Systematic meta-analysis of the risk factors for deliberate self-harm before and after treatment for first-episode psychosis

OBJECTIVE

Attempted suicide and deliberate self-injury can occur before or after presentation with a first-episode of psychosis. The aim of the study is to identify the factors associated with suicide attempts or deliberate self-injury before and after treatment for first-episode psychosis.

METHOD

A systematic review and meta-analysis of controlled studies of factors associated with either suicide attempts or deliberate self-injury, referred to here as deliberate self-harm (DSH).

RESULTS

The pooled proportion of patients who reported DSH prior to treatment for first-episode psychosis was 18.4% (95% Confidence Interval (CI) 14.4-23.3, N = 18 studies, I(2) = 93.8). The pooled proportion of patients with DSH during the period of untreated psychosis was 9.8%, (95% CI 6.7-14.2, N = 5 studies, I(2) = 58.9). The pooled proportion of patients committing DSH during periods of follow up of between 1 and 7 years was 11.4%, (95% CI, 8.3-15.5, N = 13 studies, I(2) = 89.2). Categorical factors associated with an increased risk of DSH were a prior history of DSH (OR = 3.94), expressed suicide ideation (OR = 2.34), greater insight (OR = 1.64), alcohol abuse (OR = 1.68) and substance use (OR = 1.46). Continuous variables associated with an increased risk of DSH were younger age of onset (Standardized Mean Difference (SMD) = -0.28), younger age at first treatment (SMD = -0.18), depressed mood (SMD = 0.49) and the duration of untreated psychosis (SMD = 0.20). Depressed mood and substance use were associated with DSH both before and after treatment, negative symptoms were associated with DSH after treatment but not before treatment. Positive symptoms and social and global functioning were not associated with DSH. Younger age and the duration of untreated psychosis were associated with DSH before treatment but not after treatment.

CONCLUSION

Earlier treatment of first-episode psychosis and successful treatment of depression and substance use could prevent some episodes of DSH and might reduce suicide mortality in early psychosis.

Counseling customers: emerging roles for genetic counselors in the direct-to-consumer genetic testing market

Individuals now have access to an increasing number of internet resources offering personal genomics services. As the direct-to-consumer genetic testing (DTC GT) industry expands, critics have called for pre- and post-test genetic counseling to be included with the product. Several genetic testing companies offer genetic counseling. There has been no examination to date of this service provision, whether it meets critics' concerns and implications it may have for the genetic counseling profession. Considering the increasing relevance of genetics in healthcare, the complexity of genetic information provided by DTC GT, the mediating role of the internet in counseling, and potential conflicts of interest, this is a topic which deserves further attention. In this paper we offer a discourse analysis of ways in which genetic counseling is represented on DTC GT websites, blogs and other online material. This analysis identified four types of genetic counseling represented on the websites: the integrated counseling product; discretionary counseling; independent counseling; and product advice. Genetic counselors are represented as having the following roles: genetics educator; mediator; lifestyle advisor; risk interpreter; and entrepreneur. We conclude that genetic counseling as represented on DTC GT websites demonstrates shifting professional roles and forms of expertise in genetic counseling. Genetic counselors are also playing an important part in how the genetic testing market is taking shape. Our analysis offers important and timely insights into recent developments in the genetic counseling profession, which have relevance for practitioners, researchers and policy makers concerned with the evolving field of personal genomics.

Upper and lower airway nitric oxide levels in primary ciliary dyskinesia, cystic fibrosis and asthma

BACKGROUND

Patients with primary ciliary dyskinesia (PCD) have abnormal ciliary function and low nitric oxide levels. Nitric oxide (NO) biosynthesis is dependent on nitric oxide synthases (NOS). Cilia line the bronchial but not the alveolar epithelium. It has been hypothesised that NOS function relies on normal ciliary function and that in PCD bronchial but not alveolar NO might therefore be reduced. The aim of this study was to assess bronchial and alveolar NO levels primarily comparing healthy children to PCD and secondarily to cystic fibrosis (CF) and asthmatic children.

METHODS

Multiple flow-rate fractional exhaled and nasal NO measurements were performed using a NIOX(®) Flex NO analyser (Aerocrine, Sweden) in children with PCD (n = 14), asthma (n = 18), CF (n = 12) and healthy controls (n = 18). Alveolar and bronchial NO levels were derived using a model of pulmonary NO exchange-dynamics.

RESULTS

Both the bronchial and alveolar NO were significantly lower in PCD than healthy controls (mean (SD) 264 (209) picolitres/second (pl/s) vs. 720 (514) pl/s, p = 0.024 and 1.7 (0.8) parts per billion (ppb) vs. 3.5 (1.3) ppb, p = 0.001 respectively.) In asthmatics bronchial NO was found to be significantly higher than in healthy controls and in children with CF alveolar NO was significantly lower (2100 (1935) pl/s, p = 0.045 and 2.5 (1.2) ppb, p = 0.034 respectively.)

CONCLUSION

Our findings do not support the hypothesis that NOS and ciliary function are coupled instead suggesting a more generalised mechanism for the low levels of NO seen in PCD. Our findings in CF and asthma corroborate evidence that these are diseases of the lung peripheries and bronchi respectively.

A prospective study of infliximab withdrawal after 12 months of treatment in patients with Crohn's disease: how will NICE guidance affect patient care?

Infliximab is a biological agent that is licensed for the treatment of severe Crohn's disease. The annual cost of infliximab treatment is approximately pound 16,456 (excl VAT). In May 2010, the National Institute for Health and Clinical Excellence (NICE) recommended that patients should receive biological agents as a planned course of treatment only until treatment failure or until 12 months after the start of treatment, whichever is shorter. Patients should then have their disease reassessed to determine whether they still have active disease and whether ongoing therapy is still appropriate. We assessed the impact of the new NICE guidance on patient care by prospectively auditing patients who had been receiving infliximab for 12 months or more. The audit provided the opportunity for full disease reassessment and, for patients who were in clinical remission, the option to stop treatment. Disease was reassessed in 21 patients; a further 13 patients refused consent. Four patients were in deep clinical remission and discontinued infliximab. Implementation of the NICE recommendations on the use of infliximab in Crohn's disease is likely to be challenging in the face of significant resistance from patients who have an understandable fear of relapse. It might be more appropriate to discuss treatment withdrawal when high-quality evidence is available to support this management option.

Developing sensory awareness in qualitative interviewing: a portal into the otherwise unexplored

Within the social sciences there has been an increased interest in the senses. Much of this work has focused on ethnographic methods and has concentrated on research about the senses. In this article we focus on interviews and examine the value of expanded interviewing strategies that use the senses as access points. We argue that a sensory awareness can enrich interviews by offering a portal to otherwise unexplored illness or health care experiences which are either too difficult to articulate or too intangible to describe. Sensory awareness incorporates not only attentiveness to the research environment but also the utilization of sensory questions or prompts to gain insight into the research experience. We draw from a variety of empirical studies, and offer methodological guidance to the researcher while exploring ethical and challenging aspects of incorporating sensory awareness into the research interview.

Republished review: The world through a lens: the vision of Sir Harold Ridley

Sir Harold Ridley is recognised today as the inventor of intraocular lens implantation, one the most successful and common procedures in all of surgery. His story, however, is not largely one of triumph and public accolade. This paper reviews Ridley's invention of the intraocular lens and highlights the struggles he faced after his discovery.

In a moment of mismatch: overseas doctors' adjustments in new hospital environments

This paper contributes to studies of healthcare worker migration and, more broadly, to the study of occupational adjustment, with an analysis of finely detailed sensorial data. It focuses upon doctors, who are increasingly on the move around the world, working in hospital environments different from those in which they have trained. A number of unexamined questions remain in relation to how medical practitioners shift their work across contexts, in particular the tactile nature of adjustment, which has been under-explored in health sociology. This paper examines a procedural skill; a skill in which tools have become almost natural extensions of the doctor's hands. It focuses upon what happens when doctors travel overseas and find unfamiliar equipment, and their habitual practice is interrupted. The paper argues that by studying overseas doctors' bodily adjustment during such moments of mismatch, we learn more about the environment of the doctors' past and present. It suggests that by looking at the rupture between habit and the unfamiliar, we also understand something about the ways in which we adjust to the unexpected.

The Survivor Moms’ Companion: Open Pilot of a Posttraumatic Stress Specific Psychoeducation Program for Pregnant Survivors of Childhood Maltreatment and Sexual Trauma

The Survivor Moms’ Companion (SMC) is a fully manualized, 10-module self-study psychoeducation program developed to address the pregnancy-specific needs of traumatic stress-affected abuse survivors. It aims to improve affect regulation, reduce interpersonal reactivity, and support posttraumatic stress disorder (PTSD) symptom management despite the presence of triggers. An open pilot enrolled “survivor moms” prior to 28 weeks gestation and they completed baseline diagnostic telephone interviews, fidelity measures, pretest and posttest, and self-report measures assessing the efficacy of the proposed mechanisms of intervention effect. Of 57 eligible women invited to participate, 32 took up the intervention, 9 completed at least the core 4 modules, and 18 completed all 10 modules. Participant scores showed improvements in anger expression, interpersonal reactivity, and PTSD symptom management, suggesting that participation in the SMC is beneficial. Results will inform the protocol for a cluster randomized trial of the SMC.

Do brief screening questions or provider perception accurately identify persons with low health literacy in the HIV primary care setting?

Rapid and accurate health literacy screening tools could assist interventions to improve care in the HIV clinic setting. Prior studies described brief screening questions for identification of persons with low health literacy, but the performance of these questions in HIV clinics is unknown. We examined the accuracy of provider perception and previously described brief screening questions for identification of low health literacy among 147 persons attending two HIV specialty clinics. Mean age was 41 and 48% were African American. Using the short Test of Functional Health Literacy in Adults (S-TOFHLA) as reference measure, the combined prevalence of marginal and inadequate health literacy (low health literacy) was 16%. Sensitivity and specificity of provider perception for identifying persons with low health literacy were 0.47 and 0.79. The screening question "How confident are you filling out medical forms by yourself?" had an area under the receiver operator characteristic curve (AUROC) of 0.67. Response of "somewhat" to this question had sensitivity 0.30, specificity 0.91, positive likelihood ratio 3.4 (95% confidence interval [CI] 1.8-6.4) and negative likelihood ratio 0.76 (95% CI 0.4-1.4). Educational attainment was a more sensitive but less specific measure of low health literacy (sensitivity 0.90, specificity 0.61 for completed high school or fewer years education), but was overall a more accurate discriminator of health literacy than either provider perception or screening questions (AUROC 0.79; p<0.05 for comparison of AUROCs). HIV providers often misjudge patients' health literacy. In the absence of rapid and accurate health literacy screening tools, clinics caring for persons with HIV/AIDS should implement clinic-wide interventions to improve health communication.

Healthcare professionals' attitudes towards traumatic brain injury (TBI): the influence of profession, experience, aetiology and blame on prejudice towards survivors of brain injury

PRIMARY OBJECTIVE

To investigate the attitudes of healthcare professionals towards individuals with traumatic brain injury (TBI) and their relationship to intended healthcare behaviour.

RESEARCH DESIGN

An independent groups design utilized four independent variables; aetiology, group, blame and gender to explore attitudes towards survivors of brain injury. The dependent variables were measured using the Prejudicial Evaluation and Social Interaction Scale (PESIS) and Helping Behaviour Scale (HBS).

METHODS AND PROCEDURES

A hypothetical vignette based methodology was used. Four hundred and sixty participants (131 trainee nurses, 94 qualified nurses, 174 trainee doctors, 61 qualified doctors) were randomly allocated to one of six possible conditions.

MAIN OUTCOMES AND RESULTS

Regardless of aetiology, if an individual is to blame for their injury, qualified healthcare professionals have more prejudicial attitudes than those entering the profession. There is a significant negative relationship between prejudice and helping behaviour for qualified healthcare professionals.

CONCLUSIONS

Increased prejudicial attitudes of qualified staff are related to a decrease in intended helping behaviour, which has the potential to impact negatively on an individual's recovery post-injury.