eClinicalMedicine

BackgroundHealthcare system disparities have a significant impact on chronic disease management in conflict-affected settings. Vitiligo, a stigmatizing dermatological condition, requires sustained care, yet limited evidence exists regarding how healthcare sector differences affect patient outcomes in Afghanistan. This study addresses this critical knowledge gap in a post-conflict, resource-limited setting. The main objectives of this study were to compare socio-demographic profiles, clinical characteristics, psychological burden, and health-related quality of life (HRQoL) between vitiligo patients attending public versus private hospitals in Kandahar, Afghanistan. MethodsA cross-sectional analytical study was conducted from March 2023 to January 2024 with 402 vitiligo patients (153 [38.1%] from three public hospitals and 249 [61.9%] from five private hospitals). Comprehensive assessment included socio-demographic variables, clinical severity (Vitiligo Area Severity Index [VASI]), psychological distress (General Health Questionnaire-12 [GHQ-12]), anxiety (Hamilton Anxiety Rating Scale [HAM-A]), depression (Quick Inventory of Depressive Symptomatology [QIDS-SR16]), and HRQoL (Dermatology Life Quality Index [DLQI]). Stratified analyses, multivariable linear regression, and interaction testing were performed. ResultsCompared to public hospitals, patients visiting private hospitals were younger (69.3% aged 18- 29 years, {chi}2=21.4, p<0.001), more rural (65.5%, {chi}2=12.7, p<0.001), and less educated (63.9% illiterate, {chi}2=15.2, p<0.001). However, clinical severity (VASI: public M=6.58{+/-}7.47; private M=6.84{+/-}4.64; t=-0.427, p=0.670), psychological burden, and HRQoL showed no significant differences between sectors. Interaction analyses revealed moderating effects: disease severity impacted HRQoL more strongly in public hospitals (VASIxhospital type: B=-0.168, 95%CI: - 0.258 to -0.077, p<0.001, {beta}=-0.515), while psychological distress affected HRQoL more in private settings (GHQxhospital type: B=0.440, 95%CI: 0.094 to 0.785, p=0.013, {beta}=0.442). ConclusionWhile demographic disparities exist in healthcare access, clinical and psychological outcomes are similar across sectors. However, pathways to HRQoL impairment differ significantly, suggesting sector-specific mechanisms requiring tailored interventions. These findings highlight the need for equitable, context-sensitive vitiligo care that addresses both universal and sector-specific determinants of patient well-being in conflict-affected settings.

BackgroundSkin disease affects 4.7-4.9 billion individuals globally; however, little is known about access to dermatological care. MethodsWe conducted a multinational, cross-sectional survey of dermatological care across 194 WHO member states and three additional geographic areas in 2024-2025. Primary outcomes included dermatologist density per 100,000 population and number of dermatologists globally. Secondary outcomes included training programme density, workforce distribution, perceived access to care, and health system characteristics. Descriptive statistics and nonparametric tests compared outcomes across World Bank Income (WBI) levels and WHO regions. FindingsResponses were obtained from 158 countries. Mean dermatologist density was 2.66 per 100,000, ranging from 0.37 in low-income (LICs) to 5.05 in high-income countries (HICs). There are estimated 175,633 dermatologists globally (95% CI: 173,598-177,668). Forty-two percent of countries reported inadequate or extremely poor access to dermatological care. There was significant variation (p < 0.001) in access to all types of subspecialty care (paediatric, surgical, dermatopathology) across WBI levels, with consistently worse access in lower-income countries. Dermatologists are primarily based in urban centres (79%). Twenty-one percent of countries lack dermatology training programs, with training varying by WBI level (p < 0.001). Non-dermatologist healthcare workers bear a substantial responsibility for management of skin disease. InterpretationSignificant global disparities exist in access to dermatological care, particularly in lower resource settings. Achieving skin health equity will require global commitment to expanding/funding training programmes, incentivizing decentralization of dermatology practice, and optimizing alternative care delivery including upskilling front-line healthcare workers. FundingInternational League of Dermatological Societies and LOreal Dermatological Beauty.

UK-based quantitative research on the health and education outcomes of Unaccompanied Asylum-Seeking Children (UASC) remains limited, especially at national level. Linked administrative data provide an unprecedented opportunity to study these outcomes among UASC. This paper lays a foundation for further research, particularly examining the influence of socio-demographic, legal and environmental factors on UASCs health and educational outcomes. We described the UASC population with a first recorded episode of local authority care between 1st April 2005 and 31st March 2021 in ECHILD, which gathers national records for England, by age, gender, ethnicity, region, and placement type. We calculated linkage rates between the social care and educational dataset, estimating how many UASC were recorded as being enrolled in state-funded schools. We also assessed how many of those linked to the school dataset was linked to National Health Service (NHS) datasets. Finally, we explored how linkage rates between social care, education, and NHS datasets vary by socio-demographic factors and placement type. There were 37,170 UASC recorded in the ECHILD of which 32,570 (88%) were male and 24,290 (65%) aged 16 - 17 years. We found 7,740 (21%) UASC recorded as being enrolled in state funded schools, of whom 6,690 (88%) were also linked to NHS data. The linkage rate for UASC in the social care to health datasets was therefore 19%. Of those 16-17 years at entry in social care, 4% (1,060/24,290) were recorded as enrolled in school compared to 50% (6,390/12,880) under 16 years. Linkage to the school, and subsequently to the NHS dataset, wholly depends on enrolled state-funded education, excluding College and Sixth-form education. Despite this limitation, we characterised a national cohort of 6,890 UASC in England whose social care, education, and health outcomes can be examined.

Background: Global guidelines recommend strengthening and integrating health services for skin diseases, yet evidence for strategies remains scarce. We evaluated a decentralised approach to the care of skin disease through integration within routine primary care, by assessing uptake, equity, alignment with skin disease burden and associated treatment costs. Methods and findings: A before-and-after intervention study was conducted across all 17 public health facilities in Atwima Mponua district, Ghana from November 2023 to September 2024 (intervention period). We analysed routine health facility records to compare uptake of primary care for skin diseases pre-intervention (January to October 2023) and during the intervention. We assessed the burden of skin disease through a community-based two-stage cross-sectional dermatological survey, and estimated patient and provider costs for skin disease through post-care questionnaires and health facility surveys. We compared uptake to disease burden and assessed catastrophic expenditure and factors associated with higher treatment costs. Uptake of primary care for skin disease doubled during the intervention period relative to the pre-intervention period (adjusted incidence rate ratio (aIRR) 2.0, 95% CI 1.92-2.09), with greatest increases amongst school-age children (aIRR 2.70, 2.46-2.97) and individuals residing within very rural communities (aIRR 2.79, 2.47-3.15). Amongst 42,801 individuals surveyed, odds of any skin disease were greater amongst males (adjusted odds ratio (aOR) 1.25; 1.13-1.38), pre-school age children (aOR=1.80, 1.61-2.80), and residents of very rural communities (aOR=1.68, 1.09-2.61). Males and school-age children remained underrepresented amongst those who sought care during the intervention period relative to those diagnosed during the survey. Amongst patients seeking care for skin NTDs and complex wounds, 4% experienced catastrophic expenditure, driven largely by costs prior to visiting an intervention health facility. Conclusions: Greater integration within primary care substantially increased uptake of care for skin disease, but populations at greatest risk remained underrepresented amongst those accessing care. These findings highlight the need for deliberate strategies to address persistent barriers to care, with lessons for integration efforts across primary health systems.

Background There are no licensed treatments for patients with mild to moderate patchy alopecia areata (AA). Objectives To evaluate the efficacy, safety and dose response of STS01, a novel nanoparticle controlled release, topical formulation of dithranol/Prosilic. Methods In a phase 2, double blind study, adult patients with mild to moderate AA (guideline 10% to 50% of scalp hair loss) were randomly assigned to STS01 at doses of 0.25%, 0.5%, 1%, 2% or placebo, daily for 6 months. The primary endpoints included the proportion of patients achieving a >=30% improvement in Severity of Alopecia Tool (SALT) score, and percentage change from baseline in SALT score. This minimum level of improvement is generally accepted as an indicator of the population likely to progress to complete regrowth Results A total of 155 patients were randomized and treated (placebo, n=32; STS01 groups, n=30 to 31). STS01 1% met the primary efficacy endpoint of >=30% SALT score improvement compared to placebo: 75.9% (95% CI, 60.3 to 91.4%) vs 36.7% (95% CI, 19.4 to 53.9%) at 6 months; p=0.0037. The least squares (LS) mean percentage change in SALT score from baseline to end of treatment showed a clear dose response relationship; STS01 0.5% was the minimally effective dose and 2% the maximum tolerated dose, and there was a statistically significant improvement in the STS01 1% group (minus 55.0% vs +0.6% with placebo; p<0.01). Significant improvements (p<0.05) in LS mean percentage changes from baseline in SALT scores were demonstrated in the STS01 1% group at 2 months (-28.6% vs 12.8%), 4 months (-57.2% vs 1.5%), and 6 months (minus 67.0% vs 0.6%). Clinical Global Impression improvement was reported in 72.0% of patients with STS01 1% vs 41.7% with placebo (p<0.05). The most commonly reported treatment emergent adverse events were skin irritation reactions, but were mostly mild (STS01: 56.7% to 71.0%; placebo: 21.9%) or moderate (STS01:13.3% to 35.5%; placebo: 0%) and manageable by reduced frequency of application. There were 15 skin-related discontinuations with STS01 (12.2%) and 2 (6.3%) with placebo. Conclusions STS01 demonstrated a clear dose response, with STS01 1% dose optimally more effective than placebo for hair regrowth with minimal tolerance concerns in mild to moderate patchy AA. Skin irritation reactions were generally manageable and there were no new safety signals. Further characterisation of the STS01 1% dose is planned in a phase 3 study. Chief Investigator AGM reports fees from Soterios Ltd. Chief Statistician DMF is an employee of Soterios Ltd. All other authors were Principal Investigators in the trial and their clinics were reimbursed for the work involved. Most also had sponsorship in the form of consultancies, investigational roles or lecturing roles on behalf of other Dermatological pharmaceutical companies

Background Childhood sensory and intellectual disabilities represent significant yet under-recognized barriers to learning and human capital development. This study analyzes prevalence and severity of these conditions among 149.3 million children aged 5-19 years across 25 countries in Latin America and the Caribbean (LAC) using Global Burden of Disease 2023 data. Methods We extracted GBD 2023 estimates for vision loss, hearing loss, and intellectual disability across 25 LAC countries, stratified by age, sex, and severity. Regional estimates were calculated using population-weighted averages. Severity distributions were compared with OECD countries to contextualize regional patterns. Results: These conditions are estimated to affected 9,282,921 children (6.22%; 95% UI: 5.89-6.54%). Hearing loss was predominant, affecting an estimated 5.42 million (3.63%, 3.41-3.86), with 87.6% mild-to-moderate. Intellectual disability estimated to affected 2.56 million (1.71%, 1.58-1.85), with 61.7% borderline-to-mild. Vision loss estimated to affected 1.30 million (0.87%, 0.79-0.96), with 89% that can be effectively addressed with spectacles. Prevalence increased with age across all conditions. Male predominance was consistent for intellectual disability (2.00% vs 1.42%). Annual economic cost totaled US$19.3-29.0 billion, while comprehensive interventions would require US$9.45-14.23 billion with benefit-cost ratios of 2:1 to 15:1. Conclusions The distribution of children across milder levels of difficulty underscores the opportunity for education and public health systems to provide timely and accessible support. With approximately 88% of sensory impairments addressable through established technologies, investments in inclusive services can yield strong social and economic returns.

OBJECTIVEOpioid misuse exacts a tremendous toll on society. Mindfulness-Oriented Recovery Enhancement (MORE) is an efficacious treatment for opioid misuse. Yet, the cost-effectiveness of this intervention remains unknown. METHODSCost-effectiveness and cost-benefit analyses of a randomized clinical trial with enrollment of 250 adults with chronic pain prescribed long-term opioid therapy who were misusing opioids. Participants were randomized to MORE (training in mindfulness, reappraisal, and savoring positive experiences) or supportive group psychotherapy across 8 weekly 2-hour groups. Incremental cost-effectiveness ratios (ICER) and benefit-to-cost ratios (BCRs) were computed using the primary outcome of opioid misuse at 9-month follow-up, as assessed by a composite measure based on self-report, clinical interview, and urine screen. RESULTS250 randomized patients (64.0% female) had an average age of 51.8 years (SD=11.9), were mostly taking oxycodone or hydrocodone (69%), and had mean morphine equivalent opioid dose of 101.0 (IQR=74) mg. At 9-mo. follow-up, the difference in the probability of having a positive Drug Misuse Index (DMI) rating was 0.24 (0.54 for MORE participants vs. 0.78 for controls). The ICER of MORE relative to supportive psychotherapy was $116.3 per averted case of opioid misuse, $8.9 per life-year, and $8.0 per quality-adjusted life-year. MORE is cost-saving vs. supportive psychotherapy after adjusting for healthcare costs. Excluding all benefits associated with averting fatal overdoses results in a BCR of 84.2. CONCLUSIONSGiven MOREs cost-effectiveness, private and public payers should consider disseminating this evidence-based therapy broadly across the nation to reduce mortality and morbidity associated with the ongoing opioid crisis. HIGHLIGHTSO_LIMindfulness-Oriented Recovery Enhancement (MORE) substantially reduced opioid misuse among adults with chronic pain on long-term opioid therapy. C_LIO_LIMORE was highly cost-effective vs. supportive psychotherapy, costing $116 per averted opioid misuse case, and MORE was cost saving when accounting for healthcare costs associated with opioid misuse. C_LIO_LIFindings suggest wide dissemination of this evidence-based treatment could yield major healthcare and other economic benefits in addressing the opioid crisis. C_LI

Introduction The link between Human Papillomavirus (HPV) and cancer is well-established. In Singapore, bivalent HPV vaccines are subsidised for females, but not males. Economic analysis of HPV vaccination has generally assessed the costs to the health system, but this may not be as relevant to individual decision-making as potential lost income. We estimated the impact of bivalent HPV 16/18 vaccination on sick leave, unemployment, and premature mortality as a function of age and sex to understand the broader impact of HPV-related cancers. Methods We developed a population-level economic model to estimate lifetime income losses by diagnosis age, sex and cancer type. We applied sex- and cancer-specific Cox regressions to the Singapore Cancer Registry for annual predicted survival from 1992 to 2022. These were combined with census and employment data to estimate HPV-associated income losses in Singapore. Attributable fractions and vaccine effectiveness data for HPV 16/18 from the literature were used to estimate the effectiveness of bivalent HPV vaccination. Structural sensitivity analysis examined the role of 80% population coverage conferring herd immunity. Results The registry contained 17,294 individuals with an HPV-associated cancer diagnosis. Lost income was greatest for cervical cancer due to its high prevalence, however the losses per diagnosis were highest for oropharyngeal cancer. Bivalent HPV vaccination led to income benefits of $SGD1,397 [$895 to $1,838] in girls and -$62 [-$76 to -$48] in boys. A gender-neutral HPV vaccination of 80% of 15-year-old Singaporeans, conferring herd immunity, would have lifetime income protective benefits of $24.4m [$14.2m, $33.7m] per cohort, a five-fold return on investment. Conclusions In addition to avoiding healthcare costs and lost quality of life, parents should consider vaccination as a means of avoiding potential income losses. A national policy of gender-neutral HPV vaccination could deliver substantial income protection due to both individual vaccine protection and herd immunity.

BackgroundPerinatal mood and anxiety disorders are the most common complications of pregnancy. Given the limited mental health resources, there is a need for novel treatment approaches. Though smartphone applications can increase access to evidence-based care, recent research highlights notable limitations, including varying quality and unclear effectiveness. Blended hybrid care models, which integrate synchronous telehealth services with asynchronous modalities (such as mobile apps), have emerged as an alternative. This pilot study evaluates one such model, the Digital Clinic, to determine its potential to bridge this critical treatment gap and compare outcomes to that of non-peripartum patients in the clinic. MethodsPregnant and postpartum women referred for anxiety and depression received 8 weeks of synchronous, virtual, evidence-based CBT from a trained clinician. This treatment was complemented by the asynchronous use of the mindLAMP app, providing digital phenotyping, psychoeducation, and CBT skills, with the support of a Digital Navigator. The efficacy of the intervention was evaluated by comparing GAD-7 and PHQ-9 scores from intake to the end of treatment. ResultsThis secondary analysis included 13 peripartum women from a larger sample of 224 clinic patients. At intake, they reported a mean PHQ-9 score of 9.4 (SD=3.9) and a mean GAD-7 score of 11.69 (SD=6.0). After 8 weeks, participants reported statistically significant decreases of 4.14 points on the GAD-7 (p<.01) and 3.92 points on the PHQ-9 (p<.01). Effect sizes for these reductions were 0.74 (95% CI: 0.20, 1.28) for GAD-7 and 1.10 (95% CI: 0.29, 1.90) for PHQ-9. ConclusionA novel blended hybrid care model, the Digital Clinic, was successful in reducing depression and anxiety among pregnant and postpartum women. This novel approach to maternal mental health shows promise for delivering accessible, effective, evidence-based care to peripartum patients in real-world settings. Future work should further validate its effectiveness with larger, more diverse patient populations with moderate to severe disease.

BackgroundMpox-related ophthalmic disease (MPOXROD) ranges from mild conjunctivitis to sight-threatening keratitis, however, data based on systematic ophthalmological assessment are scarce. We aimed to characterise the prevalence, features, and temporal evolution of MPOXROD during a clade Ib mpox outbreak. MethodsWe conducted MBOTE-EYE, a prospective ophthalmological sub-study, nested within a clinical characterisation cohort in Kamituga, South-Kivu, Democratic Republic of the Congo. All hospitalised patients with mpox confirmed by PCR in the prior 48 hours were eligible. Participants underwent comprehensive ophthalmological examination at enrolment, discharge, and days 29 and 59 post-diagnosis. Conjunctival swabs were collected for monkeypox virus PCR testing. MPOXROD was defined as conjunctivitis, scleritis, keratitis, uveitis, or optic nerve involvement. Risk factors were assessed using mixed-effects Poisson regression. FindingsBetween 28 October 2024 and 30 June 2025, 310 participants were enrolled (median age 14 years, IQR 2.5-25.0; 53.5% female, n=166/310). At enrolment, conjunctivitis was present in 36.1% (95% CI 31.0-41.6%, n=112/310), keratitis in 7.7% (95% CI 5.3-11.3%), and anterior uveitis in 0.6% (95% CI 0.2-2.3%). Overall, 43.2% (95% CI 37.8-48.8%) developed MPOXROD during follow-up, most often bilaterally. Visual acuity <8/10 occurred in 22.9% (95% CI 17.6-29.2%, n=24/310), and persistent blindness in 0.9% (95% CI 0.24-5.5%, n=2/225), due to ulcerative keratitis. Periorbital lesions (adjusted risk ratio [aRR] 2.82, 95% CI 1.40-5.69) and severe malnutrition (aRR 5.06, 2.25-11.38) were independently associated with MPOXROD. Conjunctival swabs with PCR Ct values < 25 occurred exclusively in participants with active MPOXROD. InterpretationOphthalmic involvement in clade Ib mpox is common and frequently bilateral, with a substantial burden of keratitis and risk of vision loss, particularly in young children and severely malnourished individuals. These findings highlight the need for systematic eye examinations in mpox care and provide critical evidence to inform future trials of targeted ophthalmic therapies. FundingNone of the funders had a role in study design, analysis, interpretation, or writing.

Objective: To independently audit vendor-reported performance claims of health AI systems deployed in Nigeria and assess discrepancies, clinical consequences, equity impacts, and implications for safe AI deployment in low- and middle-income countries. Methods and analysis: We conducted a mixed-methods longitudinal audit (October 2024-March 2026) of six health AI systems (chest X-ray interpretation, TB screening, symptom triage, maternal health risk prediction, patient history intake, and health chatbots) across 73 diverse health facilities in six Nigerian states, involving 52,000 patients and 45 key informant interviews conducted with stakeholders. All data were sourced from integrated facility-level records, and no database linkage was performed. Vendor claims were abstracted from documentation, white papers, and validation studies. Independent performance was verified by an independent third party through system logs, patient records, clinical outcomes, and stakeholder interviews. Performance gaps were quantified as absolute percentage-point differences; clinical harms were estimated using patient volume and bootstrap confidence intervals; equity impacts were assessed across vulnerability dimensions (geography, age, income, comorbidities, infrastructure) using interaction terms in mixed-effects models and an Equity Harm Index (EHI). Results: Vendor-reported accuracy averaged 91.5%, while independently measured real-world accuracy averaged 67.3%, yielding a mean performance gap of 24.2 percentage points (95% CI: 21.5 to 26.9; p<0.001) across systems. Gaps ranged from 17 to 35 percentage points and were statistically significant for all systems. These discrepancies translated to substantial preventable harm, including an estimated 1,247 undetected TB cases (186 preventable deaths) and 342 misclassified high-risk pregnancies annually. Performance gaps were 28-38% larger among vulnerable groups (e.g., rural patients showed 38% higher EHI). Gaps were classified as systematic, context-dependent, or population-dependent. Conclusion: Vendor-reported performance metrics substantially overstated the real-world effectiveness of health AI in Nigeria, leading to preventable patient harm and widening inequities. Mandatory independent post-deployment verification, analogous to pharmaceutical Phase IV surveillance, is essential to ensure safe, equitable AI use in resource-constrained settings. Donors and regulators should prioritize verification over trust-based deployment.

BackgroundClinical and genetic evidence on the association between atopic dermatitis (AD) and subsequent psoriasis remains conflicting, and it is unclear whether this risk is modified by systemic treatments. Recent reports suggest type 2-targeted biologics may unmask psoriasis in AD patients, but data are limited. We thus aimed to assess whether AD is associated with incident psoriasis and whether this risk differs by systemic treatment, particularly biologics versus conventional systemic immunosuppressants (cvIS). MethodsScoping analyses informed a locked analytic design, preregistration at OSF, and confirmatory execution. Propensity score-matched analyses compared AD with non-AD controls and biologics with cvIS. Sensitivity analyses, Cox model triangulation, and control outcomes assessed robustness. FindingsAmong [~]300,000 matched pairs, AD was associated with increased psoriasis risk (primary HR 3.81, 95% CI 3.35-4.34), consistent across all 8 sensitivity analyses and model triangulation. Biologic treatment was associated with reduced psoriasis risk versus cvIS (primary HR 0.20, 95% CI 0.11-0.35), consistent across 6 of 7 evaluable sensitivity analyses and Cox triangulation. Positive and negative control outcomes showed expected directional patterns. InterpretationAcknowledging limitations including residual confounding and coding misclassification, AD was associated with increased psoriasis risk and biologics with lower psoriasis risk than cvIS. FundingDFG (EXC2167, SFB1526, LU877/25-1), Schleswig-Holstein Excellence-Chair Program, Swedish Society for Dermatology and Venereology, and the Tore Nilson Foundation. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSAtopic dermatitis (eczema) and psoriasis are the two most common chronic inflammatory skin diseases worldwide. For a long time, doctors and researchers assumed these two conditions could not occur in the same person, as they were thought to involve opposing immune responses. However, this view has been challenged over the past decade. Some large studies, including population-based cohorts from Taiwan and the United Kingdom, have found that people with eczema may be at higher risk of developing psoriasis over time, while other studies, including genetic analyses, have suggested the opposite: that the two diseases may actually protect against each other. This conflicting picture has left clinicians uncertain about the true relationship between the two diseases in everyday clinical practice. A separate but related concern has emerged with the introduction of a new class of highly effective treatments for eczema, biologics, particularly dupilumab. Case reports and observational studies, including a large study published in JAMA Dermatology in 2025, have raised the possibility that these medications might trigger psoriasis in some patients, potentially by shifting the immune system from one inflammatory pattern to another. However, prior studies on this question had important methodological limitations: they were not pre-planned and registered before data collection, they did not always tightly link treatment use to an eczema diagnosis, and critically, none compared biologic treatment directly against conventional immunosuppressant medications, the most relevant clinical comparator. Added value of this studyThis study is a large and methodologically rigorous investigation of both questions: whether eczema itself increases the risk of developing psoriasis, and whether the type of systemic treatment used for eczema influences that risk. Using a database of over 110 million electronic health records from across the United States, we matched approximately 300,000 patients with eczema to 300,000 patients without eczema and followed them for up to seven years. We also compared nearly 5,500 patients treated with biologics to an equal number treated with conventional immunosuppressants. Crucially, our study was pre-registered before any data were analyzed, meaning the research questions, methods, and analyses were locked in advance and could not be adjusted based on what the data showed. We also used a range of additional analyses to test whether our findings were robust, including checks using outcomes that should not be affected by eczema or its treatment (such as appendectomy and hearing loss), which confirmed that our results were not likely explained by bias alone. We found that eczema was associated with an increased risk of developing psoriasis, but that this risk was substantially influenced by the choice of comparison group, ranging from approximately 1.4-fold to nearly 4-fold depending on the analytical approach. More strikingly, we found that patients treated with biologics had a markedly lower risk of developing psoriasis compared with those treated with conventional immunosuppressants, the opposite of what prior reports had suggested. This finding was consistent across nearly all additional analyses performed. Implications of all the available evidenceTaken together with existing evidence, these findings suggest two important conclusions. First, clinicians should be aware that eczema, particularly moderate-to-severe eczema requiring systemic treatment, may carry an elevated risk of developing psoriasis over time. This does not mean that all patients with eczema need to be screened for psoriasis routinely, but it does support clinical awareness and monitoring in higher-risk patients. Second, and perhaps most importantly for treatment decisions, biologics do not appear to increase the risk of psoriasis compared with conventional immunosuppressants and may in fact be associated with a lower risk. This provides reassurance for patients and clinicians considering biologic therapy and challenges the narrative that these medications trigger psoriasis. Future research should aim to confirm these findings in other populations, investigate the biological mechanisms underlying the relationship between eczema and psoriasis, and examine whether specific biologic agents differ from one another in their effects on psoriasis risk.

ObjectiveTo assess the contribution of changing child poverty rates to trends in measles, mumps and rubella (MMR) vaccination. DesignLongitudinal area-level analysis using within-between models to assess the association of increases in child poverty within-areas on MMR vaccination Setting148 upper-tier local authorities in England from 2015 and 2024. ParticipantsChildren aged 5 years or younger eligible for MMR vaccination in England between 2015 and 2024. 6,468,620 children aged 24 months were included in the study and 6,907,640 aged 5 years. ExposuresChild poverty rates for each upper-tier local authority, measured as the percentage of children aged 0 to 15 living in households below 60% of Organisation for Economic Co-operation and Development (OECD) median, before housing costs. Outcome MeasuresMMR 1st and 2nd dose uptake rates by 24 months 5 years of age respectively, at upper-tier local authority. ResultsOver the study period, MMR 1st dose fell by 4.0 percentage-points (%) (range: -20.8 to 7.7) and MMR 2nd dose by 4.9% (range: -23.4 to 10.1) while child poverty rose by 5.6% (range: 0.2 to 13.9) on average. A 1 percentage-point (%) increase in child poverty was associated with a 0.17% [95%CI: -0.29; -0.06] fall in MMR 1st dose rates and a 0.26% [95%CI: -0.42; -0.10] fall in MMR 2nd dose rates. ConclusionRising child poverty rates have contributed to a decrease in MMR vaccination in children in England. Action to reduce child poverty is needed to improve childhood vaccination uptake alongside policies and interventions specific to vaccination and infectious disease prevention. Summary boxO_ST_ABSWhat is already known on this topicC_ST_ABSInequalities in childhood vaccination uptake in England are stark and have widened, especially for MMR vaccination. Child poverty in England has increased and is associated with rising inequalities in multiple domains of childrens health but impacts on inequalities in vaccination uptake are unclear. What this study addsA 1 percentage-point increase in child poverty was associated with a 0.17 percentage point fall in uptake of MMR1 and a 0.26 percentage point fall in MMR2 between 2015 and 2024. Reducing child poverty is likely to increase vaccine uptake and reduce the burden of vaccine preventable diseases in England.

ObjectivesTo estimate current, and 5- and 10-year projected, number of cases of cancer per year in transgender and gender diverse (TGD) people in England, overall and by tumour type, accounting for uptake of gender affirming care (GAC). DesignPopulation-based epidemiological modelling study using an age-stratified Monte Carlo simulations approach and the NORDPRED method for predictions. SettingModels estimating cancer case numbers for TGD people in England based on publicly available 2023 cancer surveillance data and survey-based 2025 GAC access, and predicted at 5 and 10 years hence. ParticipantsTGD people aged 15 years and above. Main outcome measuresPrimary cancer cases per year overall, by gender, age group, tumour type, and current and planned GAC. ResultsThe estimated TGD population size in England is 441547 (95% uncertainty interval (UI) 429207- 452890). Total cases per year of cancer in TGD people is expected to be 966 (95% UI 882-1069) excluding non-melanoma skin. Most cases are expected to occur in people aged 60-64. The top 5 expected cancers in TGD people are breast (19%, n = 187, 95% UI 149-241), colorectal (12%, n = 117, 95% UI 106-129), lung (11%, n = 108, 95% UI 96-122), melanoma (7.1%, n = 69, 95% UI 64-74) and urinary (6.2%, n = 60, 95% UI 54-67). Total cases of cancer in TGD people are estimated to be 1740 (95% UI 1584-1934) in 5 years and 2258 (95% UI 2066-2507) in 10 years (excluding non-melanoma skin). If TGD people were able to access their planned level of GAC, this would reduce these figures to 1555 (95% CI 1386-1766) and 2012 (95% CI 1797-2282) respectively. ConclusionsThis study provides prediction of cancer cases in TGD people in England, supporting the planning of service provision and training. This is vital, as with increasing disclosure, and long wait times for GAC, cancer cases in TGD people are predicted to increase. Summary BoxesO_ST_ABSWhat is already known on this topicC_ST_ABSThe annual number of cases of cancer in transgender and gender diverse (TGD) people in England is currently unknown as gender incongruence is not collected as part of the National Cancer Registration and Analysis Service. Some gender-affirming care (GAC) interventions are known to modulate cancer risk. Use of testosterone and chest reconstruction for transmasculine people is known to reduce their incidence of breast cancer compared to cisgender women. Use of oestradiol alongside medical or surgical androgen suppression has been shown to reduce the incidence of prostate cancer in transfeminine people while increasing their risk of breast cancer, compared to cisgender men. What this study addsThis study found that there are likely to be approximately 966 cases of cancer (excluding non-melanoma skin) in TGD people per year in the UK. Though total annual cases of cancer in TGD people are expected to be 2258 in 10 years, improved access to gender-affirming care could reduce total cases to 2012 (a 11% reduction). These figures provide additional justification for funding to improve access to GAC via the National Health Service (NHS), as well as for training on the oncological needs of this population.

Anaemia remains a significant public health issue in India, despite five of control programs. Anaemia affects 52-67% of target populations in India despite five decades of control programmes. We conducted a review of reviews and meta-analyses (SRMAs) of regional studies to evaluate daily versus intermittent oral iron and iron-folic acid (IFA) supplementation across age groups. We identified 21 SRMAs (17 high-quality, 4 moderate-quality) and 44 regional studies from India and South Asia. IFA prophylaxis consistently improved haemoglobin levels (4.1-8.8 g/L increase) and ferritin concentrations, reducing anaemia risk by 23-70% across all age groups. IFA prophylaxis consistently improved haemoglobin levels (4.1-8.8 g/L increase) and ferritin concentrations, reducing anaemia risk by 23-70% across all age groups. Daily and intermittent regimens showed similar haematological outcomes in children, adolescents, and women of reproductive age. Among pregnant women, daily supplementation was superior for haemoglobin and ferritin levels, though intermittent dosing had fewer gastrointestinal side effects. These findings support weekly IFA supplementation for non-pregnant beneficiaries as an evidence-based strategy, even in settings where anaemia prevalence exceeds 40%. Further research on long-term safety in non-iron-deficient populations is needed.

BackgroundAdolescents with perinatally acquired HIV in India experience a high burden of stigma and mental health distress alongside gendered social constraints that limit participation in supportive programs. While physical activity-based psychosocial interventions show promise for improving adolescent mental health, little is known about how gender norms and intersecting vulnerabilities shape engagement and outcomes among this population. This study examined gender-specific patterns of participation and associations with mental health in a peer-led running intervention in southern India using intersectionality and self-determination theory. MethodsWe conducted a convergent parallel mixed-methods evaluation between March-April 2024 among 150 adolescents and young adults with perinatally acquired HIV enrolled in a physical activity intervention (Positive Running) in Karnataka and Tamil Nadu. Surveys assessed sociodemographic characteristics, viral suppression, intervention adherence, and common mental health disorders using validated screening tools for depression (PHQ-9) and anxiety (GAD-7). Gender-disaggregated comparisons used Fishers exact tests, and logistic regression estimated prevalence odds ratios for common mental health disorders by intervention adherence. Qualitative data included four age- and gender-stratified focus group discussions (n=28) with participants, and four in-depth interviews with peer implementers. Transcripts were thematically analyzed using grounded theory and Braun & Clarkes framework. ResultsAmong 150 participants (100 males, 50 females; median age 17 years [IQR 15-19]), 91% were virally suppressed. Mean adherence to the intervention was 64%, with high attendance ([&ge;]65%) significantly lower among females than males (20% vs 57%, p<0.001). Overall, 59% screened positive for at least one common mental health disorder; with higher prevalence among females than males for depression (66% vs 43%, p=0.009), and for any mental health condition (72% vs 52%, p=0.022). Higher intervention adherence was associated with lower odds of common mental disorder overall (OR 0.44, 95% CI 0.23-0.85). In age-adjusted, gender-stratified analyses, this association was significant among males (aOR 0.33, 95% CI 0.14-0.75) but not among females. Qualitative findings identified gendered barriers to participation, including restrictive norms, modesty expectations, stigma toward women in sport, and limited decision-making autonomy. Self-determination theory-informed analyses highlighted how structured training, peer mentorship, and visible female role models supported autonomy, competence, and relatedness, while also revealing constraints that attenuated mental health gains for girls. ConclusionsPeer-led, community-embedded physical activity interventions are feasible among adolescents and young adults with perinatally acquired HIV and may confer mental health benefits, though participation effects are gender-differentiated. Findings underscore the need for gender-responsive, autonomy-supportive program designs that address intersectional vulnerabilities to ensure equitable mental health impact, particularly for adolescent girls and young women.

ObjectiveInvestigate a strategy of mass asymptomatic testing and isolation ("pulse testing") aimed at early containment of outbreaks in prisons in comparison to or combination with a symptom-based isolation strategy. MethodsSimulations using an individual-based time-since-infection model were run under different pathogen and intervention strategy scenarios. Measured outcomes were the proportion of outbreaks contained and number of individuals isolated. ResultsFor R0 = 2, 25% probability of being asymptomatic (pa = 0.25), a COVID-19-like infection dynamics and perfect adherence, one pulse test contained approximately 20% of outbreaks, and three tests up to 50%. With no asymptomatic cases, three tests performed similarly to isolating cases one day after symptoms ({approx} 55% outbreaks contained), but symptom-based isolation degraded significantly faster than pulse testing with increasing pa. With perfect adherence, combining both interventions contained between {approx} 25% (R0 = 3, pa = 0.5) and > 90% (R0 = 1.5, pa = 0) of outbreaks. Across all scenarios, pulse testing isolated substantially fewer individuals than symptom-based isolation, e.g. {approx} 5% versus {approx} 30% for R0 = 2 and pa = 0.25. ConclusionIf implemented promptly upon outbreak declaration and with high adherence, pulse testing may stop outbreaks early, substantially reducing the number of isolations and mitigating the impact on prison regime and resident/staff wellbeing. However, for large R0 or delayed implementation, effectiveness drops rapidly.

Background The ageing of incarcerated populations is accelerating across high-income countries, yet dementia remains absent from routine correctional mental health statistics. We investigated whether correctional data systems in Japan, the United States, the United Kingdom, and Australia are structurally capable of detecting dementia in their prison populations. Methods We conducted a cross-national descriptive analysis of publicly available, aggregate-level correctional data. Japanese data comprised all newly admitted sentenced prisoners from 2006 to 2024 (approximately 390,000 individuals) from the Ministry of Justice Correctional Statistics Annual, including mental disorder classifications and CAPAS-derived work aptitude scores (used as a proxy for cognitive functioning; not clinical IQ measurements). US data were drawn from the Bureau of Justice Statistics Survey of Prison Inmates (2016). UK data were obtained from the Ministry of Justice Offender Management Statistics Quarterly (2015-2025). Australian data were sourced from the Australian Institute of Health and Welfare National Prisoner Health Data Collection (2022, n = 371). All analyses were descriptive; no inferential statistics were conducted. Findings Three distinct mechanisms rendered dementia statistically invisible across all four countries. First, in the United States and Australia, reliance on self-report instruments produced a paradox in which self-reported mental disorder prevalence declined with age: among US state prisoners, reported prevalence fell from 44.9% in the 35-44 age group to 31.9% among those aged 65 and older - the opposite of community epidemiological patterns. Second, in Japan - the only country with systematic cognitive assessment at prison admission - 35.0% of female theft offenders had work aptitude scores below 70, yet the classification system contains no dementia category; 43-52% of all detected mental disorders were absorbed into a residual "other" category even after a 2023 classification revision that added four new diagnostic categories but not dementia. Third, the United Kingdom lacks routine mental health prevalence data collection in prisons altogether. None of the four countries includes dementia as a standard correctional classification category. Interpretation Correctional mental health statistics across four high-income countries are structurally incapable of detecting dementia - not through clinical ignorance but by design: systems built for younger populations that have not been updated as prison demographics have changed. Japan's ageing female theft offender profile (39.4% aged 60 or older, 35.0% with low cognitive scores) represents a potential sentinel population for undetected cognitive impairment. Targeted interventions - cognitive screening at admission in the United States and Australia, introduction of a dementia classification category in Japan, and routine mental health data publication in the United Kingdom - are feasible with existing infrastructure. As prison populations continue to age, the statistical invisibility of dementia constitutes an escalating failure of health surveillance with direct consequences for clinical care, sentencing, and human rights.

Armed conflict in Sub-Saharan Africa has exposed millions of civilians to repeated and severe traumatic events, yet the prevalence of posttraumatic stress disorder (PTSD) and its associated determinants across the region have not been comprehensively synthesised. This study aimed to estimate the prevalence of PTSD and examine its associated factors among conflict-affected adult populations in Sub-Saharan Africa. Methodological quality was assessed using the Joanna Briggs Institute (JBI) criteria for cross-sectional and epidemiological studies A systematic search of PubMed, MEDLINE, Embase, Scopus, CINAHL, APA PsycINFO, the Cochrane Library, and the WHO Global Index Medicus (including African Index Medicus) was conducted for studies published between January 1, 2000, and May 31, 2025. Observational studies reporting PTSD prevalence among adults aged 18 years or older exposed to armed conflict were included. Study selection followed PRISMA 2020 guidelines, with independent screening by two reviewers. Random-effects meta-analyses with logit transformation were used to pool prevalence estimates, and determinants were synthesised narratively with emphasis on adjusted effect estimates. Heterogeneity was assessed using the I{superscript 2} statistic. Sixty-eight studies comprising 82,021 participants from 13 countries met inclusion criteria. The pooled prevalence of PTSD was 43% (95% CI, 35.9%-50.0%), with substantial heterogeneity (I{superscript 2} = 99.9%). Prevalence was highest among refugees (79%), followed by internally displaced persons (48%) and residents of conflict-affected communities (34%). Female sex was consistently associated with increased odds of PTSD (pooled adjusted odds ratio approximately 2.0), as were comorbid depression or depressive symptoms (AOR range 4.2-9.5). Additional correlates included cumulative trauma exposure, displacement, poor social support, and substance use. Overall, PTSD is highly prevalent among conflict-affected adults in Sub-Saharan Africa, underscoring the need for integrated, context-sensitive mental health strategies to address the enduring psychological consequences of armed conflict in the region.

BackgroundSexual minority (SM) individuals have worse mental health than heterosexual peers. However, there is no total population-based and national-level evidence on differences in risk of self-harm and suicide by sexual orientation. This study provides the first national population-based estimates in England and Wales. MethodsUsing 2021 Census data linked with hospital records and death registrations, we analysed sexual orientation (SO) differences in: (i) at least one hospital inpatient admission/emergency attendance for intentional self-harm, and (ii) death by suicide. We calculated age-standardised rates per 100,000 people by SO between March 2021 and December 2023, and stratified by sociodemographic, geographical, socioeconomic and health-related variables. We calculated rate ratios for lesbian/gay/bisexual/other SO (LGB+) groups compared with heterosexuals to estimate sexual identity disparities. FindingsOur study population included 28.7 million people (mean age 48.1 years, 53.7% female, 84.2% White) aged [&ge;]16 years who self-reported their SO in Census 2021 and linked to an NHS number. LGB+ individuals had 2.52 (95% CI 2.48-2.56) times higher risk for self-harm and 2.17 (95% CI 1.98-2.37) times higher risk for suicide than heterosexual people. Relative risk of self-harm was highest for LGB+ females, younger adults, and Black individuals. Relative risk of suicide was highest for LGB+ females, older adults, and Black individuals. InterpretationThis study demonstrates stark inequalities in risk of self-harm and suicide by sexual orientation, consistent across multiple sociodemographic factors. These findings are important for informing government prevention programs and further mental health research. FundingThere was no external funding for this study. Research in contextO_ST_ABSEvidence before the studyC_ST_ABSThe substantial evidence on higher risk for self-harm and suicide in sexual minority groups in the UK (and wider Europe) is impacted by regional samples, younger populations, or surveys limited by smaller numbers precluding analyses by key sociodemographic factors (like sex, ethnic group, socioeconomic indicators, faith, housing situations and geographical indicators) or combining all sexual minority groups together. To date, no study has used total population-based data to examine sexual orientation inequalities in self-harm and suicide and in relation to a range of sociodemographic factors. Added value of this studyTo our knowledge, this is the first study in the UK to provide national population-based estimates of intentional self-harm and suicide by sexual orientation, including intersectional analyses across age, sex, ethnic group, and socioeconomic position. This study used a unique linkage between the census, hospital inpatient data, emergency care records and death registrations from across England and Wales, with a study population of 28.7 million people aged [&ge;]16 years who self-reported their sexual orientation in Census 2021 and linked to a National Health Service (NHS) number. Implications of all the available evidenceThis research provides national population-level evidence of substantial increased risk for self-harm and suicide among sexual minority individuals, compared with heterosexual individuals. This study also identified key groups of individuals at an increased risk of self-harm and suicide. These findings are important for informing government prevention programs and further research supporting the mental health of sexual minority groups.