Talking about depression during interactions with GPs: a qualitative study exploring older people's accounts of their depression narratives.

BACKGROUND: Older people can struggle with revealing their depression to GPs and verbalising preferences regarding its management. This contributes to problems for GPs in both detecting and managing depression in primary care. The aim of this study was to explore older people's accounts of how they talk about depression and possible symptoms to improve communication about depression when seeing GPs. METHODS: Adopting a qualitative Interpretivist methodological approach, semi-structured interviews were conducted by IG based on the principles of grounded theory and situational analysis. GPs working in north east England recruited patients aged over 65 with depression. Data analysis was carried out with a process of constant comparison, and categories were developed via open and axial coding and situational maps. There were three levels of analysis; the first developed open codes which informed the second level of analysis where the typology was developed from axial codes. The typology derived from second level analysis only is presented here as older people's views are rarely reported in isolation. RESULTS: From the sixteen interviews with older people, it was evident that there were differences in how they understood and accepted their depression and that this influenced what they shared or withheld in their narratives. A typology showing three categories of older people was identified: those who appeared to talk about their depression freely yet struggled to accept aspects of it (Superficial Accepter), those who consolidated their ideas about depression aloud (Striving to Understand) and those who shared minimal detail about their depression and viewed it as part of them rather than a treatable condition (Unable to Articulate). The central finding was that older people's acceptance and understanding of their depression guided their depression narratives. CONCLUSIONS: This study identified differences between older people in ways they understand, accept and share their depression. Recognising that their depression narratives can change and listening for patterns in what older people share or withhold may help GPs in facilitating communication to better understand the patient when they need to implement alternative approaches to patient management.

Feasibility and acceptability of autism adapted safety plans: an external pilot randomised controlled trial.

Background: Autistic people are a high-risk group for self-harm and suicide. There are no evidence-based suicide prevention interventions developed specifically for autistic people. We undertook a pilot feasibility randomised controlled trial of autism adapted safety plans (AASP) to reduce self-harm and suicide for autistic people. Methods: This study took place in the United Kingdom and followed a randomised, two-arm, controlled design. Autistic adults (n = 53, mean age = 39, gender = 49% female, 29% not male or female) were recruited via third sector organisations and self-referral between 11.8.21 and 19.10.22. Participants were randomised without stratification to usual care with or without AASP. The AASP was completed by the autistic adults together with someone trained to support them. Research staff who completed follow-up assessments were blind to participant allocation. Primary outcomes were feasibility and acceptability. Participants were assessed at baseline, 1 and 6 months. Primary data were analysed under the intention to treat principle. Study protocol is published. The trial is closed to new participants. This study is registered with the ISRCTN registry, ISRCTN70594445. Findings: 53 participants consented, 49 were randomised to either AASP with usual care (n = 25) or usual care (n = 24). 68% of participants in the AASP arm were satisfied with the AASP and 41% rated it as useable. Feedback on the AASP and research methods were positive with suggested adaptations to some outcome measures. Retention and completion of outcomes measures in both arms was excellent, as was fidelity of delivery of the AASP. Interpretation: Study progression criteria were met, suggesting that the parameters of a future definitive trial of clinical and cost effectiveness of AASP to reduce self-harm and suicide in autistic adults are achievable, with minor recommended adaptions to outcome measures and AASP. Future research should explore the use of AASP in routine clinical practice. Funding: This study is funded by the NIHR [Public Health Research Programme (NIHR129196)].

The acceptability of addressing alcohol consumption as a modifiable risk factor for breast cancer: a mixed method study within breast screening services and symptomatic breast clinics.

OBJECTIVES: Potentially modifiable risk factors account for approximately 23% of breast cancers, with obesity and alcohol being the two greatest. Breast screening and symptomatic clinical attendances provide opportunities ('teachable moments') to link health promotion and breast cancer-prevention advice within established clinical pathways. This study explored knowledge and attitudes towards alcohol as a risk factor for breast cancer, and potential challenges inherent in incorporating advice about alcohol health risks into breast clinics and screening appointments. DESIGN: A mixed-method study including a survey on risk factors for breast cancer and understanding of alcohol content. Survey results were explored in a series of five focus groups with women and eight semi-structured interviews with health professionals. SETTING: Women attending NHS Breast Screening Programme (NHSBSP) mammograms, symptomatic breast clinics and healthcare professionals in those settings. PARTICIPANTS: 205 women were recruited (102 NHSBSP attenders and 103 symptomatic breast clinic attenders) and 33 NHS Staff. RESULTS: Alcohol was identified as a breast cancer risk factor by 40/205 (19.5%) of attenders and 16/33 (48.5%) of staff. Overall 66.5% of attenders drank alcohol, and 56.6% could not estimate correctly the alcohol content of any of four commonly consumed alcoholic drinks. All women agreed that including a prevention-focussed intervention would not reduce the likelihood of their attendance at screening mammograms or breast clinics. Qualitative data highlighted concerns in both women and staff of how to talk about alcohol and risk factors for breast cancer in a non-stigmatising way, as well as ambivalence from specialist staff as to their role in health promotion. CONCLUSIONS: Levels of alcohol health literacy and numeracy were low. Adding prevention interventions to screening and/or symptomatic clinics appears acceptable to attendees, highlighting the potential for using these opportunities as 'teachable moments'. However, there are substantial cultural and systemic challenges to overcome if this is to be implemented successfully.

Implementing online evidence-based care pathways: A mixed-methods study across primary and secondary care.

AIM: To understand what contextual influences, mechanisms and outcomes affect the implementation and use of localised, online care pathways (HealthPathways) in primary and secondary care. DESIGN AND PROCEDURE: Mixed-measures design. Quantitative data included number of page views and conditions viewed. Qualitative data from semistructured interviews and focus groups were gathered over a 6-month period, and analysed using NVivo software. SETTING: The first HealthPathways UK site, South Tyneside, England. PARTICIPANTS: General practitioners, nurses, practice managers, hospital consultants and system leaders (managers, commissioners) (n=76). RESULTS: Use of the pathways significantly increased over time. Themes were developed showing how online care pathways were used-leadership, pre-existing networks and relationships; development of systems and processes for care pathways, the use of online care pathways to support decision-making and referral, and perceived availability of resources. Inter-related themes were arranged into configurations consisting of contextual influences, mechanisms and outcomes. Recommendations were made for future implementations, such as improved data collection processes to understand how and why there was variance in the use of pathways. CONCLUSIONS: This study was early in the implementation process; however, emerging themes will facilitate the future implementation and use of online care pathways. Recommendations are made for further research to include other health and social care users and patients to inform future developments.

Supporting parents through stillbirth: A qualitative study exploring the views of health professionals and health care staff in three hospitals in England.

OBJECTIVE: To investigate the views of a range of hospital based health professionals and health care staff involved in the management of stillbirth. STUDY DESIGN: A qualitative pilot study informed by grounded theory conducted in three hospital trusts in the North East of England. In total, 21 consultant obstetricians, 3 trainees (including 1 senior trainee), 29 midwives, 3 midwife sonographers and 4 chaplains took part in six focus groups and two semi-structured interviews. RESULTS: Two different approaches in stillbirth management could be detected in our study. One approach emphasised the existing evidence-base and patient directed choice whilst the other emphasised tradition and profession-directed care. These differences were particularly apparent in choices over mode of delivery, and the location of women as well as the time interval between diagnosis of an IUD and delivery. The existence of these two approaches was underscored by a lack of high quality evidence. CONCLUSION: Robust, high quality evidence is needed regarding the longer term psychological and emotional sequelae of different modes of delivery and varying time intervals and locations of women between diagnosis and delivery in stillbirth. If the competing discourses demonstrated here are found elsewhere then such need to be considered in any future policy development, evidence implementation and training programmes.

Electrolytes Ageing in Lithium-ion Batteries: A Mechanistic Study from Picosecond to Long Timescales.

The ageing phenomena occurring in various diethyl carbonate/LiPF6 solutions are studied using gamma and pulse radiolysis as a tool to generate similar species as the ones occurring in electrolysis of Li-ion batteries (LIBs). According to picosecond pulse radiolysis experiments, the reaction of the electron with (Li(+), PF6(-)) is ultrafast, leading to the formation of fluoride anions that can then precipitate into LiF(s). Moreover, direct radiation-matter interaction with the salt produces reactive fluorine atoms forming HF(g) and C2H5F(g). The strong Lewis acid PF5 is also formed. This species then forms various R(1)R(2)R(3) P=O molecules, where R is mainly -F, -OH, and -OC2H5. Substitution reactions take place and oligomers are slowly formed. Similar results were obtained in the ageing of an electrochemical cell filled with the same model solution. This study demonstrates that radiolysis enables a description of the reactivity in LIBs from the picosecond timescale until a few days.

Insights from ambulatory blood pressure monitoring: diagnosis of hypertension and diurnal blood pressure in renal transplant recipients.

BACKGROUND: Accurate diagnosis of hypertension is essential in chronic kidney disease patients, as it is linked to increased left ventricular mass, stroke, cardiovascular mortality and morbidity, and progression to end-stage renal disease. Elevated blood pressure (BP) detected by ambulatory BP monitoring (ABPM) has been shown to be predictive of worse outcome in chronic kidney disease patients. Another predictor of worse outcome is diurnal BP variation, measured also by ABPM. In this study, the authors examined the relationship (concordance or discordance) between blood pressure measured by ABPM compared with daytime office BP, and also explored the predictors of diurnal variation in renal transplant recipients. METHODS: All the patients who underwent renal transplantation and follow-up at the authors' institution from January 1998 to January 2003 were involved in this study (n=177) in addition to another randomly selected 64 patients that underwent transplantation before 1998. All patients had their ABPM performed according to previously described protocols at least 2 weeks after discharge from the hospital, dialysis-independent and with a functioning renal allograft. RESULTS: The authors found a positive correlation between systolic BP (SBP) diurnal variation and age (r =0.263, P <0.0001), glomerular filtration rate (GFR) (r =-0.229, P <0.0001), cyclosporine trough (r =0.171, P =0.047), and ABPM-to-transplant interval (r =-0.133, P =0.039). After fitting a regression model, the authors found that only GFR (P <0.0001) and age (P =0.001) were independent predictors of SBP diurnal variation (r =0.357). Concordance rate between casual BP and ABPM was 80%, and by using casual BP, only 15% of hypertensive renal transplant patients would be erroneously diagnosed as normotensive. CONCLUSIONS: The authors found that SBP diurnal variation is predicted independently by age and GFR, although it does correlate with cyclosporine trough and ABPM-to-transplant interval. In addition, the authors showed that ABPM is a more sensitive method for diagnosing hypertension than is sole reliance on office BP in renal transplant recipients.

Drug interaction in a renal transplant patient: cyclosporin-Neoral and orlistat.

An overweight 56-year-old type II diabetic on peritoneal dialysis (body mass index 35 kg/m(2)) was taking Orlistat for some months up until live-unrelated renal transplantation. Despite oral cyclosporin A (CyA) for 48 hours pretransplantation, it was very difficult to achieve adequate CyA blood levels for the first week postengraftment despite the use of much larger oral CyA doses. After opening his bowels on day 7, and the use of 3 days intravenous CyA, good CyA blood levels were achieved then maintained with conventional oral doses. The authors believe that this case shows important interactions between CyA and Orlistat.