Online Resources for Robin Sequence; an Analysis of Readability

The objective was to evaluate the readability of easily accessible parent-directed information concerning Robin Sequence (RS) online, compared to the American Medical Association (AMA)-recommended sixth grade (age 11-12) readability level.

A Google search of the term "Pierre Robin Sequence information" was performed. The first ten websites were evaluated using six commonly used readability formulas. Sample texts from three websites were 'translated' by the authors, with the aim of achieving a sixth grade readability level.

The following outcomes were used: Automated Readability Index (ARI), Coleman Liau Index (CLI), Gunning Fog Score, Simple Measure of Gobbledygook (SMOG), Flesch Kincaid Grade Level (FKGL), and Flesch Reading Ease (FRE) score.

The mean pooled grade level of the top 10 included websites was 12.1 (age 17-18). The overall FRE Index was 45.8, which is equivalent to a College-grade reading level. The mean grade level by each test used was: Flesch-Kincaid Grade Level 11.6 (age 16-17), Gunning Fog Score 13.3 (age 18+), SMOG 10.0 (age 14-15), Coleman-Liau Index 13.8 (age 18+), and ARI 12.0 (age 17-18). The author-translated resources achieved pooled mean grade levels of 6.3-6.5.

Parent-directed online materials concerning RS have a readability in excess of the AMA-recommended sixth grade reading level. Even though the condition is complex, more readable resources are achievable. Coproduction of parent-directed resources in association with public an patient involvement (PPI) contributors is encouraged.

Psychometric properties of the TACT framework-Determining rigor in qualitative research

Introduction

The credibility of qualitative research has long been debated, with critics emphasizing the lack of rigor and the challenges of demonstrating it. In qualitative research, rigor encompasses explicit, detailed descriptions of various research stages, including problem framing, study design, data collection, analysis, and reporting. The diversity inherent in qualitative research, originating from various beliefs and paradigms, challenges establishing universal guidelines for determining its rigor. Additionally, researchers' often unrecorded thought processes in qualitative studies further complicate the assessment of research quality.

Methods

To address these concerns, this article builds on the TACT framework, which was developed to teach postgraduate students and those new to qualitative research to identify and apply rigorous principles and indicators in qualitative research. The research reported in this article focuses on creating a scale designed to evaluate the psychometric properties of the TACT framework. This involves analyzing the stability of its dimensions and understanding its effectiveness as a tool for teaching and research.

Results

The study's findings indicate that the TACT framework, when assessed through the newly developed scale, exhibits stable dimensions consistent with rigorous qualitative research principles. The framework effectively guides postgraduate students and new researchers in assessing the rigor of qualitative research processes and outcomes.

Discussion

The application of the TACT framework and its evaluation scale reveals several insights. Firstly, it demonstrates the framework's utility in bridging the gap in pedagogical tools for teaching rigor in qualitative research methods. Secondly, it highlights the framework's potential in providing a structured approach to undertaking qualitative research, which is essential given this field's diverse methodologies and paradigms. However, the TACT framework remains a guide to enhancing rigor in qualitative research throughout all the various phases but by no means a measure of rigor.

Conclusion

In conclusion, the TACT framework and its accompanying evaluative scale represent significant steps toward standardizing and enhancing the rigor of qualitative research, particularly for postgraduate students and early career researchers. While it does not solve all challenges associated with obtaining and demonstrating rigor in qualitative research, it provides a valuable tool for assessing and ensuring research quality, thereby addressing some of the longstanding criticisms of the quality of research obtained through qualitative methods.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Shared goals for mental health research: what, why and when for the 2020s

Mental health problems bring substantial individual, community and societal costs and the need for innovation to promote good mental health and to prevent and treat mental health problems has never been greater. However, we know that research findings can take up to 20 years to implement. One way to push the pace is to focus researchers and funders on shared, specific goals and targets. We describe a consultation process organised by the Department of Health and Social Care and convened by the Chief Medical Officer to consider high level goals for future research efforts and to begin to identify UK-specific targets to measure research impact. The process took account of new scientific methods and evidence, the UK context with a universal health care system (the NHS) and the embedded research support from the National Institute for Health Research Clinical Research Network, as well as the views of individual service users and service user organisations. The result of the consultation is a set of four overarching goals with the potential to be measured at intervals of three, five or ten years.

Central Slip Repair using Trans-articular K-wires: A Comparative Study

Central slip disruption may lead to PIP joint dysfunction causing significant morbidity. Existing evidence for any specific surgical management of these injuries is limited but does favor early mobilization of the PIP joint. Aim: To assess the functional outcome in a cohort of patients undergoing central slip repair with internal K-wire proximal interphalangeal joint splinting and complete immobilization against those with external splinting only. Methods: A single center retrospective analysis of all patients that underwent operative central slip repair in our institution over a 5-year period. Data were collected via the HIPE database and clinical notes. Data relating to demographics as well as range of motion, total active motion {(TAM) (TAM%)} score, and hand therapy rehabilitation type were analyzed. Results: The study population was n = 44 patients. N = 33 patients were treated without a K-wire and n = 11 treated with a K-wire. There was a male predominance, 81.8% (n = 36). Mean age was 40.4 years. There was no significant difference in the mean TAM achieved at final measurement between the "no K-wire" and the "K-wire" treatment groups [no K-wire 202.1° (standard deviations (SD) 40.0) vs. K-wire 187.4° (SD 28.2), p = 0.208]. The "no K-wire group" achieved a mean TAM % of 78.0 (SD 11.4) and the "K-wire group" achieved a mean TAM % of 72.1 (SD 10.8); no statistically significant difference in mean scores was observed between groups. Conclusion: Our study has shown comparable functional outcomes between those having complete joint immobilization with internal K-wire splinting and those that are externally splinted only following central slip repair.

Conceptualizing the peer contribution in Open Dialogue practice

In English mental health services, people with their own experience of mental distress have trained as Open Dialogue practitioners and have been employed as peer practitioners, co-working as equals alongside workers with professional backgrounds in Network Meetings. The conceptual underpinnings of the peer practitioner role have been drawn from the principles and relational approach of Intentional Peer Support. These have significant similarities with Open Dialogue, in terms of philosophical and theoretical orientations, with a particular focus on what happens in the "between" of a relational encounter. However, there are also significant differences in how practice principles are conceptualized, particularly around areas such as mutuality and self-disclosure. This article offers an analysis of this conceptual territory drawing on the relevant literature. This is then taken forward with the teasing out of specific practice principles that capture the unique contribution that peer practitioners can bring to Open Dialogue practice. These are derived through discussions that took place in an Action Learning Set for peer practitioners who have been involved in delivering Open Dialogue services in mainstream mental health service settings. This was part of a wider research study entitled Open Dialogue: Development and Evaluation of a Social Network Intervention for Severe Mental Illness (ODDESSI). The principles address how peer practitioners may be particularly well-placed to offer attunement, validation, connection and mutuality, and self-disclosure - and hence how they may be able to contribute an additional dimension to dialogical practice.

Service user experiences of mental health assessments: a systematic review and thematic synthesis of qualitative literature

BACKGROUND

Successive governments have placed service users' experiences at the heart of mental health services delivery and development. However, little is known about service users' experiences of assessments and there is some evidence that assessments can cause harm.

AIMS

To synthesise the qualitative literature on service users' experiences of undergoing mental health service assessments.

METHODS

Literature was systematically searched, screened and extracted, following PRISMA guidelines. Several search strategies were employed, including electronic database searches, handsearching, and forward and backward citation tracking, to identify literature which contained data on service users' experiences of mental health assessments. Thematic synthesis was used to derive a set of themes underpinning these experiences.

RESULTS

Of the 10,137 references screened, 47 were identified as relevant to the review. Two main themes were identified: the importance of humanising assessment processes and experiences of service user agency, with each theme containing four sub-themes.

CONCLUSIONS

Findings highlight key factors determining service user experience. We identify key practice implications, contextualised within the literature on trauma-informed approaches and conclude that trauma-informed approaches may aid understanding and improvement of people's assessment experiences. Further research into the experiences of people from Black and minority ethnic communities is indicated.

Lesbian and bisexual women's experiences of aversion therapy in England

This article presents the findings of a study about the history of aversion therapy as a treatment technique in the English mental health system to convert lesbians and bisexual women into heterosexual women. We explored published psychiatric and psychological literature, as well as lesbian, gay, and bisexual archives and anthologies. We identified 10 examples of young women receiving aversion therapy in England in the 1960s and 1970s. We situate our discussion within the context of post-war British and transnational medical history. As a contribution to a significantly under-researched area, this article adds to a broader transnational history of the psychological treatment of marginalised sexualities and genders. As a consequence, it also contributes to LGBTQIA+ history, the history of medicine, and psychiatric survivor history. We also reflect on the ethical implications of the research for current mental health practice.

Acellular dermal substitute use in the reconstruction of axillary hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic recurrent debilitating condition that affects the skin near to the follicular glands. The disease manifests with the formation of abscesses that can be complicated by rupture, sinus tracts, and scarring leading to pain, chronic discharge, malodor, and scar contractures. The management of HS is multidisciplinary, involving general lifestyle modification, medical treatment, and surgery. A wide range of surgical interventions has been described for HS disease control and management. However, surgical management strategies are highly variable. We describe the case of a 33-year-old female with refractory HS which was reconstructed with Matriderm® and an immediate split-thickness skin graft. Acellular dermal skin substitutes may be an alternative to conventional means of HS reconstruction, producing subtle, pliable, and durable skin.

247 Axillary Hidradenitis Suppurativa: A One-Stage Reconstruction Approach Using Acellular Dermal Substitute

Hidradenitis suppurativa (HS) is a chronic recurrent debilitating condition. It is characterized by abscesses, and can be complicated by rupture, scarring sinuses. The management of HS is multidisciplinary, involving general lifestyle modification, medical treatment, and surgery. A wide range of surgical interventions have been described for HS disease control and management. However, surgical management strategies are highly variable. We present a case of a 33-year-old female with extensive HS in both axillae resulting in extreme pain, restriction of shoulders movement with severe impact on quality of life. After failure of non-operative management, she underwent a wide excision of all pathological axillary disease. One week later, she had a single-stage reconstruction with Matriderm®. and a meshed split thickness skin graft. Acellular dermal skin substitutes may be an alternative to conventional means of hidradenitis suppurativa reconstruction, producing subtle, pliable, and durable skin.

965The estimated impact of improved breast screening tests targeted at women with dense breasts

Background

There is increasing interest in risk-based breast cancer screening, including interventions to improve outcomes for women with mammographically dense breasts.

Methods

Policy1-Breast is a continuous-time, multiple-cohort micro-simulation whole-population model which incorporates breast cancer risk, life-course breast density, menopause, hormone therapy use and screening participation. Outcomes include cancer diagnoses and characteristics (invasive/DCIS, tumour size, grade), mode of detection (screen-detected/interval/other) and mortality (breast cancer and other cause). Policy1-Breast validates well against key observed clinical outcomes in Australia. We estimate changes in outcomes within and outside the BreastScreen program upon the introduction of a hypothetical screening test with improved sensitivity for women with dense breasts.

Results

We estimate that introducing in year 2020 a screening test for women in the highest quintile of breast density at age 50 that halves the masking effect of their breast density would, by 2026-2030, increase diagnosis rates of population-level invasive cancers ( 10%) and screen-detected cancers (20%) and decrease rates of interval cancers (17%) and community-detected cancers (6%).

Conclusions

Targeted screening tests with improved sensitivity for women with dense breasts are expected to markedly reduce interval cancers and other cancers diagnosed outside the BreastScreen program, while increasing all cancer diagnoses due to increased rates of screen-detected cancers.

Key messages

Specialised breast cancer screening tests directed at women with very high breast density are expected to reduce interval cancers and increase overall cancer diagnoses. Population simulation models such as Policy1-Breast can complement trial evidence by evaluating a range of scenarios and estimating short and long-term implications.

906Can mammographic density add value to the Gail model in risk-stratifying women in BreastScreen Australia?

Background

There is significant interest in personalised, risk-based breast cancer screening. This requires high quality risk assessment. The ‘Gail model’ risk assessment tool has been validated on over 40,000 BreastScreen Australia participants. We assess whether adding mammographic density (MD) information improves risk stratification on that cohort.

Methods

We used questionnaire data, baseline MD readings (using AutoDensity) and linked screening and cancer registry records from 40,158 BreastScreen Australia participants aged 50–69 years (via the lifepool cohort). We investigated incident invasive breast cancer rates by quintiles of Gail model scores, MD, and combinations of Gail and MD.

Results

Gail scores and MD values were weakly correlated (r≤0.02). Gail and MD were each strong predictors of incident breast cancer, but stronger predictors when used in combination. For example, the odds ratio for incident invasive breast cancer was 3.6 (95%CI 2.5-6.3) for the 17% of women in the upper two quintiles of both Gail and MD scores compared to the 17% of women in the lower two quintiles of both scores. In comparison, the odds ratio for breast cancer between same-size (each 17%) upper and lower groups for Gail score alone was 2.5 (95%CI 1.8-3.4), and for MD 1.9 (95%CI 1.2-2.9).

Conclusions

Combining Gail and MD categories improves risk stratification on BreastScreen Australia participants, compared to using Gail or MD alone.

Key messages

While questionnaire data and MD measures are each strong predictors of future invasive breast cancer among BreastScreen Australia participants, risk prediction is stronger when questionnaire and MD measures are combined.

Atypical facial presentation of subcutaneous fat necrosis of the newborn

Subcutaneous fat necrosis of the newborn (SCFN) is a rare self-limiting panniculitis. It is thought to be associated with perinatal hypoxia and therapeutic hypothermia. It is characterised by firm subcutaneous nodules on the back, shoulder and arms. We present a rare facial presentation of SCFN in a 4-week-old infant with no history of therapeutic cooling. She presented with a discrete right cheek mass with no overlying skin changes. We present the diagnostic challenge and undertake a review of the literature. SCFN is an important differential diagnosis in a neonate with subcutaneous facial lesions. SCFN can be complicated by metabolic derangements including hypercalcaemia.

Camptodactyly and DiGeorge syndrome: A rare hand anomaly

The most common deletion syndrome is 22q11.2 and it effects an estimated 1 in 3000 live births. Major features of this multisystem condition include congenital abnormalities, developmental delay, learning difficulties, immunodeficiency, endocrine anomalies and an array of psychiatric disorders. However, variability in phenotype and severity may cause the diagnosis to be overlooked. Early clinical recognition and treatment of DiGeorge syndrome has been shown to increase early life survival, decrease complications and enhance overall quality of life.

Skeletal anomalies are infrequently described in 22q11.2 but a subset of patients exhibit upper and lower limb deformities. We present the case of a 5 year-old girl with bilateral fifth digit camptodactyly caused by a fibrous band, and the surgical management of this condition. The current report adds to the body of evidence that camptodactyly is a rare clinical feature of 22q11.2 deletion syndrome, and may serve as a diagnostic aid in these patients.

A history of lesbian politics and the psy professions

This article explores the relationship between lesbian activists and the “psy professions” (especially psychology and psychiatry) in England from the 1960s to the 1980s. We draw on UK-based LGBTQIA+ archive sources and specifically magazines produced by, and for, lesbians. We use this material to identify three key strategies used within the lesbian movement to contest psycho-pathologisation during this 30-year period: from respectable collaborationist forms of activism during the 1960s; to more liberationist oppositional politics during the early 1970s; to radical feminist separatist activism in the 1980s. Whilst these strategies broadly map onto activist strategies deployed within the wider lesbian and gay movement during this time, this article explores how these politics manifested in particular ways, specifically in relation to the psy disciplines in the UK. We describe these strategies, illustrating them with examples of activism from the archives. We then use this history to problematise a linear, overly reductionist or binary history of liberation from psycho-pathologisation. Finally, we explore some complexities in the relationship between sexuality, activism and the psy professions.

Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses

PURPOSE

The COVID-19 pandemic has many potential impacts on people with mental health conditions and on mental health care, including direct consequences of infection, effects of infection control measures and subsequent societal changes. We aimed to map early impacts of the pandemic on people with pre-existing mental health conditions and services they use, and to identify individual and service-level strategies adopted to manage these.

METHODS

We searched for relevant material in the public domain published before 30 April 2020, including papers in scientific and professional journals, published first person accounts, media articles, and publications by governments, charities and professional associations. Search languages were English, French, German, Italian, Spanish, and Mandarin Chinese. Relevant content was retrieved and summarised via a rapid qualitative framework synthesis approach.

RESULTS

We found 872 eligible sources from 28 countries. Most documented observations and experiences rather than reporting research data. We found many reports of deteriorations in symptoms, and of impacts of loneliness and social isolation and of lack of access to services and resources, but sometimes also of resilience, effective self-management and peer support. Immediate service challenges related to controlling infection, especially in inpatient and residential settings, and establishing remote working, especially in the community. We summarise reports of swiftly implemented adaptations and innovations, but also of pressing ethical challenges and concerns for the future.

CONCLUSION

Our analysis captures the range of stakeholder perspectives and experiences publicly reported in the early stages of the COVID-19 pandemic in several countries. We identify potential foci for service planning and research.

Impact on mental health care and on mental health service users of the COVID-19 pandemic: a mixed methods survey of UK mental health care staff

PURPOSE

The COVID-19 pandemic has potential to disrupt and burden the mental health care system, and to magnify inequalities experienced by mental health service users.

METHODS

We investigated staff reports regarding the impact of the COVID-19 pandemic in its early weeks on mental health care and mental health service users in the UK using a mixed methods online survey. Recruitment channels included professional associations and networks, charities, and social media. Quantitative findings were reported with descriptive statistics, and content analysis conducted for qualitative data.

RESULTS

2,180 staff from a range of sectors, professions, and specialties participated. Immediate infection control concerns were highly salient for inpatient staff, new ways of working for community staff. Multiple rapid adaptations and innovations in response to the crisis were described, especially remote working. This was cautiously welcomed but found successful in only some clinical situations. Staff had specific concerns about many groups of service users, including people whose conditions are exacerbated by pandemic anxieties and social disruptions; people experiencing loneliness, domestic abuse and family conflict; those unable to understand and follow social distancing requirements; and those who cannot engage with remote care.

CONCLUSION

This overview of staff concerns and experiences in the early COVID-19 pandemic suggests directions for further research and service development: we suggest that how to combine infection control and a therapeutic environment in hospital, and how to achieve effective and targeted tele-health implementation in the community, should be priorities. The limitations of our convenience sample must be noted.

How mental health care should change as a consequence of the COVID-19 pandemic

The unpredictability and uncertainty of the COVID-19 pandemic; the associated lockdowns, physical distancing, and other containment strategies; and the resulting economic breakdown could increase the risk of mental health problems and exacerbate health inequalities. Preliminary findings suggest adverse mental health effects in previously healthy people and especially in people with pre-existing mental health disorders. Despite the heterogeneity of worldwide health systems, efforts have been made to adapt the delivery of mental health care to the demands of COVID-19. Mental health concerns have been addressed via the public mental health response and by adapting mental health services, mostly focusing on infection control, modifying access to diagnosis and treatment, ensuring continuity of care for mental health service users, and paying attention to new cases of mental ill health and populations at high risk of mental health problems. Sustainable adaptations of delivery systems for mental health care should be developed by experts, clinicians, and service users, and should be specifically designed to mitigate disparities in health-care provision. Thorough and continuous assessment of health and service-use outcomes in mental health clinical practice will be crucial for defining which practices should be further developed and which discontinued. For this Position Paper, an international group of clinicians, mental health experts, and users of mental health services has come together to reflect on the challenges for mental health that COVID-19 poses. The interconnectedness of the world made society vulnerable to this infection, but it also provides the infrastructure to address previous system failings by disseminating good practices that can result in sustained, efficient, and equitable delivery of mental health-care delivery. Thus, the COVID-19 pandemic could be an opportunity to improve mental health services.

The social underpinnings of mental distress in the time of COVID-19 - time for urgent action

We argue that predictions of a ‘tsunami’ of mental health problems as a consequence of the pandemic of coronavirus disease 2019 (COVID-19) and the lockdown are overstated; feelings of anxiety and sadness are entirely normal reactions to difficult circumstances, not symptoms of poor mental health.  Some people will need specialised mental health support, especially those already leading tough lives; we need immediate reversal of years of underfunding of community mental health services.  However, the disproportionate effects of COVID-19 on the most disadvantaged, especially BAME people placed at risk by their social and economic conditions, were entirely predictable. Mental health is best ensured by urgently rebuilding the social and economic supports stripped away over the last decade. Governments must pump funds into local authorities to rebuild community services, peer support, mutual aid and local community and voluntary sector organisations.  Health care organisations must tackle racism and discrimination to ensure genuine equal access to universal health care.  Government must replace highly conditional benefit systems by something like a universal basic income. All economic and social policies must be subjected to a legally binding mental health audit. This may sound unfeasibly expensive, but the social and economic costs, not to mention the costs in personal and community suffering, though often invisible, are far greater.

Form of Supplemental Selenium in Vitamin-Mineral Premixes Differentially Affects Early Luteal and Gestational Concentrations of Progesterone, and Postpartum Concentrations of Prolactin in Beef Cows

Simple Summary

Soils with inadequate levels of selenium are widespread in the northwest, northeast, and southeast USA. Therefore, dietary supplementation of forage-grazing beef cattle with additional selenium is recommended in these regions for optimal growth, immune function, and fertility. We have reported that the form of selenium provided to Angus-cross cows can affect circulating concentrations of progesterone on day 6 of the estrous cycle, a time when increased progesterone is known to promote fertility. Hence, we sought to confirm this initial finding, determine the effect of the form of selenium on peripheral concentrations of progesterone during gestation, and determine the effect of the form of selenium on circulating concentrations of prolactin during lactation. Cows were supplemented with equimolar amounts of either an inorganic form, or a 1:1 mixture of inorganic and organic forms of selenium throughout this study. We confirmed our original finding that the mixed (1:1 inorganic to organic selenium) supplement increased systemic progesterone in the early luteal phase of the estrous cycle, and determined that cows maintained on this same supplement had elevated concentrations of progesterone throughout gestation. Interestingly, these same cows revealed a treatment-induced decrease in systemic prolactin during late lactation. The form of selenium provided to cows can be manipulated to affect reproductive responses and offers a viable management tool to improve fertility in cows in regions with selenium-deficient soils.

Abstract

Soils with marginal to deficient levels of selenium (Se) are widespread in the northwest, northeast, and southeast US. Supplementation to the diet of forage-grazing beef cattle with a vitamin-mineral mix containing additional Se is recommended in these geographic regions. We have reported that the form of supplemental Se provided to Angus-cross beef cows can affect circulating levels of progesterone (P4) on day 6 of the estrous cycle, a time when increased P4 is known to promote fertility. The objectives of this study were to (1) confirm and expand upon our initial report that the form of Se provided to cows affects early luteal-phase concentrations of systemic P4, (2) determine the effects of the form of Se on concentrations of P4 during gestation, and (3) determine the effects of the form of Se on concentrations of prolactin (PRL) during lactation. Throughout this study, Angus-cross beef cows had ad libitum access to a vitamin-mineral mix containing 35 ppm of Se in either an inorganic form (ISe) or a 1:1 mix of inorganic and organic forms (MIX). We observed a MIX-induced increase (p = 0.006) in systemic concentrations of P4 on day 7 but not on days 4 or 10 of the estrous cycle, consistent with our earlier report. We observed a MIX-induced increase (p = 0.02) in the systemic concentration of P4 at months 1, 3, 5, and 7 of gestation, and a MIX-induced decrease (p < 0.05) in systemic concentrations of PRL at months 5 and 6 of lactation. In summary, the form of Se provided to cows can be manipulated to affect the early luteal phase and gestational concentrations of P4, and postpartum concentrations of PRL.

Lost in the shadows: reflections on the dark side of co-production

This article is a response to Oliver et al.'s Commentary 'The dark side of coproduction: do the costs outweigh the benefits for health research?' recently published in Health Research Policy and Systems (2019, 17:33). The original commentary raises some important questions about how and when to co-produce health research, including highlighting various professional costs to those involved. However, we identify four related limitations in their inquiry, as follows: (1) the adoption of a problematically expansive definition of co-production that fails to acknowledge key features that distinguish co-production from broader collaboration; (2) a strong focus on technocratic rationales for co-producing research and a relative neglect of democratic rationales; (3) the transposition of legitimate concerns relating to collaboration between researchers and practitioners onto work with patients, service users and marginalised citizens; and (4) the presentation of bad practice as an inherent flaw, or indeed 'dark side', of co-production without attending to the corrupting influence of contextual factors within academic research that facilitate and even promote such malpractice. The Commentary's limitations can be seen to reflect the contemporary use of the term 'co-production' more broadly. We describe this phenomenon as 'cobiquity' - an apparent appetite for participatory research practice and increased emphasis on partnership working, in combination with the related emergence of a plethora of 'co' words, promoting a conflation of meanings and practices from different collaborative traditions. This phenomenon commonly leads to a misappropriation of the term 'co-production'. Our main motivation is to address this imprecision and the detrimental impact it has on efforts to enable co-production with marginalised and disadvantaged groups. We conclude that Oliver et al. stray too close to 'the problem' of 'co-production' seeing only the dark side rather than what is casting the shadows. We warn against such a restricted view and argue for greater scrutiny of the structural factors that largely explain academia's failure to accommodate and promote the egalitarian and utilitarian potential of co-produced research.

CSACI guidelines for the ethical, evidence-based and patient-oriented clinical practice of oral immunotherapy in IgE-mediated food allergy

Background

Oral immunotherapy (OIT) is an emerging approach to the treatment of patients with IgE-mediated food allergy and is in the process of transitioning to clinical practice.

Objective

To develop patient-oriented clinical practice guidelines on oral immunotherapy based on evidence and ethical imperatives for the provision of safe and efficient food allergy management.

Materials and methods

Recommendations were developed using a reflective patient-centered multicriteria approach including 22 criteria organized in five dimensions (clinical, populational, economic, organizational and sociopolitical). Data was obtained from: (1) a review of scientific and ethic literature; (2) consultations of allergists, other healthcare professionals (pediatricians, family physicians, nurses, registered dieticians, psychologists, peer supporters), patients and caregivers; and patient associations through structured consultative panels, interviews and on-line questionnaire; and (3) organizational and economic data from the milieu of care. All data was synthesized by criteria in a multicriteria deliberative guide that served as a platform for structured discussion and development of recommendations for each dimension, based on evidence, ethical imperatives and other considerations.

Results

The deliberative grid included 162 articles from the literature and media reviews and data from consultations involving 85 individuals. Thirty-eight (38) recommendations were made for the practice of oral immunotherapy for the treatment of IgE mediated food allergy, based on evidence and a diversity of ethical imperatives. All recommendations were aimed at fostering a context conducive to achieving objectives identified by patients and caregivers with food allergy. Notably, specific recommendations were developed to promote a culture of shared responsibility between patients and healthcare system, equity in access, patient empowerment, shared decision making and personalization of OIT protocols to reflect patients' needs. It also provides recommendations to optimize organization of care to generate capacity to meet demand according to patient choice, e.g. OIT or avoidance. These recommendations were made acknowledging the necessity of ensuring sustainability of the clinical offer in light of various economic considerations.

Conclusions

This innovative CPG methodology was guided by patients' perspectives, clinical evidence as well as ethical and other rationales. This allowed for the creation of a broad set of recommendations that chart optimal clinical practice and define the conditions required to bring about changes to food allergy care that will be sustainable, equitable and conducive to the well-being of all patients in need.

Abstract TS1-2: Proteogenomic Landscape of Prospectively Collected Breast Cancer

A persistent central deficiency in our knowledge of cancer concerns how genomic changes drive the proteome and phosphoproteome to execute phenotypic characteristics. Furthermore increasing evidence implicating epigenetic and post-translational changes in cancer biology reinforce the notion that molecular profiles based on nucleic acids are incomplete and are critically complemented by analyses of proteins and their post-translational modifications. We present the first integrated proteogenomic study on a prospectively collected breast cancer cohort, and provide new insights including on taxonomy, metabolic dependencies, and immune milieu. 122 invasive ductal breast cancer samples were collected under the auspices of the National Cancer Institute’s Clinical Proteomics Tumor Analysis Consortium using rigorous protocols to minimize ischemic time and other pre-analytical variability. Samples underwent comprehensive genomic and proteomic characterization, providing whole exome, whole genome, copy number, RNAseq, global proteome, phosphoproteome, and acetylome data. Multi-omics clustering by nonnegative matrix factorization revealed basal-, luminal A-, and HER2-enriched clusters, as well as a combined luminal A/B cluster. Luminal A and A/B clusters were distinguished by differential expression of cytoskeletal signatures possibly driven by YAP1 overexpression and hyper-phosphorylation in the luminal A subset. Kinase outlier analysis revealed luminal A enrichment of PEAK1, an atypical kinase that regulates YAP1 expression. PTPN2, recently shown to synergize with anti-PD1 therapy, was an outlier in basal tumors, suggesting therapeutic opportunities in that difficult-to-treat subtype. Acetylation plays a dominant role in mitochondrial metabolism, and downregulation of deacetylase SIRT3 in basal and HER2-enriched samples was associated with upregulation of TCA cycle- and amino acid metabolism-related proteins suggesting metabolic dependencies that could be exploited. Immunological subtyping of the breast cohort identified immune-cold, immune-hot, immune-excluded and interferon-independent clusters associated with distinct patterns of tumor-infiltrating lymphocytes. Basal tumors generally overexpressed PDL1 relative to other subtypes, whereas the newly described immuno-oncology target SIGLEC15 was overexpressed in luminal tumors. While these and other analyses are intended to provide new insights into breast cancer biology and facilitate testable therapeutic hypotheses, the larger purpose of the program is to provide a resource to the breast cancer and broader scientific communities. To facilitate this, these and previously published data will be integrated to provide a sample set of 199 proteogenomically characterized breast cancers for further exploration.

Citation Format: M Gillette, K Krug, S Satpathy, E Jaehnig, A Karpova, K Clauser, L Tang, L Blumenberg, R Kothadia, K Ruggles, B Zhang, L Ding, P Mertins, DR Mani, M Ellis, S Carr. Proteogenomic Landscape of Prospectively Collected Breast Cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr TS1-2.

Unpaid carer inequalities: a public health concern

Key messages

unpaid (family)carers are at risk of being exposed to a range of health inequalities which can have individual and societal consequences. Interventions that acknowledge the relationship and draw on social dimensions may off coping may offer effective ways forward.

'Dignity and respect': An example of service user leadership and co-production in mental health research

This paper explores the methodological aspects of a user‐led study investigating mental health service user experiences of targeted violence and abuse (often called 'hate crime'). 'Keeping Control' was a 16‐month qualitative study, undertaken in the context of adult safeguarding reforms in England. By collecting data on service user concepts and experiences, the research sought to address a gap in research and practice knowledge relating to targeted violence, abuse and hostility against people with mental health problems. In this paper, we discuss the significance of the design and methodology used for this study, with a particular focus on the interviews with service users. The research was both user‐led and carried out in collaboration with practitioners and academics, a form of research co‐production. Our aim is to inform researchers, practitioners and policymakers about the value of user leadership in co‐productive research with practitioners, particularly for a highly sensitive and potentially distressing topic.

Conducting sexualities research: an outline of emergent issues and case studies from ten Wellcome-funded projects

This letter seeks to synthesise methodological challenges encountered in a cohort of Wellcome Trust-funded research projects focusing on sexualities and health. The ten Wellcome Trust projects span a diversity of gender and sexual orientations and identities, settings; institutional and non-institutional contexts, lifecourse stages, and explore a range of health-related interventions.  As researchers, we originate from a breadth of disciplinary traditions, use a variety of research methods and data sources. Despite this breadth, four common themes are found across the projects: (i) inclusivity, representations and representativeness, (ii) lumping together of diverse groups, (iii) institutions and closed settings (iv) ethical and governance barriers.

"Keeping Control": A user-led exploratory study of mental health service user experiences of targeted violence and abuse in the context of adult safeguarding in England

The situation for people with mental health problems as a group of disabled people who experience targeted violence and abuse is a complex one. Disabled people, particularly those with mental health problems, are at higher risk of targeted violence and hostility with few effective evidence-based prevention and protection strategies. Achieving effective safeguarding for adults with mental health problems is characterised by differential attitudes to and understandings of abuse by safeguarding practitioners, as well as systemic issues arising from multi-agency working. "Keeping Control" was a 16-month user-led, co-produced exploratory qualitative study into service user experiences of targeted violence and abuse that was examined in the context of Care Act 2014 adult safeguarding reforms in England. User-controlled interviews of mental health service users (N = 23) explored their experiences and concepts of targeted violence and abuse, prevention and protection. Preliminary findings from these interviews were discussed in adult safeguarding and mental health stakeholder and practitioner focus groups (N = 46). The data were also discussed via two facilitated Twitter chats (responses N = 585 and N = 139). Mental health service users' experiences and concepts of risk from others, vulnerability and neglect can be different to those of practitioners but should be central to adult safeguarding. Histories of trauma, multi-factorial abuse; living with fear and stigma as well as mental distress; the effects of "psychiatric disqualification" and individual blaming should be addressed in adult safeguarding in mental health. Fragmented responses from services can mean a person becomes "lost in the process". Staff can feel disempowered, afraid or lacking in confidence to "speak up" for individuals in complex service systems with poor communication and lines of accountability. Adult safeguarding practitioners and stakeholders need to be confident, accessible and respond quickly to service users reporting incidents of targeted violence and abuse particularly in closed environments such as wards or supported housing.

A systematic review of qualitative studies of adults' experiences of being assessed for psychological therapies

Objective

To synthesize the qualitative literature on adults’ experiences of psychological therapy assessments. The review was led by people with experience of undergoing assessments, with high levels of client involvement throughout.

Search strategy

A comprehensive search of electronic databases was undertaken, with additional search strategies employed to locate further literature.

Inclusion criteria

Studies were included that qualitatively explored the experiences of people aged 16+ who had been assessed for psychological therapy services. Assessments could be structured or unstructured. Qualitative was defined as any analysed account of people's experiences, including qualitative survey data.

Data extraction and synthesis

Literature quality was appraised using the Critical Appraisal Skills Program checklist, modified to include client involvement and intersectionalities. Following data extraction, thematic synthesis was used to synthesize findings across studies.

Results

Of 12 743 titles were screened, with 13 studies relevant to the review. Themes and subthemes were identified at three stages of the assessment process: the journey to the assessment, at the assessment, and after the assessment. Findings highlighted the emotional impact of assessments, collaboration, intersectionalities, rights, pathologization, socioeconomic restrictions, and information and support needs. Implications and limitations were indicated.

Discussion and conclusions

Findings were situated within the trauma‐informed (TIA) literature. Trauma‐informed assessment principles, including collaborative assessments, may be fruitful means of improving people's experiences. Whilst the benefits of collaboration appear self‐evident, explicitly collaborative approaches were not the norm, nor were studies conducted independently. Further service user research is needed. A greater understanding of the experience of minority groups is also needed.

Prospective validation of the NCI Breast Cancer Risk Assessment Tool (Gail Model) on 40,000 Australian women

Background

There is a growing interest in delivering more personalised, risk-based breast cancer screening protocols. This requires population-level validation of practical models that can stratify women into breast cancer risk groups. Few studies have evaluated the Gail model (NCI Breast Cancer Risk Assessment Tool) in a population screening setting; we validated this tool in a large, screened population.

Methods

We used data from 40,158 women aged 50–69 years (via the lifepool cohort) participating in Australia’s BreastScreen programme. We investigated the association between Gail scores and future invasive breast cancer, comparing observed and expected outcomes by Gail score ranked groups. We also used machine learning to rank Gail model input variables by importance and then assessed the incremental benefit in risk prediction obtained by adding variables in order of diminishing importance.

Results

Over a median of 4.3 years, the Gail model predicted 612 invasive breast cancers compared with 564 observed cancers (expected/observed (E/O) = 1.09, 95% confidence interval (CI) 1.00–1.18). There was good agreement across decile groups of Gail scores (χ² = 7.1, p = 0.6) although there was some overestimation of cancer risk in the top decile of our study group (E/O = 1.65, 95% CI 1.33–2.07). Women in the highest quintile (Q5) of Gail scores had a 2.28-fold increased risk of breast cancer (95% CI 1.73–3.02, p < 0.0001) compared with the lowest quintile (Q1). Compared with the median quintile, women in Q5 had a 34% increased risk (95% CI 1.06–1.70, p = 0.014) and those in Q1 had a 41% reduced risk (95% CI 0.44–0.79, p < 0.0001). Similar patterns were observed separately for women aged 50–59 and 60–69 years. The model’s overall discrimination was modest (area under the curve (AUC) 0.59, 95% CI 0.56–0.61). A reduced Gail model excluding information on ethnicity and hyperplasia was comparable to the full Gail model in terms of correctly stratifying women into risk groups.

Conclusions

This study confirms that the Gail model (or a reduced model excluding information on hyperplasia and ethnicity) can effectively stratify a screened population aged 50–69 years according to the risk of future invasive breast cancer. This information has the potential to enable more personalised, risk-based screening strategies that aim to improve the balance of the benefits and harms of screening.

Electronic supplementary material

The online version of this article (10.1186/s13058-018-1084-x) contains supplementary material, which is available to authorized users.

Referral of patients to plastic surgeons following self-harm: Opportunities for suicide prevention

Self-harm is a common source of referral to plastic and hand surgery services. Appropriate management of these patients is complex and includes the need for close liaison with mental health services. Self-harm is the single biggest risk factor for completed suicide, thereby increasing the risk by a factor of 66.¹ This study aimed to analyse the clinical pathway and demographics of patients referred to plastic surgeons following self-harm. This 6-year retrospective series included patients referred to plastic surgeons following self-harm within the Galway University Hospital group. Patients were identified through the Hospital inpatient enquiry system, cross-referenced with data from the National Suicide Research Foundation. Data collected included demographics, psychiatric history, details of self-harm injury, admission pathway and operative intervention. Forty-nine patients were referred to plastic surgery services during the study period, accounting for 61 individual presentations. The male-to-female ratio was 26 (53%) to 23 (47%). Mean age was 40 years (range 21-95 years). Alcohol or illicit substance use was recorded in 17 of 61 (28%) presentations. Mortality from suicide occurred in 4 patients (8%). Mental health assessment was not carried out in 9 presentations (15%). Documentation of need for close or one-to-one observation was made in 11 cases (20%) and was not referred to in 43 cases (83%) following mental health assessment. This study demonstrates significant diversity in the management of this vulnerable patient group and may inform development of referral pathways to improve the safety of transfer, surgical admission and discharge of patients following self-harm, in consultation with mental health services.