The association between area-level factors and mortality in severe mental illnesses: A systematic review

BACKGROUND

Premature mortality is a well-documented adverse outcome for people living with severe mental illnesses (SMI). Emerging evidence suggests that area-level factors play a role that are experienced disproportionately by this population. This review assesses the potential association between area-level factors and mortality in people with SMI.

METHOD

We searched Medline, EMBASE, PsychINFO, Social Policy and Practice, Web of Science and OpenGrey databases. Literature searches were conducted in May 2020 and updated in June 2023. Reference lists were hand-searched and authors of included studies contacted to identify additional studies and minimise publication biases. Narrative synthesis was used to appraise the included studies. The review protocol was registered on PROSPERO (CRD42019155447).

RESULTS

Our searches identified 7 studies (8 papers), which were included in the review, and indicated evidence of an association between deprivation and mortality. One study suggested an association between mortality in SMI and urbanicity in low to middle income settings which was not observed in studies from high income settings. One study suggested a protective association of area-level ethnic density with mortality within urbanised settings.

CONCLUSION

Consistent associations were reported between residence in areas of higher deprivation and increased risk of mortality in SMI. Two studies suggested an association between area-level ethnic density and urbanicity and mortality in SMI. Most studies were conducted across high income countries and therefore future research could benefit from similar investigations being conducted in low- and middle-income countries. These methods would inform health and social policies, including interventions to reduce premature mortality in SMI.

Outcomes of first emergency admissions for alcohol-related liver disease in England over a 10-year period: retrospective observational cohort study using linked electronic databases

OBJECTIVES

To examine time trends in patient characteristics, care processes and case fatality of first emergency admission for alcohol-related liver disease (ARLD) in England.

DESIGN

National population-based, retrospective observational cohort study.

SETTING

Clinical Practice Research Datalink population of England, 2008/2009 to 2017/2018. First emergency admissions were identified using the Liverpool ARLD algorithm. We applied survival analyses and binary logistic regression to study prognostic trends.

OUTCOME MEASURES

Patient characteristics; 'recent' General Practitioner (GP) consultations and hospital admissions (preceding year); higher level care; deaths in-hospital (including certified cause) and within 365 days. Covariates were age, sex, deprivation status, coding pattern, ARLD stage, non-liver comorbidity, coding for ascites and varices.

RESULTS

17 575 first admissions (mean age: 53 years; 33% women; 32% from most deprived quintile). Almost half had codes suggesting advanced liver disease. In year before admission, only 47% of GP consulters had alcohol-related problems recorded; alcohol-specific diagnostic codes were absent in 24% of recent admission records. Overall, case fatality rate was 15% in-hospital and 34% at 1 year. Case-mix-adjusted odds of in-hospital death reduced by 6% per year (adjusted OR (aOR): 0.94; 95% CI: 0.93 to 0.96) and 4% per year at 365 days (aOR: 0.96; 95% CI: 0.95 to 0.97). Exploratory analyses suggested the possibility of regional inequalities in outcome.

CONCLUSIONS

Despite improving prognosis of first admissions, we found missed opportunities for earlier recognition and intervention in primary and secondary care. In 2017/2018, one in seven were still dying during index admission, rising to one-third within a year. Nationwide efforts are needed to promote earlier detection and intervention, and to minimise avoidable mortality after first emergency presentation. Regional variation requires further investigation.

Healthcare Costs Before and After Diagnosis of Cancer of Unknown Primary Versus Ovarian Cancer in Australia

BACKGROUND

Little is known about the healthcare resource usage and costs for patients with cancer of unknown primary (CUP).

OBJECTIVE

The aim of this study was to describe and quantify healthcare resource use and costs in Australia, 6 months prior to and after a diagnosis of CUP, and compare to those of women with ovarian cancer.

METHODS

Individual-level data combining baseline surveys, clinical records and Medicare Benefits Schedule (MBS) claim records were analysed for 149 patients with CUP and 480 patients with ovarian cancer from two prospective cohort studies. MBS data were aggregated for the period 6 months prior to diagnosis date and 6 months after diagnosis. Data included doctor consultations, pathology, diagnostics, therapeutic procedures, imaging, allied health and medicines. Generalised linear models were used to evaluate the cost differences between CUP and ovarian cancer using gamma family and log link functions. Models were adjusted for age, employment, marital status, surgery, chemotherapy and number of comorbidities.

RESULTS

The mean healthcare costs in the 6 months prior to diagnosis of CUP were Australian (AU) $3903 versus AU$1327 for ovarian cancer (adjusted cost ratio 2.94, 95% confidence interval [CI] 2.08-4.15). Mean healthcare costs 6 months post-diagnosis were higher for patients with CUP versus ovarian cancer (AU$20,339 vs AU$13,819, adjusted cost ratio 1.47, 95% CI 1.13-1.92). Higher costs for patients with CUP were driven by imaging (AU$1937 vs AU$1387), procedures (AU$5403 vs AU$2702) and prescribed medicines for all conditions (AU$10,111 vs AU$6717).

CONCLUSIONS

Pre-diagnosis costs for patients with CUP are nearly triple those for ovarian cancer. Six months after diagnosis, healthcare costs for CUP remained higher than for ovarian cancer due to imaging, procedures and medicines.

Chronic pain through COVID

Objectives

To identify good practice in the community management of chronic pain, and to understand the perspective of a group of healthcare service users towards the management of chronic pain using technology during the COVID-19 pandemic.

Methods

Forty-five people, recruited via social media and Pain Association Scotland, participated in three focus groups hosted over Zoom. Focus groups were conducted using semi-structured questions to guide the conversation. Data were analysed using Ritchie / Spencer's Framework Analysis.

Results

The participants shared observations of their experiences of remotely supported chronic pain services and insights into the potential for future chronic pain care provision. Experiences were in the majority positive with some describing their rapid engagement with technology during the COVID pandemic.

Conclusion

Results suggest there is strong potential for telehealth to complement and support existing provision of pain management services.

Rational design, synthesis and testing of novel tricyclic topoisomerase inhibitors for the treatment of bacterial infections part 1

The alarming reduction in drug effectiveness against bacterial infections has created an urgent need for the development of new antibacterial agents that circumvent bacterial resistance mechanisms. We report here a series of DNA gyrase and topoisomerase IV inhibitors that demonstrate potent activity against a range of Gram-positive and selected Gram-negative organisms, including clinically-relevant and drug-resistant strains. In part 1, we present a detailed structure activity relationship (SAR) analysis that led to the discovery of our previously disclosed compound, REDX05931, which has a minimum inhibitory concentration (MIC) of 0.06 μg mL^-1 against fluoroquinolone-resistant Staphylococcus aureus. Although in vitro hERG and CYP inhibition precluded further development, it validates a rational design approach to address this urgent unmet medical need and provides a scaffold for further optimisation, which is presented in part 2.

Rational design, synthesis and testing of novel tricyclic topoisomerase inhibitors for the treatment of bacterial infections part 2

Building on our previously-reported novel tricyclic topoisomerase inhibitors (NTTIs), we disclose the discovery of REDX07965, which has an MIC90 of 0.5 μg mL-1 against Staphylococcus aureus, favourable in vitro pharmacokinetic properties, selectivity versus human topoisomerase II and an acceptable toxicity profile. The results herein validate a rational design approach to address the urgent unmet medical need for novel antibiotics.

Dynamics of multimorbidity in England between 2004 and 2019: a descriptive epidemiology study

Background

An estimated 25% of GP patients within the UK have multimorbidity, a large proportion of which is attributable to non-communicable diseases, many of them preventable. The heterogeneity of existing study methodologies limits comparisons to assess temporal trends. This study aims to use a large population-representative dataset to describe changes over time in multimorbidity incidence and prevalence.

Methods

We used two measures of multimorbidity a) basic: two or more chronic conditions; b) complex: at least three chronic conditions affecting at least three body systems. Chronic conditions for inclusion were discussed by a multidisciplinary team. A 1m random sample of patients registered between 2004 and 2019 at GP practices in England were drawn from the UK Clinical Practice Research Datalink. We calculated crude and age-sex standardised annual multimorbidity prevalence and incidence using standard formulae. Analyses were conducted using R v3.6.3. Participants will be linked to the 2015 Index of Multiple Deprivation to describe equity trends over time.

Results

Preliminary results show that age-sex standardised annual prevalence increased from 32.9% (95% CI: 32.7% - 33.1%) with basic multimorbidity and 14.9% (95% CI: 14.7%-15.0%) with complex multimorbidity in 2004 to 51.0% (95% CI: 50.8% - 51.3%) and 29.9% (95% CI: 29.7% - 30.1%) in 2019. Basic multimorbidity incidence per 10,000 person-years showed little change, however there was an increase in the incidence of complex multimorbidity from 322 (95% CI: 315- 330) to 418 (95% CI: 407 - 430).

Conclusions

The burden of multimorbidity has increased substantially over the last 15 years. Complex multimorbidity incidence and prevalence have increased more rapidly than for basic multimorbidity. This highlights the need for improved population-level prevention strategies to postpone and prevent the onset of long-term conditions. Next, we will assess whether there are socioeconomic differences in these temporal trends.

Key messages

The burden of multimorbidity increased between 2004 and 2019. The increase in incidence and prevalence of complex multimorbidity was greater than for basic multimorbidity.

Pain in older adults with dementia : A survey across Europe on current practices, use of assessment tools, guidelines and policies

BACKGROUND

We aimed to explore the existing use of pain assessment tools and guidelines, and develop understanding of the practical considerations required to facilitate their use within the nursing home, hospital and community settings.

METHODS

A self-administered web-based survey was conducted with nurses, health and social care workers with an interest in the assessment of pain in older adults with cognitive impairment. The survey was distributed to participants in Austria, Belgium, Denmark, Germany, The Netherlands, Switzerland and United Kingdom.

RESULTS

Only a minority of staff reported use of (inter-)national or local standards or specific pain assessment tools in daily practice. A range of tools were reported as being used, which varied across country. While participants generally reported that these pain assessment tools were easy/very easy to use, many participants reported that they were difficult to interpret. Assessment is generally performed whilst providing nursing care. This was highlighted in 70-80% of all participating countries. While many of these tools rely on facial expression of pain, facial expressions were considered to be the least useful in comparison to other items. Furthermore findings showed that nurses employed in long-term care settings did not feel that they were educated enough in pain assessment and management.

CONCLUSION

Our findings suggest that pain education is required across all countries surveyed. This should include a focus on guidelines and standards for assessment and subsequent management of pain. Findings suggest that clinical staff find interpreting facial expressions in relation to pain more difficult.

Outcomes and outcome measures used in evaluation of communication training in oncology - a systematic literature review, an expert workshop, and recommendations for future research

BACKGROUND

Communication between health care provider and patients in oncology presents challenges. Communication skills training have been frequently developed to address those. Given the complexity of communication training, the choice of outcomes and outcome measures to assess its effectiveness is important. The aim of this paper is to 1) perform a systematic review on outcomes and outcome measures used in evaluations of communication training, 2) discuss specific challenges and 3) provide recommendations for the selection of outcomes in future studies.

METHODS

To identify studies and reviews reporting on the evaluation of communication training for health care professionals in oncology, we searched seven databases (Ovid MEDLINE, CENTRAL, CINAHL, EMBASE, PsychINFO, PsychARTICLES and Web of Science). We extracted outcomes assessed and the respective assessment methods. We held a two-day workshop with experts (n = 16) in communication theory, development and evaluation of generic or cancer-specific communication training and/or outcome measure development to identify and address challenges in the evaluation of communication training in oncology. After the workshop, participants contributed to the development of recommendations addressing those challenges.

RESULTS

Out of 2181 references, we included 96 publications (33 RCTs, 2 RCT protocols, 4 controlled trials, 36 uncontrolled studies, 21 reviews) in the review. Most frequently used outcomes were participants' training evaluation, their communication confidence, observed communication skills and patients' overall satisfaction and anxiety. Outcomes were assessed using questionnaires for participants (57.3%), patients (36.0%) and observations of real (34.7%) and simulated (30.7%) patient encounters. Outcomes and outcome measures varied widely across studies. Experts agreed that outcomes need to be precisely defined and linked with explicit learning objectives of the training. Furthermore, outcomes should be assessed as broadly as possible on different levels (health care professional, patient and interaction level).

CONCLUSIONS

Measuring the effects of training programmes aimed at improving health care professionals' communication skills presents considerable challenges. Outcomes as well as outcome measures differ widely across studies. We recommended to link outcome assessment to specific learning objectives and to assess outcomes as broadly as possible.

Nature-Based Supportive Care Opportunities: Responding to Health and Recovery Needs of People With Cancer

Background: Human health and nature is an emerging research field exploring nature's impact on health and well-being. Given preliminary evidence for positive health outcomes related to nature engagement in cancer populations, research is warranted to ascertain strategies for incorporating nature-based care opportunities as additional support care strategies for addressing multidimensional aspects of patients' health and recovery needs. Aim: To consolidate findings from a comprehensive research program investigating opportunities for nature-based supportive care interventions and oncology setting design and discern relevant applications in oncology and palliative care contexts. Methods: Drawing on findings from a program of mixed-method research that investigated nature-based engagement in oncology contexts, a 2-step analytic process was used to construct a conceptual framework for informing and guiding future nature-based oncology design. Firstly, concept analysis methodology was applied to generate new insight into the needs of people with cancer by extracting and synthesizing qualitative data describing participants´ own appraisal of nature´s role in their experiences of health and recovery. Next, patient-reported and expert-developed recommendations generated in an international Delphi study were aligned with the newly formulated concepts and incorporated into a guiding framework for nature-based supportive care. Results: Five theoretical concepts were formulated describing the reasons for why people with cancer engage with nature and the underlying needs these interactions address. These included: meaningful connections, distancing from the cancer experience, meaning-making, finding comfort and safety, and vital nurturance. Eight shared patient and expert recommendations were compiled, which correspond with the identified patient needs and propose nature-based initiatives to address them. Eleven additional patient recommendations arose as important when attending to the experiential qualities patients value when using nature for addressing their health and recovery needs. Conclusion: The proposed framework outlines salient findings about helpful nature-based care opportunities for ready access by healthcare practitioners, designers, researchers and patients themselves. Research collaboration that includes patient and expert engagement is critical for bringing together personal, practical and clinical perspectives that can ensure successful design and clinically safe delivery of nature-based supportive care solutions that are meaningful to people with cancer.

The modified Memorial Symptom Assessment Scale Short Form: a modified response format and rational scoring rules

PURPOSE

The Memorial Symptom Assessment Scale Short Form (MSAS-SF) is a widely used symptom assessment instrument. Patients who self-complete the MSAS-SF have difficulty following the two-part response format, resulting in incorrectly completed responses. We describe modifications to the response format to improve useability, and rational scoring rules for incorrectly completed items.

METHODS

The modified MSAS-SF was completed by 311 women in our Peer and Nurse support Trial to Assist women in Gynaecological Oncology; the PeNTAGOn study. Descriptive statistics were used to summarise completion of the modified MSAS-SF, and provide symptom statistics before and after applying the rational scoring rules. Spearman's correlations with the Functional Assessment for Cancer Therapy-General (FACT-G) and Hospital Anxiety and Depression Scale (HADS) were assessed.

RESULTS

Correct completion of the modified MSAS-SF items ranged from 91.5 to 98.7%. The rational scoring rules increased the percentage of useable responses on average 4% across all symptoms. MSAS-SF item statistics were similar with and without the scoring rules. The pattern of correlations with FACT-G and HADS was compatible with prior research.

CONCLUSION

The modified MSAS-SF was useable for self-completion and responses demonstrated validity. The rational scoring rules can minimise loss of data from incorrectly completed responses. Further investigation is recommended.

Depression and pain: primary data and meta-analysis among 237 952 people across 47 low- and middle-income countries

BACKGROUND

Depression and pain are leading causes of global disability. However, there is a paucity of multinational population data assessing the association between depression and pain, particularly among low- and middle-income countries (LMICs) where both are common. Therefore, we investigated this association across 47 LMICs.

METHODS

Community-based data on 273 952 individuals from 47 LMICs were analysed. Multivariable logistic and linear regression analyses were performed to assess the association between the International Classification of Diseases, 10th Revision depression/depression subtypes (over the past 12 months) and pain in the previous 30 days based on self-reported data. Country-wide meta-analysis adjusting for age and sex was also conducted.

RESULTS

The prevalence of severe pain was 8.0, 28.2, 20.2, and 34.0% for no depression, subsyndromal depression, brief depressive episode, and depressive episode, respectively. Logistic regression adjusted for socio-demographic variables, anxiety and chronic medical conditions (arthritis, diabetes, angina, asthma) demonstrated that compared with no depression, subsyndromal depression, brief depressive episode, and depressive episode were associated with a 2.16 [95% confidence interval (CI) 1.83-2.55], 1.45 (95% CI 1.22-1.73), and 2.11 (95% CI 1.87-2.39) increase in odds of severe pain, respectively. Similar results were obtained when a continuous pain scale was used as the outcome. Depression was significantly associated with severe pain in 44/47 countries with a pooled odds ratio of 3.93 (95% CI 3.54-4.37).

CONCLUSION

Depression and severe pain are highly comorbid across LMICs, independent of anxiety and chronic medical conditions. Whether depression treatment or pain management in patients with comorbid pain and depression leads to better clinical outcome is an area for future research.

Type 2 diabetes mellitus in people with severe mental illness: inequalities by ethnicity and age. Cross-sectional analysis of 588 408 records from the UK

AIMS

To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age.

METHODS

We conducted a cross-sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes.

RESULTS

Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18-34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35-54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti-psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness.

CONCLUSIONS

The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti-psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account.

Neighbourhood Ethnic Density and Incidence of Psychosis – First and Second Generation Migrants Compared

Introduction

Living in an area with few people from the same ethnic background has been associated with increased incidence of psychosis (the ethnic density effect).

Objectives

Compare associations between neighbourhood ethnic density and incidence of non-affective psychosis for first and second generation migrants.

Methods

Population based cohort (2.2 million) of all those born 1st January 1965 or later and living in Denmark on their 15th birthday. We looked at a total of 106,000 migrants, including 62% first generation migrants. Ethnic density was determined at age 15 and we adjusted for age, gender, calendar period, parental psychiatric history and parental income at age 15.

Results

For the first generation, we found no evidence that rates of non-affective psychosis were related to neighbourhood ethnic density for migrants from Africa (comparing lowest and highest quintiles): IRR 1.02 (95% CI 0.6–1.73), and the Middle East: IRR 0.96 (CI 0.68–1.35) and only weak evidence for migrants from Europe (excluding Scandinavia): IRR 1.35 (CI 0.98–1.84). Conversely, for the second generation rates of non-affective psychosis were increased for migrants from Africa in lower ethnic density neighbourhoods (comparing lowest and highest quintiles): IRR 3.97 (95% CI 1.81–8.69), Europe (excluding Scandinavia): IRR 1.82 (CI 1.28–2.59) and the Middle East: IRR 2.42 (CI 1.18–4.99).

Conclusions

There is strong evidence for an area ethnic density effect on psychosis incidence for second generation migrants, but not for first generation migrants. This could reflect a greater resilience among the latter group to the adverse effects of minority status.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Minority status and mental distress: a comparison of group density effects

BACKGROUND

It has been observed that mental disorders, such as psychosis, are more common for people in some ethnic groups in areas where their ethnic group is less common. We set out to test whether this ethnic density effect reflects minority status in general, by looking at three situations where individual characteristics differ from what is usual in a locality.

METHOD

Using data from the South East London Community Health study (n = 1698) we investigated associations between minority status (defined by: ethnicity, household status and occupational social class) and risk of psychotic experiences, common mental disorders and parasuicide. We used a multilevel logistic model to examine cross-level interactions between minority status at individual and neighbourhood levels.

RESULTS

Being Black in an area where this was less common (10%) was associated with higher odds of psychotic experiences [odds ratio (OR) 1.34 95% confidence interval (CI) 1.07-1.67], and attempted suicide (OR 1.84 95% CI 1.19-2.85). Living alone where this was less usual (10% less) was associated with increased odds of psychotic experiences (OR 2.18 95% CI 0.91-5.26), while being in a disadvantaged social class where this was less usual (10% less) was associated with increased odds of attempted suicide (OR 1.33 95% CI 1.03-1.71). We found no evidence for an association with common mental disorders.

CONCLUSIONS

The relationship between minority status and mental distress was most apparent when defined in terms of broad ethnic group but was also observed for individual household status and occupational social class.

Does depression diagnosis and antidepressant prescribing vary by location? Analysis of ethnic density associations using a large primary-care dataset

BACKGROUND

Studies have linked ethnic differences in depression rates with neighbourhood ethnic density although results have not been conclusive. We looked at this using a novel approach analysing whole population data covering just over one million GP patients in four London boroughs.

METHOD

Using a dataset of GP records for all patients registered in Lambeth, Hackney, Tower Hamlets and Newham in 2013 we investigated new diagnoses of depression and antidepressant use for: Indian, Pakistani, Bangladeshi, black Caribbean and black African patients. Neighbourhood effects were assessed independently of GP practice using a cross-classified multilevel model.

RESULTS

Black and minority ethnic groups are up to four times less likely to be newly diagnosed with depression or prescribed antidepressants compared to white British patients. We found an inverse relationship between neighbourhood ethnic density and new depression diagnosis for some groups, where an increase of 10% own-ethnic density was associated with a statistically significant (p < 0.05) reduced odds of depression for Pakistani [odds ratio (OR) 0.81, 95% confidence interval (CI) 0.70-0.93], Indian (OR 0.88, CI 0.81-0.95), African (OR 0.88, CI 0.78-0.99) and Bangladeshi (OR 0.94, CI 0.90-0.99) patients. Black Caribbean patients, however, showed the opposite effect (OR 1.26, CI 1.09-1.46). The results for antidepressant use were very similar although the corresponding effect for black Caribbeans was no longer statistically significant (p = 0.07).

CONCLUSION

New depression diagnosis and antidepressant use was shown to be less likely in areas of higher own-ethnic density for some, but not all, ethnic groups.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study

PURPOSE

People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK.

METHODS

E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers.

RESULTS

In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)).

CONCLUSIONS

There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.

Psychological wellness and health-related stigma: a pilot study of an acceptance-focused cognitive behavioural intervention for people with lung cancer

People with lung cancer experience health-related stigma that is related to poorer psychosocial and quality of life outcomes. The present Phase 1 study applied mixed methods to test the acceptability of an acceptance-focused cognitive behavioural intervention targeting stigma for this patient group. Fourteen lung cancer patients completed a 6-week Psychological Wellness intervention with pre- and post-test outcome measures of psychological and cancer-specific distress, depression, health-related stigma and quality of life. In-depth interviews applying interpretative phenomenological analysis assessed participants' experiences of the intervention. Moderate to large improvements were observed in psychological (ηp (2)  = 0.182) and cancer-specific distress (ηp (2)  = 0.056); depression (ηp (2)  = 0.621); health-related stigma (ηp (2)  = 0.139). In contrast, quality of life declined (ηp (2)  = 0.023). The therapeutic relationship; self-management of distress; and relationship support were highly valued aspects of the intervention. Barriers to intervention included avoidance and practical issues. The lung cancer patients who completed the Psychological Wellness intervention reported improvements in psychological outcomes and decreases in stigma in the face of declining quality of life with patients reporting personal benefit from their own perspectives. A randomised controlled trial is warranted to establish the effectiveness of this approach.

Facilitating knowledge exchange between health-care sectors, organisations and professions: a longitudinal mixed-methods study of boundary-spanning processes and their impact on health-care quality

Background

Relatively little is known about how people and groups who function in boundary-spanning positions between different sectors, organisations and professions contribute to improved quality of health care and clinical outcomes.

Objectives

To explore whether or not boundary-spanning processes stimulate the creation and exchange of knowledge between sectors, organisations and professions and whether or not this leads, through better integration of services, to improvements in the quality of care.

Design

A 2-year longitudinal nested case study design using mixed methods.

Setting

An inner-city area in England (‘Coxford’) comprising 26 general practices in ‘Westpark’ and a comparative sample of 57 practices.

Participants

Health-care and non-health-care practitioners representing the range of staff participating in the Westpark Initiative (WI) and patients.

Interventions

The WI sought to improve services through facilitating knowledge exchange and collaboration between general practitioners, community services, voluntary groups and acute specialists during the period late 2009 to early 2012. We investigated the impact of the four WI boundary-spanning teams on services and the processes through which they produced their effects.

Main outcome measures

(1) Quality-of-care indicators during the period 2008–11; (2) diabetes admissions data from April 2006 to December 2011, adjusted for deprivation scores; and (3) referrals to psychological therapies from January 2010 to March 2012.

Data sources

Data sources included 42 semistructured staff interviews, 361 hours of non-participant observation, 36 online diaries, 103 respondents to a staff survey, two patient focus groups and a secondary analyses of local and national data sets.

Results

The four teams varied in their ability to, first, exchange knowledge across boundaries and, second, implement changes to improve the integration of services. The study setting experienced conditions of flux and uncertainty in which known horizontal and vertical structures underwent considerable change and the WI did not run its course as originally planned. Although knowledge exchanges did occur across sectoral, organisational and professional boundaries, in the case of child and family health services, early efforts to improve the integration of services were not sustained. In the case of dementia, team leadership and membership were undermined by external reorganisations. The anxiety and depression in black and minority ethnic populations team succeeded in reaching its self-defined goal of increasing referrals from Westpark practices to the local well-being service. From October to December 2010 onwards, referrals have been generally higher in the six practices with a link worker than in those without, but the performance of Westpark and Coxford practices did not differ significantly on three national quality indicators. General practices in a WI diabetes ‘cluster’ performed better on three of 17 Quality and Outcomes Framework (QOF) indicators than practices in the remainder of Westpark and in the wider Coxford primary care trust. Surprisingly, practices in Westpark, but not in the diabetes cluster, performed better on one indicator. No statistically significant differences were found on the remaining 13 QOF indicators. The time profiles differed significantly between the three groups for elective and emergency admissions and bed-days.

Conclusions

Boundary spanning is a potential solution to the challenge of integrating health-care services and we explored how such processes perform in an ‘extreme case’ context of uncertainty. Although the WI may have been a necessary intervention to enable knowledge exchange across a range of boundaries, it was not alone sufficient. Even in the face of substantial challenges, one of the four teams was able to adapt and build resilience. Implications for future boundary-spanning interventions are identified. Future research should evaluate the direct, measurable and sustained impact of boundary-spanning processes on patient care outcomes (and experiences), as well as further empirically based critiques and reconceptualisations of the socialisation → externalisation → combination → internalisation (SECI) model, so that the implications can be translated into practical ideas developed in partnership with NHS managers.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

ICRP PUBLICATION 120: Radiological protection in cardiology

Cardiac nuclear medicine, cardiac computed tomography (CT), interventional cardiology procedures, and electrophysiology procedures are increasing in number and account for an important share of patient radiation exposure in medicine. Complex percutaneous coronary interventions and cardiac electrophysiology procedures are associated with high radiation doses. These procedures can result in patient skin doses that are high enough to cause radiation injury and an increased risk of cancer. Treatment of congenital heart disease in children is of particular concern. Additionally, staff(1) in cardiac catheterisation laboratories may receive high doses of radiation if radiological protection tools are not used properly. The Commission provided recommendations for radiological protection during fluoroscopically guided interventions in Publication 85, for radiological protection in CT in Publications 87 and 102, and for training in radiological protection in Publication 113 (ICRP, 2000b,c, 2007a, 2009). This report is focused specifically on cardiology, and brings together information relevant to cardiology from the Commission's published documents. There is emphasis on those imaging procedures and interventions specific to cardiology. The material and recommendations in the current document have been updated to reflect the most recent recommendations of the Commission. This report provides guidance to assist the cardiologist with justification procedures and optimisation of protection in cardiac CT studies, cardiac nuclear medicine studies, and fluoroscopically guided cardiac interventions. It includes discussions of the biological effects of radiation, principles of radiological protection, protection of staff during fluoroscopically guided interventions, radiological protection training, and establishment of a quality assurance programme for cardiac imaging and intervention. As tissue injury, principally skin injury, is a risk for fluoroscopically guided interventions, particular attention is devoted to clinical examples of radiation-related skin injuries from cardiac interventions, methods to reduce patient radiation dose, training recommendations, and quality assurance programmes for interventional fluoroscopy.

Expression and synthesis of insulin-like growth factor (IGF)-I, -II and their receptors in human glioma cell lines

Insulin-like growth factor (IGF)-I and -II are involved in the regulation of brain development and are thought to play a pivotal role in the proliferation of gliomas. Expression of IGF-I, IGF-II, the type I and type II IGF receptor were studied in a panel of thirty glioma cell lines by Northern blotting and PCR analysis. IGF-II mRNA expression with transcripts of 4.8 and 6.0 kb was shown only in one glioma cell line (NCE-G96) and no transcripts for IGF-I, IGF-I-R and IGF-II-R could be detected by Northern analysis in total RNA. However, PCR analysis revealed signals in 19/28 cell lines for IGF-I, 27/30 for ICE-II, 19/28 for IGF-I-R and 22/28 glioma cell lines for IGF-II-R. Additional IGF-I, IGF-II, IGF-I-R and IGF-II-R PCR products were detected which might represent alternative splicing products or variants. In addition, the secretion of IGF-I and IGF-II peptides was measured by radioimmunoassay. IGF receptor status and binding characteristics were established by Scatchard analysis. Proliferation assays showed different effects of IGFs and IGF analogues on the proliferation of these cell lines. Des-(1-3)IGF-I showed an unexpected inhibitory activity on glioma cell proliferation. This may have either been due to a direct effect of the ligand for the induction of a more differentiated state refractory to its action.

Impact of a novel nurse-led prechemotherapy education intervention (ChemoEd) on patient distress, symptom burden, and treatment-related information and support needs: results from a randomised, controlled trial

BACKGROUND

High levels of distress and need for self-care information by patients commencing chemotherapy suggest that current prechemotherapy education is suboptimal. We conducted a randomised, controlled trial of a prechemotherapy education intervention (ChemoEd) to assess impact on patient distress, treatment-related concerns, and the prevalence and severity of and bother caused by six chemotherapy side-effects.

PATIENTS AND METHODS

One hundred and ninety-two breast, gastrointestinal, and haematologic cancer patients were recruited before the trial closing prematurely (original target 352). ChemoEd patients received a DVD, question-prompt list, self-care information, an education consultation≥24 h before first treatment (intervention 1), telephone follow-up 48 h after first treatment (intervention 2), and a face-to-face review immediately before second treatment (intervention 3). Patient outcomes were measured at baseline (T1: pre-education) and immediately preceding treatment cycles 1 (T2) and 3 (T3).

RESULTS

ChemoEd did not significantly reduce patient distress. However, a significant decrease in sensory/psychological (P=0.027) and procedural (P=0.03) concerns, as well as prevalence and severity of and bother due to vomiting (all P=0.001), were observed at T3. In addition, subgroup analysis of patients with elevated distress at T1 indicated a significant decrease (P=0.035) at T2 but not at T3 (P=0.055) in ChemoEd patients.

CONCLUSIONS

ChemoEd holds promise to improve patient treatment-related concerns and some physical/psychological outcomes; however, further research is required on more diverse patient populations to ensure generalisability.

Ethnic isolation and psychosis: re-examining the ethnic density effect

BACKGROUND

Elevated incidence of psychotic illness has been consistently shown among migrant populations. Ethnic density, the proportion of an ethnic group in a defined area, is cited as one factor with a reduced risk of psychosis where ethnicity is shared. However, UK studies have shown mixed results. We set out to re-examine the ethnic density effect at a greater level of geographic detail than previous studies.

METHOD

Using a large sample of patient records from general practitioners in South East London, we were able to assess neighbourhood factors at the detailed lower super output area level. This comprises, on average, 1500 people compared with around 6000 per ward, the measure used in previous studies. We compared black (Afro-Caribbean) and white psychosis incidence by neighbourhood ethnic density over a 10-year period.

RESULTS

We found a clear negative association between ethnic density and psychosis incidence. In neighbourhoods where black people comprised more than 25% of the population, there was no longer a statistically significant ethnic difference in psychosis rates. However, where black people were less well represented, their relative risk increased nearly threefold [odds ratio (OR) 2.88, 95% confidence interval (CI) 1.89-4.39]. Furthermore, incidence rates for black people in the lowest density quintiles were over five times greater than in the most dense quintile (OR 5.24, 95% CI 1.95-14.07). However, at ward level this association was much weaker and no longer statistically significant.

CONCLUSIONS

Ethnic density is inversely related to psychosis incidence at a detailed local neighbourhood level.

Quality of life research: is there a difference in output between the major cancer types?

As a result of more people living with or surviving cancer, outputs for quality of life research may have increased over time to reflect the needs of the growing number of people affected by cancer. To determine if this is the case, the authors sought to examine the number and proportion of publications concerned with cancer patients' quality of life for four major cancer sites (breast, lung, prostate, colorectal) over five equal time periods (1985, 1990, 1995, 2000, 2005). A computer-based literature search using Medline and PsycINFO databases was undertaken. A comparison search with cancer-related biomedical terms was conducted. The results showed that the number of quality of life publications was substantially lower compared with biomedical publications over time, although the average annual relative increase in publications was greatest for quality of life. The total number of quality of life publications was greatest for breast cancer and lowest for colorectal cancer at all five time points. The relative increase over time of quality of life publications was greatest for prostate cancer and lowest for breast cancer. More research is needed regarding quality of life for cancer patients. Breast cancer has dominated quality of life research outputs despite a lower relative increase in publications over time compared with other cancer sites. There is need for debate among funding agencies and researchers to ensure research efforts are shared among cancer types.

The development of audio-visual materials to prepare patients for medical procedures: an oncology application

This paper describes a systematic process for the development of educational audio-visual materials that are designed to prepare patients for potentially threatening procedures. Literature relating to the preparation of patients for potentially threatening medical procedures, psychological theory, theory of diffusion of innovations and patient information was examined. Four key principles were identified as being important: (1) stakeholder consultation, (2) provision of information to prepare patients for the medical procedure, (3) evidence-based content, and (4) promotion of patient confidence. These principles are described along with an example of the development of an audio-visual resource to prepare patients for chemotherapy treatment. Using this example, practical strategies for the application of each of the principles are described. The principles and strategies described may provide a practical, evidence-based guide to the development of other types of patient audio-visual materials.

The assessment of pain in older people

Pain is under-recognised and under-treated in older people. It is a subjective, personal experience, only known to the person who suffers. The assessment of pain is particularly challenging in the presence of severe cognitive impairment, communication difficulties or language and cultural barriers. These guidelines set out the key components of assessing pain in older people, together with a variety of practical scales that may be used with different groups, including those with varying levels of cognitive or communication impairment. The purpose is to provide professionals with a set of practical skills to assess pain as the first step towards its effective management. The guidance has implications for all healthcare and social care staff and can be applied in all settings, including the older person's own home, in care homes, and in hospital.

Tailored chemotherapy (CT) information (info) faxed to general practitioners (GP) improves knowledge and confidence in managing side effects (SFX): Results from a randomized controlled trial (RCT)

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Background: The literature indicates discontinuity in patient (pt) care and poor communication between hospitals and community practice. GPs would like more info about CT, SFX and how to manage these. We aimed to develop standardized info for GPs about CT and to assess the impact of this in an RCT. Primary endpoints were: confidence managing pts having CT, knowledge of CT SFX, and satisfaction with both info and shared care of pts. Secondary endpoints included how useful and instructive GPs found the info. Methods: Peter Mac IRB approved the study. Initial focus group work with GPs informed the development of info about 23 CT regimens. GPs of pts due to commence a CT regimen for the first time were randomized to receive usual correspondence (UC) or UC plus info. Prior to randomization GPs were telephoned and verbal consent obtained. Telephone questionnaire (qstnre) assessed GPs confidence in managing pts and knowledge of CT SFX, as well as satisfaction with info and shared care of pts. GPs in the intervention group were then faxed the relevant info. One week later all GPs were phoned and completed a similar standardized qstnre. Measures used a 5 point scale/range. Results: 97 GPs managed 97 pts receiving 21 types of CT. GPs on average had 27.1 yrs clinical experience (SD=9.8) and were managing 5.5 pts receiving CT (SD=6.8). Of 97 GPs randomized, 81 (83.5%) completed the follow up qstnre. GPs confidence in managing CT SFX was fair at baseline (M=3.34, SD=0.69). GPs in the intervention group demonstrated a significantly greater increase in confidence (difference 0.36; p<0.01) and knowledge of CT SFX - eg febrile neutropenia (diff 0.55; p<0.01) - and close to significant effect for satisfaction with info / shared care (diff 0.35; p=0.051) compared with UC. GPs receiving info + UC also considered it significantly more useful (diff 1.48; p<0.001) and instructive (diff 1.88; p<0.001) than GPs who only received UC. Conclusions: Info about CT faxed to GPs is a simple, inexpensive intervention that increases GPs knowledge of CT SFX and confidence in managing pts. Further, GPs find this info more useful and instructive than UC alone. This intervention could have widespread application.

No significant financial relationships to disclose.

Meeting the support and information needs of women with advanced breast cancer: a randomised controlled trial

Addressing psychosocial and quality of life needs is central to provision of excellent care for people with advanced cancer. This study tested a brief nurse-delivered intervention to address the needs of urban women with advanced breast cancer. This study was conducted at four large urban hospitals in Australia. One hundred and five women with advanced breast cancer were recruited and randomised to receive the intervention or usual care, then asked to complete the European Organisation of Research and Treatment of Quality of life Q-C30 version (2.0) (EORTC Q-C30) (version 2) and Supportive Care Needs Survey (SCNS) at 1 month and 3 months postrecruitment. No significant differences were detected between intervention and usual care groups in the SCNS or the EORTC Q-C30 subscale scores. However, when the groups were divided into high needs (score of above 50) and low baseline needs (score of 50 or below) for each SCNS subscale, a significant difference between intervention and usual care groups was found in the psychological/emotional subscale among women with high baseline needs. In conclusions, this study demonstrated that a face-to-face session and follow-up phone call with a breast care nurse significantly reduced the psychological and emotional needs of those with high initial needs. There was no evidence of the intervention influencing the quality of life; or perceived needs of women with low initial psychological/emotional needs or perceived needs in other domains. Possibly, the intervention was not sufficiently intense to achieve an effect.