged from n = 24,403 (2012) to n = 19,504 (2020). Prevalence of maternal multimorbidity ranged from 18.2