Paul Little

Background: Acne is very common, affecting > 90% of adolescents. Current UK guidelines recommend topical treatments as the first-line therapy for mild-to-moderate acne, but treatment adherence is low, estimated by larger studies to be 50–65%. This is attributed to the challenges of maintaining consistent application over several weeks and the potential for skin irritation. The effectiveness of strategies aimed at improving adherence is unclear. Objectives: To identify the range of interventions used to improve adherence to acne treatments and to assess the effectiveness of these interventions. Methods: We conducted a systematic review of randomized controlled trials (RCTs) of interventions to improve adherence to acne treatments. We searched MEDLINE, PubMed, Embase, PsycINFO and CINAHL, without language restrictions, from inception until 24 March 2025. Eligibility criteria required studies to include participants aged 13–25 years with acne. Eligible interventions included medicinal or behavioural approaches to improve adherence to acne treatment. The main outcome was adherence to acne treatment. The risk of bias was assessed using RoB 2 and the results were summarized in a structured table. Results: A total of 11 RCTs met the eligibility criteria, comprising 789 participants in 5 countries. All studies assessed treatment adherence to topical medications, most commonly adapalene 0.1% with benzoyl peroxide 2.5% (four RCTs) or adapalene gel (two RCTs). Outcomes from educational interventions were inconsistent (five RCTs), as were outcomes for studies of medication reminders (five RCTs) and more frequent consultations (two RCTs). Combining products to simplify the treatment regimen (one RCT), and the use of moisturizer to improve tolerability (one RCT) had weak evidence showing potential benefit. Meta-analysis was not possible due to variation in the interventions and outcome measurement. Conclusions: The reporting of the design and conduct of randomized trials of interventions to improve adherence to acne treatments was limited and sample sizes were small. Robust interventions need to be developed and tested, including greater involvement of end users in intervention design. Standardized adherence outcomes and larger, high-quality randomized trials are required to provide reliable estimates of the effectiveness of adherence interventions in acne.

Objectives: Streptococcus salivarius K12 (SsK12) is a bacterium used as a probiotic with some evidence for preventing acute sore throat/tonsillitis, but the optimal dosing strategy is unclear. This study aimed to evaluate two dosing regimens of SsK12 to establish (a) the prevalence and duration of colonisation with SsK12 and (b) the acceptability and feasibility of these regimens. Design: A randomised, non-blinded feasibility trial. Setting: Primary care in the south of England. Participants: Adults with ≥2 episodes of sore throat within the 3 years before recruitment. Interventions: Participants were randomised to take SsK12 lozenges once weekly or daily over 14 days. Main outcome measures: The primary outcome was the prevalence and duration of colonisation with SsK12. This was determined by real-time PCR conducted on self-taken whole-mouth swabs provided by participants at baseline and on days 2, 7, 14, 21 and 35. Secondary outcomes were the compliance and acceptability of the two SsK12 dosing regimens, based on questionnaire data. Results: 53 participants were recruited (26 randomised to weekly and 27 to daily dosing) between 26 April and 5 December 2023. All swabs were returned by 65.4% (17/26) and 70.4% (19/27) of the weekly and daily groups respectively. Swabs at all timepoints from participants with PCR positives observed at baseline (two and four from the weekly and daily group, respectively) were excluded. Therefore, swabs from 23 participants in the weekly and 22 in the daily group did not have evidence of baseline colonisation and were included in the microbiology analysis. SsK12 colonisation was found in 59.1% (13/22, 95% CI 38.6% to 79.6%) of samples in both groups on day 2; in 13.6% (3/22, 95% CI 0.0% to 28.0%) and 85.7% (18/21, 95% CI 70.8% to 100.0%) of the weekly and daily groups, respectively, on day 7; in 19.1% (4/21, 95% CI 2.3% to 35.8%) and 59.1% (13/22, 95% CI 38.6% to 79.6%), respectively, on day 14; and in only one participant (weekly group) on days 21 and 35. The dosing regimen was reported as easy to follow by 85.0% (17/20, 95% CI 69.4% to 100.0%) of the weekly and 96.2% (25/26, 95% CI 88.8% to 100.0%) of the daily dosing groups. Conclusions: SsK12 colonisation was more prevalent with daily dosing; however, colonisation was not maintained when dosing stopped. Both dosing regimens were acceptable to participants. These findings support the use of daily dosing in a future trial to evaluate the efficacy of SsK12 in preventing recurrence of sore throat/tonsillitis. Trial registration number: NCT04297878 .

Why our topic is important: Respiratory tract infections (known as ‘RTIs’) such as coughs, colds and flu are a very common reason for being ill and for needing time off work. Some studies have shown that nose sprays could help prevent people catching RTIs and reduce symptoms. Other research shows that managing stress and taking more exercise can also help. What we did: We decided to use two sprays: Vicks First Defence and plain salt water (saline). We interviewed people to find out how they felt about using nose sprays to treat RTIs and built a website to help them use the sprays and address any issues. We then asked people to use the website and tell us what they thought and we made any changes needed. We used the same process to build another website to help people deal with stress in a healthy way and also to encourage them to take more exercise. To find out whether the sprays or the healthy lifestyle website had any effect we asked people to use them for a year. We compared their health during that year with another group who did not use sprays or the healthy lifestyle website (the ‘usual care’ group). The people who took part were put into groups randomly. Nearly 14,000 people took part, and we collected information such as how long and how bad RTIs were, how often people contacted their doctor’s surgery, and whether they went to a hospital emergency department. What we found: The people in the usual care group who caught an RTI were unwell for 15 days, on average. In both the nasal spray groups, illness was reduced to an average of 12 days, even though people did not use the sprays as often as recommended. However, the overall number of RTIs was not reduced compared with the usual care group. People in the healthy lifestyle website group had 5% fewer RTIs than the people in the usual care group, but did not have fewer days of illness. Both sprays reduced days lost off work or normal activity. Both sprays and the healthy lifestyle website reduced the use of antibiotics, the number of days with bad symptoms, and the need to contact a doctor. Headache was more common with Vicks First Defence (8% compared with 5% in usual care). We asked patients about why they didn’t use the sprays to prevent RTIs. They said they didn’t believe sprays could prevent RTIs. The importance of our findings: Widely available, inexpensive sprays help people manage RTIs, and a website to manage stress or take more exercise can reduce the number of RTIs. Improving the advice to support people using sprays might make them even more effective, resulting in fewer or shorter RTIs. This could be especially important for people at risk of becoming very unwell from RTIs, such as those with asthma or other lung problems.

Background Effective communication during consultations is facilitated by clinical empathy and realistic optimism, and can enhance patient satisfaction with care, alleviate symptoms, and improve quality of life. However, primary care systems are under significant strain and changing rapidly, which may affect practitioners' ability to communicate empathically and convey realistic optimism, with implications for the patient-practitioner relationship and patient outcomes. Understanding patients' perspectives of healthcare communication in the current clinical context is therefore important. We aimed to explore patients' experiences and perceptions of communication in UK primary care consultations, focussing on the communication of clinical empathy and realistic optimism. Methods A qualitative interview study was conducted as part of a multi-centre cluster-randomised trial of EMPathicO, a brief e-learning package for Primary Care Practitioners (PCPs) on communicating clinical empathy and realistic optimism. Participants were not aware whether their general practice had access to EMPathicO or not. Interviews were conducted within 7-14 days of participants' consultations, explored their views and experiences of clinical empathy and realistic optimism, and were transcribed verbatim. Interviews were analysed using Ritchie and Spencer's Framework Method. Results We conducted semi-structured audio-recorded qualitative telephone interviews with 71 participants from 29 primary care practices taking part in the EMPathicO trial. Following comprehensive mapping of data to the framework derived following initial analysis, four themes were agreed. Overall, most participants described positive empathic consultations with their PCPs, however, participants' experiences were shaped by wider systemic and contextual factors. They described a stretched and inefficient primary care system impacting empathy and optimism; the impact of PCP 'preparedness' as a marker for empathy; how consultation modality (i.e. in-person or telephone) shaped perceptions of empathy, and how PCPs sharing next steps in participants' treatment and management could foster realistic optimism. Conclusions While clinical empathy and realistic optimism may be experienced by patients during consultations with practitioners, the wider contextual challenges of accessing and navigating primary care systems can threaten overall perceptions of feeling cared for. Future primary care policy and workforce training must consider these system pressures to preserve effective communication in consultations and positive patient-practitioner encounters.

Background: Acne vulgaris is common and has a substantial impact on patients’ quality of life. Low adherence to acne treatments is a barrier to successful management. Objectives: To examine the prevalence of adherence to oral and topical treatments for acne, factors associated with adherence and reasons for nonadherence. Methods: We included primary quantitative studies that investigated acne-related experiences and behaviours, including predictors, determinants and outcomes associated with treatment adherence. We searched the following databases from inception until 24 March 2025, with no language restrictions: MEDLINE, PubMed, Embase, PsycINFO and CINAHL. Quality was appraised using the Mixed Methods Appraisal Tool. We present the findings related to observational studies, analysed using narrative synthesis. Results: Twenty-six eligible papers reported studies in the Americas, Europe and Asia. Thirteen papers reported quantitative descriptive studies (8111 survey participants plus 2 studies that reported data from electronic health records) and 13 papers (12 studies, 37 884 participants) reported other designs such as analytic cross-sectional or cohort studies. Methods for evaluating adherence varied: 21 studies used self-report with differing questionnaire designs, 3 used prescription data to evaluate medication possession ratio, 3 assessed drug refills, 1 carried out database drug survival analysis and 1 used pill count or tube weighing. Four studies used more than one method. The prevalence of adherence estimates varied from 6% to 84%, with larger studies estimating 50–65% adherence. Adherence was lower among younger people, but there was inconsistent evidence for differences between men and women, or between topical and oral treatments. Reasons for nonadherence included cost, side effects, perceived treatment ineffectiveness or symptom resolution. Conclusions: Improving treatment adherence in acne remains a priority, particularly for younger people. Interventions addressing the management of side effects and time to effectiveness of treatments may be beneficial.

Lower respiratory tract infections (LRTI) are common and can trigger acute cardiovascular events. Previous studies focussing on this association only repor

Depressive symptoms are commonly experienced by people with persistent musculoskeletal (MSK) pain. There is evidence for some individuals that this may be best characterised as pain-related distress; a reaction to living with the impact of pain, rather than a depressive illness. No explorations exist of how to differentiate between these in primary care. This study aimed to explore key factors that may differentiate between pain-related distress and depression, and the effectiveness of existing symptom screening tools (Patient Health Questionnaire-9 [PHQ-9] and 4-Dimensional Symptom Questionnaire [4DSQ]) in identifying distress through a mixed methods approach. First, 21 general practitioners and 21 people with pain were interviewed about their experiences of pain-related distress. Second, 597 primary care patients with MSK pain completed a cross-sectional questionnaire study reporting on their pain, mental health symptoms, and other life events. Qualitative data suggested key factors distinguishing between pain-related distress and depression included general positive outlook, physical function, and acceptance. Quantitative findings showed that the PHQ-9 may overcategorise participants as depressed; of the 207 participants classified as distressed (but not depressed) on the 4DSQ, 118 (57%) were categorised as moderately or severely depressed on the PHQ-9. Lower positive outlook and sleep interference scores, and higher PHQ-9 and perceived stress scores significantly predicted participants experiencing distress only compared with distress and depression, matching the qualitative findings. These findings indicate that differentiation between pain-related distress and depression may be possible in primary care consultations for persistent musculoskeletal pain. This is essential to ensure that patients are offered appropriate, acceptable, and effective management.

Objectives To explore patient and clinician experiences of participation in the MACRO randomised controlled trial (RCT)—which found endoscopic sinus surgery (ESS) to be clinically effective whereas clarithromycin was no better than placebo for chronic rhinosinusitis (CRS)—and to identify barriers and facilitators to the implementation of the trial results. Design Qualitative study embedded within the multicentre MACRO RCT. Semistructured interviews with patients and clinicians were analysed using thematic analysis. Setting 21 secondary and tertiary ear, nose and throat centres in England and Scotland participating in the MACRO RCT. Participants 20 CRS patients (16 with nasal polyps, 4 without) were interviewed approximately 6 months after trial completion, and 17 clinical staff including principal investigators (PIs), associate PIs and research nurses. Results This study explored patients’ and clinicians’ experiences of the trial to identify barriers and facilitators to implementing the findings. Adopting the outcomes of the trial would involve recommending surgery to more patients with CRS. Yet patient and clinician interviews highlighted polarised views on ESS among patients, between those with positive experiences and expectations of ESS and those expressing fear of complications and hesitancy to receive surgery. During the trial, many participants randomised to surgery reported rapid improvement in symptoms, but with postoperative challenges for some patients including pain, unexpected symptoms and variations in recovery period. Priorities for implementation include providing patients with information about risks and support to make informed choices. Clinicians also reflected on the resource implications for offering ESS to more patients. Conclusions ESS is effective for CRS, but patient hesitancy and recovery concerns persist. Implementation requires clear communication, recognition and respect for individual preferences, tailored support for decision-making and post-surgical care to optimise acceptance and outcomes. Trial registration number ISRCTN36962030.

Background: There are increasing numbers of cancer survivors who have finished their primary treatment, but whose quality of life remains consistently poor over years. There is limited evidence for pragmatic, brief interventions to support cancer survivors in primary care, where most patients are managed. Objective: To develop, trial and assess the effectiveness and cost-effectiveness of a digital intervention to support cancer survivors (named ‘Renewed’) designed to require minimal health service resources. Design: Qualitative development of the intervention, then open randomised controlled trial, with a process analysis and health economic analysis. Setting: United Kingdom primary care Interventions: Development of the intervention: We systematically reviewed the relevant qualitative and quantitative literature to inform initial intervention planning, intervention content and design features of a digital intervention. This was followed by iterative development and optimisation of intervention content and the human support component – in qualitative studies of the views of cancer survivor, and of National Health Service, volunteer and charity workers. Main trial: Participants: People who had finished primary treatment for colorectal, breast or prostate cancer with lower quality of life (European Organization for Research and Treatment of Cancer QLQ-C30 score < 85) within the last 10 years. Participants were randomised to one of three groups: (1) ‘generic’ advice: detailed digital National Health Service support for healthier living (‘Living Well’), (2) a bespoke digital intervention (‘Renewed’) addressing symptom management, physical activity, diet, weight, distress and/or fear of recurrence, or (3) ‘Renewed’ plus support (additional brief support by e-mail, telephone, or face to face) Main outcome measures: Primary outcome: European Organization for Research and Treatment of Cancer QLQ-C30 (overall score). Secondary outcomes: subscales of European Organization for Research and Treatment of Cancer QLQ-C30 (global self-rated health; functional subscales; symptom subscales), EuroQol-5 Dimensions, five-level version, psychological measures and costs. Results: At the primary time point of 6 months, there were clinically important improvements in European Organization for Research and Treatment of Cancer QLQ-C30 score contrary to the expected trajectory of quality of life in this population, but with no evidence of differences between groups. By 12 months, the Renewed plus support group had continued to improve and was better than generic advice (1.42, 95% confidence intervals 0.33 to 2.51), with the largest differences in the prostate cancer subgroup. 13 of the 14 subscales also improved compared to generic advice, statistically significant for self-rated global health (Renewed: 3.06, 1.39 to 4.74; Renewed plus support: 2.78, 1.08 to 4.48), dyspnoea, constipation and enablement. For Renewed plus support, there were also statistically significant differences for physical, cognitive and emotional functioning and fatigue. Renewed and Renewed plus support were dominant given improved effectiveness combined with and lower mean primary care National Health Service costs per patient (respectively −£141, −153 to −128; −£77, −90 to −65). Limitations: Of those sent invitation letters, 14% (7883/59,295) were assessed for eligibility and 35% (2732/7883) of those assessed were eligible and agreed to participate – which is normal with the ‘cold calling’ method of invitation. The digital intervention would not suit people who find technology or the internet difficult to access, but only 25% (2649/10,697) of those who gave reasons for declining did so due to lack of internet access. The extensive generic advice available to participants in the National Health Service limited the ability to assess the specific benefits of Renewed in the short term, but nevertheless longer-term benefit and lower National Health Service costs are likely to be achieved with the bespoke intervention. Conclusions: Cancer survivors with lower quality of life given detailed generic online support improve significantly. Providing robustly developed, low-cost, bespoke digital support can provide further modest long-term improvements in enablement, symptom management and self-rated global health, with substantially lower National Health Service costs. Future work: The cost-effectiveness and benefits for symptom management on self-rated health suggest a more widespread implementation study should be undertaken. Trial registration: This trial is registered as Current Controlled Trials ISRCTN 96374224. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: RP-PG-0514-20001) and is published in full in Programme Grants for Applied Research ; Vol. 14, No. 4. See the NIHR Funding and Awards website for further award information.