Figure 1: Number of antidepressants dispensed in Blackpool and Windsor, Ascot and Maidenhead

One of the medications I looked at was antidepressant drugs. Figure 1 shows the number of antidepressant drugs dispensed in the Blackpool CCG and the Windsor, Ascot and Maidenhead CCG between January and March 2015. It shows that antidepressant drugs were dispensed almost three times more in Blackpool CCG than Windsor, Ascot and Maidenhead CCG. This is evident as there were 53,986 items per 100,000 people of antidepressant drugs dispensed in Blackpool CCG, whereas there was only 18,898 items per 100,000 people of it dispensed in Windsor, Ascot and Maidenhead. According to research by The Department for Communities and Local Government Blackpool is a poor city as it was part of the 10% most deprived areas in England, while Windsor, Ascot and Maidenhead is described as one the richest areas in England. This may explain why antidepressant drugs are dispensed more in Blackpool CCG than Windsor, Ascot and Maidenhead CCG.

Figure 2a: Antidepressant prescribing per 100,000 of population by Care Commissioning Group

Figure 2a compares the number of items of antidepressants dispensed in CCG’s across England with the population of the CCG’s. The orange map is the number of antidepressants dispensed in CCG’S between January and March 2015. The areas shaded in cream orange dispensed small amount of antidepressants, while the brown areas dispensed large amounts. The green map shows the population of CCG’s in 2012, the areas shaded in light green have smaller populations, while the dark green areas had the highest populations.

Figure 2b: Population for each Care Commissioning Group (CCG)

Figure 2b shows that the population size of the CCG did not have much effect on the number of antidepressants that were dispensed. This is evident as Cambridgeshire and Peterborough CCG had a population size of 850,073 which was one of the highest populations but it only dispensed 29,502 antidepressants per 100,00 people. It also shows that although Durham Dales, Ealing and Sedgefield CCG does not have a high population size, it dispensed 47,641 antidepressants per 100,000 people, when the highest number of antidepressants dispensed out of all the CCG’s was 53,986 items per 100,000 people. It also shows that generally there were more antidepressants dispensed in the north of England than the south.

Figure 3

Figure 3: Number of drugs used in diabetes dispensed in Richmond CCG and Lincolnshire CCG

Figure 3 shows the number of drugs used in diabetes dispensed in Richmond CCG and Lincolnshire East CCG between January and March 2012. It shows that Lincolnshire East CCG dispensed over twice as many drugs used in diabetes than Richmond CCG. This is evident as per 100,000 people there were 34,368 items dispensed in Lincolnshire East whereas there was only 13,106 items dispensed in Richmond. According to Public Health England Lincolnshire was worse than the benchmark for excess weight in adults, while Richmond was better than the benchmark. This may affect why there were fewer drugs used in diabetes dispensed in Richmond CCG than in Lincolnshire East CCG as diabetes is often linked to being overweight.

Figure 4: Age distribution in Islington and Somerset 2013

From figures 4 it can be concluded that Islington had a higher proportion of young people than Somerset. This is evident as 25% of Islington’s population was aged 21-30, compared to 10% of Somerset’s population. It also shows that there were more old people in Somerset than Islington as the age group with the highest number of people in Somerset was those aged 61-70. This is evident as 15% of Somerset’s population was in this age category, compared only 7% of Islington’s.

Figure 5: Number of drugs for dementia dispensed in Islington and Somerset

Figure 5 shows the number of drugs for dementia dispensed in Islington CCG and Somerset CCG between January and March 2015. It shows that there were more drugs for dementia dispensed in Somerset than Islington. This is evident as there were 1,333 items per 100,000 people dispensed in Somerset, compared to 831 items per 100,000 people that was dispensed in Islington. There are more old people in Somerset and this may contribute to why there were more drugs dispensed in Somerset than Islington, which has more young people.

Figure 6: Levels of corticosteroids dispensed

Figure 6 shows the number of items of corticosteroids (Respiratory) dispensed in different CCG’s across England between January and March 2015. The areas shaded in the light grey are where the smallest numbers of corticosteroids (respiratory) that were dispensed, while the areas shaded dark pink dispensed the highest number of items. The map shows that the East of England dispensed large numbers of corticosteroids, especially when compared to areas in and around London. It also shows that Blackpool CCG dispensed the highest number of Corticosteroids (Respiratory) at 16,194 items per 100,000 people, while the smallest number of items was dispensed in Southwark at 4,141 items per 100,000 people.

Conclusion

I found that for many of the drugs the north of England dispensed more than the south of England. It therefore might be argued that the South is generally healthier than the North. I would also conclude from looking at a range of medications that The Durham Dales, Easington and Sedgefield CCG, Lincolnshire CCGs, the Norfolk CCG and the Blackpool CCG are among the unhealthiest CCG’s in England, as they dispensed the highest number of items for many medications.

Findings:

Figure 1 – Number of items dispensed for branded (Zocor tablets) and generic (Simvastatin)

This is evident as Figure 1 shows the number of items of the branded medication called Zocor tablets 40mg that were dispensed, and the number of items of it’s generic version called Simvastatin tablets 40mg that were dispensed in August 2014. The generic medication was dispensed at a much higher rate than it’s branded alternative. This is evident as there were 1,748,989 Simvastatin tablets dispensed, compared to the 345 Zocor tablets that were dispensed. These tablets are used to reduce levels of low-density lipoprotein and increase levels of high-density lipoprotein.

Figure 2: Cost per item of branded (Zocor tablets) and generic (Simvastatin tablets)

Figure 2 shows the cost per item of Zocor 40mg tablets and its generic alternative called Simvastatin 40mg tablets that were dispensed in August 2014. It shows that the branded medication was a lot more expensive than the generic medication. This is apparent as the branded item, Zocor 40mg Tablets cost £39.10 per item, while the generic item, Simvastatin 40mg tablets only cost £1.33 per item. Figures 1 and 2 illustrate how general practioners often dispense more generic items than branded items to reduce the expenditure pressure on the NHS as they show that the cheaper generic version of the medication was dispensed more than the expensive branded version.

Figure 3: Number of branded and generic items of skin cream dispensed

Figure 3 shows the number of branded and generic items of skin creams dispensed in March 2014. It shows that the branded medication, called Aveeno cream, was dispensed to a much larger extent than its generic alternative, called Dimeticone/Cetrimide cream 10%. There were 72,597 items of Aveeno Cream dispensed, whereas there were only 170 items of the generic version dispensed.

These creams are used to prevent and treat dry skin.

Figure 4: Cost per item of the branded and generic versions of skin creams

Figure 4 is the cost per item of the branded and generic versions of skin cream. It shows that the branded cream, Aveeno Cream was more expensive than the generic version called Dimeticone/Cetrimide cream 10%. The branded medication was about £5 more expensive than the generic as Aveeno Cream costs £8.92 per item while Dimeticone/Cetrimide cream cost £3.14.

Patients trusting the branded medication that they are used to over the newer generic versions could affect this, and the doctor may be likely to give in to their requests.

Figure 5: Number of branded and generic oral powder sachets dispensed

Figure 5 shows the number of branded and generic versions of oral powder sachets that were dispensed in August 2014. The branded version is called Laxido oral powder sachets and the generic version is called Macrogol Co oral powder sachets. The branded version of the medication was dispensed over 2x’s more than it’s generic alternative. This is evident as there were 209,449 items of Laxido oral powder sachets dispensed, compared to only 94,864 items of Macrogol Co oral powder sachets. This medication is a laxative used to treat patients who have had long-term constipation.

Figure 6: Cost per item of branded and generic versions of oral powder sachets

Figure 6 shows the cost per item of branded and generic versions of Oral powder sachets in August 2014. It shows that the branded medication was half the price of the generic version. This is evident as Laxido Oral Powder Sachets cost £5.78 per item, whereas Macrogol Co Oral Powder Sachets cost £10.80 per item. When looking at Figures 5 and 6 together they show that the branded medication was cheaper than the generic and was dispensed more than the expensive generic version.

The table below summarises the data on the number of branded and generic items dispensed and the ratio for each of the medications I looked at, as well as the cost per item and the ratio of that.

Conclusion:

I was expecting to find that the generic version would be cheaper and so dispensed more than the branded version of the medicines, and I did find this for a few medications. However I was surprised to find that there are medicines where the branded medication was dispensed more than generic alternative even though it was more expensive, and that branded medication can be cheaper than it’s generic alternative. Also the absolute level of prescription for the different medication is interesting as there were only 72,597 items of Aveeno Cream dispensed, compared to 1,748,989 Simvastatin tablets. The difference could be because Aveeno Cream can be bought without a prescription and it is used for dry skin, whereas Simvastatin tablets can be used to lower cholesterol and risk of heart disease, diabetes and stroke.

BNF Chapter 1: Gastro-intestinal System

The most prescribed item was Omeprazole Tablets 20mg as there were 2,002,522 items of this medication dispensed in April 2014.This is shown in Figure 1. Omeprazole tablets are used to treat symptoms caused by excess amounts of acid in the stomach such as stomach ulers, heartburn and indigestion, by reducing acid in the stomach.It can also be used to promote healing of erosion in the esophagitis, caused by stomach acid.This medication may have been dispensed in large amounts because there is a lack of enzymes in the food a lot of us eat today, such as white bread, pasta, cookies, cakes,cracker etc ,therefore the stomach produces an excessive amount of stomach acid to compensate, leading to acid indigestion.

Top 10 prescribed items for BNF Chapter 1

BNF Chapter 2: Cardiovascular System

The most prescribed item was Simvastatin tablets 40mg at 1,829,256 items dispensed in April 2014. This medication is used to reduce levels of “bad” low-density lipoprotein cholesterol, while increasing levels of ‘good’ high- density cholesterol. However the second most prescribed medication under BNF Chapter 2 was Aspirin Dispersible tablets at 1,781,963 items. Aspirin Dispersible tablets are used for pain relief, reducing temperature and also act as an anti-inflammatory to reduce swelling and aspirin can be used to prevent formation of blood clots. It is argued that Simvastatin tablets were dispensed a lot because many doctors prescribe them to patients who have high blood pressure as preventive measure, as well as prescribing it to patients with high cholesterol. Another reason why Aspirin Dispersible tablets were dispensed in large amounts is that it can be used to treat a number of different symptoms that are common as most people suffer from them at some point in their life.

BNF Chapter 3: Respiratory System

The most prescribed item was the Salbutamol inhaler 100mcg in April 2014. It is used to treat breathing disorders, it relaxes muscles in the lungs and helps to keep the airways open, making it easier to breathe. It is used by adults, adolescents and children aged 4 to 11 years, as it is a good, reliable way to help those with either mild, moderate or severe asthma.There were 890,667 items dispensed of this medication.The high number of items of the Salbutamol Inhaler 100mcg is likely to be because asthma is a serious long-term condition that affected 1 in 12 adults and 1 in 11 children in 2014 in the UK according to Asthma UK. There were 1,167 deaths from asthma in the UK in 2011 and the use of the fast working Salbutamol Inhaler can reduce and prevent symptoms of asthma and so decrease the number of deaths caused by this condition. This again shows why the Salbutamol Inhaler was the most prescribed item in BNF Chapter 3.

BNF Chapter 4: Central Nervous System

The most prescribed medication was Paracetamol tablets 500mg, which are used to treat pain including headaches, toothache, cold or flu symptoms and back or period pain. This item was prescribed a lot more than other items in this BNF Chapter as 1,551,769 items of it were dispensed in April 2014. This is evident when it is compared to the 676,756 items dispensed of the second most prescribed medication which was Citalopram Hydrobromide tablets 20mg.Citalopram Hydrobromide is a medicine that is used in depression and panic disorders. A reason why paracetamol may be dispensed so much is because the symptoms it treats are common to many people.

BNF Chapter 5 : Infections

The most prescribed medication in April 2014 was Amoxicillin Capsules 500mg at 548,282 items. It is a penicillin antibiotic that can be used to treat many different types of infection caused by bacteria, such as tonsillitis, bronchitis, pneumonia, gonorrhea, and infections of the ear, nose, throat and skin.

BNF Chapter 6:Endocrine System

The most prescribed medication was Metformin Hydrochloride tablets 500 mg, which are used in diabetes mellitus. There were 996,821 items of this dispensed in April 2014.It is used to control high blood sugar levels and helps the body to have the correct response to the insulin it produces.Therefore it is typically used by people who have type2 diabetes.

BNF Chapter 7: Obstetrics, Gynaecology and Urinary- tract Disorders

The most prescribed item was Tamsulosin Hydrochloride tablets 400mcg at 497,341 items. It is used to relax the muscles in the prostate and bladder neck, making it easier for men with enlarged prostate to urinate. There is a large difference between the most prescribed medication and the second most prescribed medication as solifenacin tablets 5 mg was dispensed 116,124 times in April 2014.This medication is used in reducing the frequency of passing urine. The large difference is shown in figure2

Top 10 prescribed items in BNF chapter 7

BNF Chapter 8: Malignant Diseases and Immunosuppression

The most prescribed item was Azathioprine tablets 500mg, which helps to suppress over activity in the immune system and helps to limit inflammation reducing pain and swelling. It is also used by people who have undergone organ transplants as it helps to reduce the chance of the body rejecting the new organ. There were 52,476 items of this medication dispensed in April 2014.This is closely followed by the second most prescribed item at 49,661 items dispensed of Tamoxifen Citrate tablets 20mg. Tamoxifen Citrate tablets are effective in the treatment of breast cancer in women and men that can spread to vital organs. This condition is life threatening, therefore tamoxifen Citrate tablets that can be effective in treating it were dispensed in large amounts.

BNF Chapter 9: Nutrition and Blood

The most prescribed item in April 2014 was Folic Acid 5mg at 442,617 items. This is used to help produce and maintain new cells and prevent changes to DNA that could cause cancer. According to Cancer Research UK there were 331,487 new cases of cancer in the UK in 2011. This is a large number and it can be argued that in order to reduce the number of people who get cancer, there are large quantities of drugs dispensed that are useful in preventing cancer such as Folic Acid 5MG. Therefore explaining why it was the most prescribed item in BNF Chapter 9 in all the months I looked at.

BNF Chapter 10: Musculoskeletal and Joint Diseases

The most prescribed medication was Naproxen tablets 500mg at 307,772 items in April 2014. Naproxen is used to reduce hormones that cause inflammation and pain in the body.

BNF Chapter 11: Eye

The most prescribed item in April 2014 was Latanoprost Eye Drops 500mcg at 182,354 items. This is used for conditions such as Ocular Hypertension and Glaucoma as it helps to lower pressure in the eye by increasing fluid drainage from the eye.

BNF Chapter 12: Ear, Nose and Oropharynx

The most prescribed item was Beclometasone Dipropionate, which is used to relieve symptoms of asthma and chronic obstructive pulmonary disease. There were 140,352 items of this medication dispensed in April 2014. The drug Mometasone Furoate Nasal Spray 5mg at 134,921 items closely followed this.This medication is a steroid used to treat nasal symptoms such as sneezing, and runny nose caused by allergies. It is likely that these two medications were dispensed in large amounts at this time because there is a lot of pollen in the air in April, leading to symptoms that these drugs treat .

BNF Chapter 13: Skin

The most prescribed medication in April 2014 was Doublebase Gel at 143,002 items dispensed. It is used to moisturize skin by replacing lost water within the skin. Figure 3 shows that BNF Chapter 13 has the closest number of the items for the top two most prescribed items as the second most prescribed item Diprobase Cream was dispensed 142,806 times. This medication is used to treat eczema and other dry skin conditions.

Top 10 prescriptions for BNF chapter 13

BNF Chapter 14 :Immunological products and Vaccines

The most prescribed medication was Revaxis vaccine 0.5ml at 38,473 items in April 2014. Revaxis is used to protect against diphtheria, tetanus and polio.It is usually given to children from the age of six, teenagers and adults.The booster vaccine is typically given out at secondary school.

BNF Chapter 15: Anaesthesia

The most prescribed item was Lido Hydrochloride Injection 1% 2ml, which is used as local anaesthetic used when performing operations. There were 19,954 items of this dispensed in April 2014.

Conclusion

The final figure is the most prescribed items for each BNF Chapter in April 2014. It shows that out of all of the most prescribed items of all the BNF Chapters ,Omeprazole Capsule under BNF Chapter 1( Gastro-intestinal system) was dispensed in the largest amount, as there were 2,002,522 items of this medication dispensed.It also shows that one of the least dispensed medications when looking at the most prescribed items was Azathioprine tablets 500mg at 52,476 items. The BNF Chapter that had the smallest number of items dispensed was chapter 15( Anaesthesia).

Overall I have not been surprised with the drugs that were the most prescribed for each BNF Chapter as they are drugs that treat long-term illnesses or symptoms that most people will experience in their life.This is apparent when looking at the most prescribed items for BNF Chapters 2,3,6,9,12 and 13 which treat or prevent long-term illnesses such as high cholesterol, asthma, diabetes and cancer.Whilst the most prescribed items for most of the other BNF Chapters are helpful with common symptoms that nearly everyone will experience in their lives such as sneezing,inflammation and pain in the body,headaches, toothache and different types of infection caused by bacteria.

The most prescribed medication for each BNF Chapter in April 2014

I now look forward to digging deeper into the GP Prescribing data to find out more new things such as whether there are seasonal variations in the medication that is prescribed and whether there are variations by location.

Prescriptions Dispensed in the Community, Statistics for England

Every year this bulletin gives a summary of prescriptions dispensed in the community by community pharmacists, appliance contractors and dispensing doctors in England for the previous 10 years. The first one that was made publicly accessible was prescriptions dispensed in the community , statistics for England 1994-2004 and since then every year there has been one that gives an overview of the previous 10 years.The latest bulletin is prescriptions dispensed in the community, statistics for England 2004-2014.

Each bulletin shows the changes within the most recent 10 years. It also includes the overall net ingredient cost of prescriptions, the leading BNF sections in terms of chemical name, number of items, item difference and NIC difference.

The specific source for these statistics is the Prescription Cost Analysis (PCA) data. The Health and Social Care Information Centre (HSCIC) publishes the Prescription Cost Analysis National Statistic, based on PCA figures for the most recent year in April annually.

Clinical Commissioning Group Prescribing Data

Clinical Commissioning Groups are part of the NHS and are responsible for the services in their local area by finding out what services are needed and what is provided. The Clinical Commissioning Group prescribing data is released every quarter of the year,therefore there is clinical commissioning group data for January-March,April- june, July – September and October – December. It uses a (CSV) file to make it more accessible to the public.

The Clinical Commissioning Group data covers prescription data on the North of England,Midlands and East of England, London and South of England. Variations in number of items and NIC may be affected by the population in the different areas.

GP Practice Prescribing Presentation-level Data

The practice level data is the finest-grain presentation of the prescribing data. It is collected and presented every month for each year and has a large file size (over 1GB). It includes a list of all medications, dressings  and appliances that are prescribed and dispensed each month under their BNF code and BNF name. For all the medicine, dressings and appliances the data shows the total number of items prescribed and dispensed, the total net ingredient cost, the total actual cost and the total quantity. It also gives the code of each practice, period, strategic health authority and primary care trust. This data covers prescriptions written and dispensed in England and those dispensed outside of England.

NICE Technology Appraisals in the NHS in England, Innovation Scorecard – Experimental statistics

The National Institute for Health and Care Excellence (NICE) work  to reduce variation in the availability and quality of NHS treatments and care and so try to provide equal high quality care across the different area of England by giving advice on the use of medication and treatment by the NHS. This dataset is experimental and uses available data to show variations and trends across time and type of medication and location. It includes interactive maps and spreadsheets that allow users to pick the organisations and time periods they want to find trends for and therefore it also includes national level data medication use, area team level data for medicine use, CCG medicine use and trust level data for medication technology sales and purchases.

Hospital Prescribing

This data has been  presented every year since 2004, it compares cost of NICE appraised medicines for primary and secondary care trusts and every year the focus is on a different kind of medication for example in 2010 it was on ADHD, psychosis and anti –  tumour necrosis factor (TNF) medicines, in 2011 it was on medicines for HIV and AIDS and in 2012 it was focused on antibacterial drugs.

The report includes: the information sources, NIC, Coverage, Overall cost (nationally and strategic health authority level, medications appraised by NICE, specific therapeutic area, sources and definitions and drugs included in the Analyses. The last hospital prescribing dataset available on the Health and Social Care Information Centre data catalogue page was in 2012.

What’s next ?…

After reading about what each of the datasets were about, I decided that the GP Prescribing Presentation Level Dataset would be the best for me to use when trying to discover trends and patterns in GP Prescribing data. I now look forward to trying to find out what the most prescribed medication is for each BNF Chapter, whether there are seasonal variations for some items and maybe the differences in the amount of money the NHS is spending on proprietary drugs and generic drugs.

As part of my internship, provided by the Q-step programme,  I am trying to think more quantitatively.

One of the things I have learnt is that when given a dataset the first thing to do with it is to break it down and make sure the meaning of everything is understood. Therefore with the data I am looking at I researched the meaning of each heading for the columns on the dataset. In this blog I will explain what each of these terms mean.

The British National Formulary (BNF)

Central to the GP prescribing data is the BNF. This is the British National Formulary which is produced by The British Medical Association and the Royal Pharmaceutical Society. It is used to give doctors and nurses advice on the selection, prescribing, dispensing and administration of medication in the UK. The BNF classifies medicines into therapeutic groups which are known as BNF Chapters. There are 15 BNF chapters and some ‘pseudo BNF chapters’ (numbered 18 to 23) that include items such as dressings and appliances. The 15 BNF Chapters are:

• Chapter 1:Gastro-intestinal System
• Chapter 2: Cardiovascular System
• Chapter 3: Respiratory System
• Chapter 4: Central Nervous system
• Chapter 5: Infection
• Chapter 6: Endocrine System
• Chapter 7: Obstetrics, Gynaecology and Urinary- tract disorders
• Chapter 8: Malignant Diseases and Immunosuppression
• Chapter 9: Nutrition and blood
• Chapter 10: Musculoskeletal and joint diseases
• Chapter 11: Eye
• Chapter 12:Ear, nose, and oropharynx
• Chapter 13: Skin
• Chapter14: Immunological Products and Vaccines
• Chapter 15: Anesthesia

Under each BNF Chapter there are subsections for example, under Chapter 2 (Cardiovascular System) one of the subsections is 2.12 Lipid-regulating drugs.

The BNF Code is the unique code that each medication has. An example of a BNF Code is 0212000U0AAADAD which is for the drug Simvastatin Tablet 40mg. The BNF Code for each drug is formed as follows:

• Characters 1 & 2 show the BNF Chapter (02)
• 3 & 4 show the BNF Section (12)
• 5 & 6 show the BNF paragraph (00)
• 7 shows the BNF sub-paragraph (0)
• 8 & 9 show the Chemical Substance (U0)
• 10 & 11 show the Product (AA)
• 12 & 13 indicate the Strength and Formulation (AD)
• 14 & 15 show the equivalent (AD). The ‘equivalent’ is defined as follows:
  • If the presentation is a generic, the 14th and 15th character will be the same as the 12th and 13th character.
  • Where the product is a brand the 14 and 15 digit will match that of the generic equivalent, unless the brand does not have a generic equivalent in which case A0 will be used.

The BNF Name is the individual preparation name for each drug. It includes the name of the drug, which could be branded or generic, followed by form it comes in and the strength of the medication. On the GP Prescribing Data – Presentation Level  dataset I used, the BNF names were often presented in an abbreviated form due to the limited number of characters available in the dataset.

Other terms

• The Strategic Health Authorities (SHA) is an NHS organisation established to lead the strategic development of the local health service and manage Primary Care Trusts and NHS Trusts and are responsible for organising working relationships by getting service level agreement.
• A Primary Care Trust (PCT) are under SHAs and are local organisations that are responsible for managing health services in the community. Examples of PCT are GP surgeries, NHS walk-in centres, dentists and opticians. However in the last 2-3 years the PCTs have been converted to Care Commissioning Groups (CCG), but much of the data that I was looking at talks about PCTs.
• Items are defined as the number of items that were dispensed in the specified month. A prescription item is a single supply of a medicine, dressing or appliance written on a prescription form. If one prescription form includes four medicines, it is counted as four prescription items.
• Quantity is the drug dispensed measured in the units. The units are dependent on the makeup of the medication, for example if it is a tablet or capsule the quantity will be the number of tablets or capsules, whereas if it is a solid such as a cream or gel the quantity will be in grammes.
• Net Ingredient Cost (NIC) is the price of the drug written on the price list or drug tariff.
• Actual Cost is the estimated cost to the NHS. It is calculated by subtracting the average percentage discount per item (based on the previous month) from the Net Ingredient Cost, and adding in the cost of a container for each prescription item. It is usually lower than NIC.
• Period is the year and month that the dataset covers.

Now that I understand the meanings of each column of the dataset I am looking at, I am trying to find new things with it. Feel free to refer back to this blog when reading my future blogs on my findings, especially if you stumble upon something you have forgotten the meaning of.