Portable System for In-Clinic Differentiation of Skin Cancers from Benign Skin Lesions and Inflammatory Dermatoses.

The exquisite sensitivity of Raman spectroscopy for detecting biomolecular changes in skin cancer has previously been explored; however, this mostly required analysis of excised tissue samples using bulky, immobile laboratory instrumentation. In this study, the technique was translated for clinical use with a portable Raman system and customized fiber optic probe and applied to differentiation of skin cancers from benign lesions and inflammatory dermatoses. The aim was to provide an easy-to-use, easy-to-manage assessment tool for clinicians to use in their daily patient examination routine to perform rapid Raman measurements of skin lesions in vivo. Using this system, >867 spectra were measured in vivo from 330 patients with a wide variety of different benign skin lesions (n = 603), inflammatory dermatoses (n = 140), and skin cancers (n = 124). Ethnicities represented were 70% European; 16% Asian; 6% Maori; 5% Pacific people; and 4% Middle East, Latin American, and African. Accurate differentiation of skin cancers from benign lesions and inflammatory dermatoses was achieved using partial least squares discriminant analysis, with area under curve for the receiver operator curves for external validation sets ranging from 0.916 to 0.958. This study shows evidence for robust clinical translation of Raman spectroscopy for rapid, accurate diagnosis of skin cancer.

Complete Genome Sequences of Chop, DelRio, and GrandSlam, Three Gordonia Phages Isolated from Soil in Central Arkansas.

Chop, DelRio, and GrandSlam are phage with a Siphoviridae morphotype isolated from soil in Arkansas using the host Gordonia terrae 3612. All three are temperate, and their genomes share at least 96% nucleotide identity. These phage are assigned to cluster DI based on gene content similarity to other sequenced actinobacteriophage.

Detecting Phytoplankton Cell Viability Using NIR Raman Spectroscopy and PCA.

Raman spectroscopy has long been suggested as a potentially fast and sensitive method to monitor phytoplankton abundance and composition in marine environments. However, the pitfalls of visible detection methods in pigment-rich biological material and the complexity of their spectra have hindered their application as reliable in situ detection methods. In this study we combine 1064 nm confocal Raman spectroscopy with multivariate statistical analysis techniques (principle component analysis and partial leas-squares discriminant analysis) to reliably measure differences in the cell viability of a diatom species (Chaetoceros muelleri) and two haptophyte species (Diacronema lutheri and Tisochrysis lutea) of phytoplankton. The low fluorescence background due to this combined approach of NIR Raman spectroscopy and multivariate data analysis allowed small changes in the overall spectral profiles to be reliably monitored, enabling the identification of the specific spectral features that could classify cells as viable or nonviable regardless of their species. The most significant differences upon cell death were shown by characteristic shifts in the carotenoid bands at 1527 and 1158 cm-1. The contributions from other biomolecules were less pronounced but revealed changes that could be identified using this combination of techniques.

Experiences and Perspectives on Adopting New Practices for Social Needs-targeted Care in Safety-net Settings: A Qualitative Case Series Study.

INTRODUCTION: Clinical settings are being encouraged to identify and address patients' social needs within the clinic or through partner organizations. The purpose of this qualitative study was to describe the current practice of social needs-targeted care in 3 Texas safety net clinics, and facilitators and barriers to adopting new social needs-targeted care tools and practices. METHODS: Interviews were conducted with staff at 3 safety net clinics serving small and mid-sized communities. Analysis focused on perspectives and decisions around adopting new tools or practices related to social needs-targeted care, including standardized screening tools and community resource referral platforms. RESULTS: Nine staff across 3 organizations were interviewed. Two organizations were currently using a standard social needs screening tool in their routine practice, and a third was considering doing so. One organization had adopted a community resource referral platform in partnership with a large community collaboration. Three case studies illustrate a range of facilitators, barriers, perceived benefits, and drawbacks influencing social needs-targeted practices. Benefits of systematic data collection on social needs included the generation of data for community action. Drawbacks include concerns about data privacy. Community resource referral platforms were seen as valuable for creating accountability, but required an influential community partner and adequate community resources. Concerns about disempowering clients and blurring roles were voiced, and potential to increase provider job satisfaction was identified. CONCLUSIONS: Benefits and drawbacks of adopting new tools and practices related to social needs-targeted care are strongly influenced by the community context. For the adoption of community resource referral platforms, the outer setting is particularly relevant; adoption readiness is best assessed at the community or regional level rather than the clinic system level. While screening tools are much easier than referral platforms for clinics to adopt, the ability to address identified needs remains heavily based on the outer setting.

'Five hours to sort out your life': qualitative study of the experiences of university students who access mental health support.

BACKGROUND: Previous qualitative research suggests that university students feel that current service provision does not meet their needs. Exploring the reasons for this may help to promote service change, encourage the uptake of care, improve outcomes and increase satisfaction within university services. AIMS: This study aimed to improve the understanding of how students experience the process of accessing and using mental health support, barriers and facilitators to treatment, and how students would adapt provision to improve experiences. METHOD: Semi-structured interviews were conducted with 16 full-time students who had used mental health services at university. Data were analysed using thematic analysis. RESULTS: Five higher-order themes were identified: personalisation and informed choice, simplifying the process, feeling abandoned ignored or invisible, stigma, and superiority of private and external services. Sixteen subthemes were identified within these themes. CONCLUSIONS: Findings indicate that access to mental health support should be simplified, with collaboration across university and external health and care services, to prevent students feeling lost or abandoned when seeking care. An inclusive approach to support access and provision of services for all presentations of mental health problems should be developed.

The efficacy of psychological interventions for the prevention and treatment of mental health disorders in university students: A systematic review and meta-analysis.

BACKGROUND: Mental health problems are becoming increasingly prevalent among students and adequate support should be provided to prevent and treat mental health disorders in those at risk. METHODS: This systematic review and meta-analysis examined the efficacy of psychological interventions for students, with consideration of how adaptions to intervention content and delivery could improve outcomes. We searched for randomised controlled trials (RCTs) of interventions in students with or at risk of mental health problems and extracted data for study characteristics, symptom severity, wellbeing, educational outcomes, and attrition. Eighty-four studies were included. RESULTS: Promising effects were found for indicated and selective interventions to treat anxiety disorders, depression and eating disorders. PTSD and self-harm data was limited, and did not demonstrate significant effects. Relatively few trials adapted intervention delivery to student-specific concerns, and overall adapted interventions showed no benefit over non-adapted interventions. There was some suggestion that adaptions based on empirical evidence and provision of additional sessions, and transdiagnostic models may yield some benefits. LIMITATIONS: The review is limited by the often poor quality of the literature and exclusion of non-published data. CONCLUSIONS: Interventions for students show benefit though uncertainty remains around how best to optimise treatment delivery and content for students. Additional research into content targeting specific underlying mechanisms of problems and transdiagnostic approaches to provision could be promising avenues for further research.

Twelve things we have learned from medical students during the Pandemic.

This article was migrated. The article was marked as recommended. While the COVID-19 pandemic has disrupted every aspect of modern life, including medical education, the response has been remarkable. Ingenuity and innovation have flourished in the face of adversity. An international community of practice has blossomed in response to the challenges posed by COVID-19. Communication and sharing of information have been a hallmark of this community. In Australasia, the Medical Education Collaborative Committee hosted a series of meetings and webinars which enabled educators from all Australian and New Zealand medical schools to share experiences, solutions and resources. This group is auspiced by the Medical Deans Australia and New Zealand, which is the peak body representing professional entry-level medical education, training and research. One of these webinars focused on the student experience, featuring a panel of Australasian medical students drawn from a range of medical schools. The discussion during this session was wide reaching, including topics such as communication, co-designing curriculum changes, the importance of compassion, innovative practice, and meaningful student participation in placements. The ideas drawn from the panel discussion augmented by rich audience participation form the basis of the twelve tips presented in this paper. While derived from the experience in Australia and New Zealand, the authors believe these lessons are likely to be relevant in other jurisdictions.

Long-term outcomes of psychological interventions on children and young people's mental health: A systematic review and meta-analysis.

BACKGROUND: Over 600 RCTs have demonstrated the effectiveness of psychosocial interventions for children and young people's mental health, but little is known about the long-term outcomes. This systematic review sought to establish whether the effects of selective and indicated interventions were sustained at 12 months. METHOD: We conducted a systematic review and meta-analysis focusing on studies reporting medium term outcomes (12 months after end of intervention). FINDINGS: We identified 138 trials with 12-month follow-up data, yielding 165 comparisons, 99 of which also reported outcomes at end of intervention, yielding 117 comparisons. We found evidence of effect relative to control at end of intervention (K = 115, g = 0.39; 95% CI: 0.30-0.47 I2 = 84.19%, N = 13,982) which was maintained at 12 months (K = 165, g = 0.31, CI: 0.25-0.37, I2 = 77.35%, N = 25,652) across a range of diagnostic groups. We explored the impact of potential moderators on outcome, including modality, format and intensity of intervention, selective or indicated intervention, site of delivery, professional/para-professional and fidelity of delivery. We assessed both risk of study bias and publication bias. CONCLUSIONS: Psychosocial interventions provided in a range of settings by professionals and paraprofessionals can deliver lasting benefits. High levels of heterogeneity, moderate to high risk of bias for most studies and evidence of publication bias require caution in interpreting the results. Lack of studies in diagnostic groups such as ADHD and self-harm limit the conclusions that can be drawn. Programmes that increase such interventions' availability are justified by the benefits to children and young people and the decreased likelihood of disorder in adulthood.

Reasons behind the rising rate of involuntary admissions under the Mental Health Act (1983): Service use and cost impact.

There has been a significant rise in the use of the Mental Health Act (1983) in England over the last 10 years. This includes both health-based Place of Safety detentions and involuntary admissions to NHS mental health facilities. Although these trends should clearly inform the implementation of mental health care and legislation, there is currently little understanding of what caused these increased rates. We therefore sought to explore potential underlying reasons for the increase in involuntary admissions and Place of Safety detentions and to ascertain the associated service costs. We extracted publicly available data to ascertain the observed number of involuntary admissions (Section 2 or 3) and health-based Place of Safety detentions in England between 1999/2000 and 2015/2016. A simple regression analysis then enabled us to compare observed admission rates with predicted rates, between 2008/2009 and 2015/2016. This prediction model was based on observed figures before 2008. We then generated a costing model for these rates and compared admission costs to alternative interventions. Finally, we added relevant covariates to the prediction model, to explore potential relationships with observed rates. Since 2008/2009, there has been a marked increase in the number of involuntary admissions (38%) and Place of Safety detentions (617%). The analysis revealed that for involuntary admissions, the period of greatest increase occurred after 2012, two years after austerity measures were implemented. For Place of Safety detentions, substantial rises were seen from 2008/2009 to 2015/2016, coinciding with the economic recession. The rise in Place of Safety detentions may have been worsened by a reduction in mental health bed availability. During the study period, involuntary admissions are estimated to have cost the English NHS £6.8 billion; with a further £120 million spent on Place of Safety detentions. This is approximately £597 million greater than predicted, had involuntary admissions continued to change at pre-2008 rates. We conclude that the rise in involuntary admissions, and to a lesser extent Place of Safety detentions, were associated with three specific impactful events: the economic recession, legislative changes and the impact of austerity measures on health and social care services. In addition to the extensive arguments presented elsewhere, there is also an urgent economic case for addressing this trend.

Chest computed tomography for staging renal tumours: validation and simplification of a risk prediction model from a large contemporary retrospective cohort.

OBJECTIVES: To externally validate a nomogram recently proposed by Larcher et al. (BJU Int. 2017; 120: 490) and to develop a simplified model with comparable accuracy to guide on the need for staging chest computed tomography (CT) for patients with new renal masses. PATIENTS AND METHODS: We analysed the data of 1082 consecutive patients with unilateral enhancing renal masses referred to urology multidisciplinary team meetings at two centres between 2011 and 2017. All patients underwent a staging chest CT at diagnosis. We fitted multivariable logistic regression models and tested the Larcher model performance using area under the receiver-operating curve (AUC), calibration and decision curve analysis. RESULTS: Forty-two patients (3.9%) had a positive chest CT. The Larcher nomogram had an AUC of 83.8% (95% confidence interval [CI] 77.1-90.6), but was only moderately well calibrated (calibration-in-the-large = -0.61, slope = 0.82). Specifically, the nomogram overestimated the risk of positive chest CT, and the magnitude of miscalibration increased with increasing predicted risks. Using a stepwise backward approach, a new model was developed including tumour size, nodal stage and systemic symptoms. Compared with the Larcher model, the new model had a similar AUC (82.7% [95% CI 75.5-90.0]), but improved calibration and clinical net benefit. The predicted risk of positive chest CT was <1% in the low-risk group and 1.9-79.9% in the high-risk group. CONCLUSION: The Larcher nomogram is an accurate prediction tool that was moderately well calibrated with our dataset. However, our simplified model has similar accuracy and uses more objective variables available from referral, so may be easier to incorporate into clinical practice. The low-risk group from our model (tumour size ≤4 cm and no systemic symptoms) had a risk of positive chest CT <1%, suggesting these patients may forego chest CT.

Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data.

BACKGROUND: Evidence suggests that black, Asian and minority ethnic (BAME) groups have an increased risk of involuntary psychiatric care. However, to our knowledge, there is no published meta-analysis that brings together both international and UK literature and allows for comparison of the two. This study examined compulsory detention in BAME and migrant groups in the UK and internationally, and aimed to expand upon existing systematic reviews and meta-analyses of the rates of detention for BAME populations. METHODS: For this systematic review and meta-analysis, we searched five databases (PsychINFO, MEDLINE, Cochrane Controlled Register of Trials, Embase, and CINAHL) for quantitative studies comparing involuntary admission, readmission, and inpatient bed days between BAME or migrant groups and majority or native groups, published between inception and Dec 3, 2018. We extracted data on study characteristics, patient-level data on diagnosis, age, sex, ethnicity, marital status, and occupational status, and our outcomes of interest (involuntary admission to hospital, readmission to hospital, and inpatient bed days) for meta-analysis. We used a random-effects model to compare disparate outcome measures. We assessed explanations offered for the differences between minority and majority groups for the strength of the evidence supporting them. This study is prospectively registered with PROSPERO, number CRD42017078137. FINDINGS: Our search identified 9511 studies for title and abstract screening, from which we identified 296 potentially relevant full-text articles. Of these, 67 met the inclusion criteria and were reviewed in depth. We added four studies after reference and citation searches, meaning 71 studies in total were included. 1 953 135 participants were included in the studies. Black Caribbean patients were significantly more likely to be compulsorily admitted to hospital compared with those in white ethnic groups (odds ratio 2·53, 95% CI 2·03-3·16, p<0·0001). Black African patients also had significantly increased odds of being compulsorily admitted to hospital compared with white ethnic groups (2·27, 1·62-3·19, p<0·0001), as did, to a lesser extent, south Asian patients (1·33, 1·07-1·65, p=0·0091). Black Caribbean patients were also significantly more likely to be readmitted to hospital compared with white ethnic groups (2·30, 1·22-4·34, p=0·0102). Migrant groups were significantly more likely to be compulsorily admitted to hospital compared with native groups (1·50, 1·21-1·87, p=0·0003). The most common explanations for the increased risk of detainment in BAME populations included increased prevalence of psychosis, increased perceived risk of violence, increased police contact, absence of or mistrust of general practitioners, and ethnic disadvantages. INTERPRETATION: BAME and migrant groups are at a greater risk of psychiatric detention than are majority groups, although there is variation across ethnic groups. Attempts to explain increased detention in ethnic groups should avoid amalgamation and instead carry out culturally-specific, hypothesis-driven studies to examine the numerous contributors to varying rates of detention. FUNDING: University College London Hospitals National Institute for Health Research (NIHR) Biomedical Research Centre, NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust, King's College London, and NIHR Collaboration for Leadership in Applied Health Research and Care North Thames at Bart's Health NHS Trust.

Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis.

BACKGROUND: Compulsory community treatment (CCT) aims to reduce hospital readmissions among people with mental illness. However, research examining the usefulness of CCT is inconclusive. We aimed to assess the effectiveness of CCT in reducing readmission and length of stay in hospital and increasing community service use and treatment adherence. METHODS: For this systematic review and meta-analysis, we searched three databases (PsycINFO, MEDLINE and Embase) for quantitative studies on CCT published in English between Jan 1, 1806, and Jan 4, 2018. We included both randomised and non-randomised designs that compared CCT with no CCT, and pre-post designs that compared patients before and after CCT. Studies were eligible if they had been peer-reviewed, if 50% or more of patients had severe mental illness, and if CCT was the intervention. Trials in which CCT was used in response to a criminal offence were excluded. We extracted data on study characteristics and length of follow-up, patient-level data on diagnosis, age, sex, race, and admission history, and outcomes of interest (readmission to hospital, inpatient bed-days, community service use, and treatment adherence) for meta-analysis, for which we extracted summary estimates. We used a random-effects model to compare disparate outcome measures and convert effect size statistics into standardised mean differences. This systematic review is registered with PROSPERO, number CRD42018086232. FINDINGS: Of 1931 studies identified, 41 (2%) met inclusion criteria and had sufficient data for analysis. Before and after CCT comparisons showed significant large effects on readmission to hospital (standardised mean difference 0·80, 95% CI 0·53-1·08; I2=94·74), use of community services (0·83, 0·46-1·21; I2=87·26), and treatment adherence (2·12, 1·69-2·55; I2=0), and a medium effect on inpatient bed-days (0·66, 0·46-0·85; I2=94·12). Contemporaneous controlled comparison studies (randomised and non-randomised) showed no significant effect on readmission, inpatient bed-days, or treatment adherence, but a moderate effect on use of community services (0·38, 0·19-0·58; I2=96·92). A high degree of variability in study quality was found, with observational study ratings ranging from three to nine. Bias most frequently centred on poor comparability between CCT and control participants. INTERPRETATION: We found no consistent evidence that CCT reduces readmission or length of inpatient stay, although it might have some benefit in enforcing use of outpatient treatment or increasing service provision, or both. Future research should focus on why some people do not engage with treatment offered and on enhancing quality of the community care available. Shortcomings of this study include high levels of variability between studies and variation in study quality. FUNDING: National Institute for Health Research.

'It's a silver lining': A template analysis of satisfaction and quality of life following post-mastectomy breast reconstruction.

OBJECTIVE: In the United Kingdom, the number of women undergoing post-mastectomy breast reconstruction is increasing. Consequently, exploring patient-reported outcomes in breast surgery has become increasingly important. This study investigated satisfaction and quality of life following post-mastectomy breast reconstruction. DESIGN: Qualitative research design. METHODS: In-depth, semi-structured telephone interviews were conducted with 25 women (age, M = 53.08, SD = 8.41) following breast reconstruction in the United Kingdom. Data were analysed using template analysis which produced three-first-level, 13 second-level, and 19 third-level themes. RESULTS: Following reconstruction, women reported improved emotional functioning, although this was often accompanied by deterioration in physical, sexual, and/or social functioning. Women positively appraised their breast appearance, although some reported a decline in satisfaction over time, attributing this decline to their chosen reconstructive technique. Many women accepted the inevitability of scarring and most perceived their scars as a representation of their journey, signifying survival. Generally, women were satisfied with the outcome of their reconstruction, although on reflection some would not have opted for reconstruction. Following breast reconstruction, women were increasingly likely to experience the fear of recurrence, attributed to no longer being able to have a mammogram on the affected breast(s). CONCLUSIONS: This study provides new insights into post-mastectomy breast reconstruction and is a novel application of template analysis. The analysis demonstrates only slight variation in some categories of experience among women, despite a heterogeneous sample. The findings allow researchers and clinicians to focus on specific dimensions of satisfaction and quality of life to support the needs of women following reconstruction. Statement of contribution What is already known on this subject? Patient satisfaction and quality of life are key patient-reported outcomes of breast reconstruction, although relatively few studies distinguish between types of satisfaction. The number of women electing to undergo reconstructive surgery is steadily increasing. As a consequence, exploring patient-reported outcomes in reconstructive breast surgery has become increasingly important for research and clinical practice. It is often suggested that breast reconstruction offers psychosocial benefits, although within the literature some mixed findings have been reported. Therefore, a qualitative exploration has the potential to add some clarity to the experiences of women following post-mastectomy breast reconstruction. What does this study add? To our knowledge, this is the first study to employ template analysis to explore the experiences of women following post-mastectomy breast reconstruction. Template analysis demonstrated that there was only slight variation in some categories of experience among women, despite a heterogeneous sample. This study distinguishes between the patient-reported outcomes breast satisfaction and outcome satisfaction to identify the key factors that are involved in determining satisfaction. The findings allow researchers and clinicians to focus on specific dimensions of satisfaction and quality of life which require improvement to support the unmet needs of women following breast reconstruction. The study presents two novel findings. Women attributed the fear of cancer recurrence to no longer being able to have a mammogram on the affected breast(s). Women also reported a decline in appearance-related satisfaction over time due to either the ptotic nature of autologous-based reconstruction or the fuller projected breast implant-based reconstruction affords.

Predictors of satisfaction and quality of life following post-mastectomy breast reconstruction.

OBJECTIVE: Breast reconstruction is associated with multiple psychological benefits. However, few studies have identified clinical and psychological factors associated with improved satisfaction and quality of life. This study examined factors, which predict satisfaction with breast appearance, outcome satisfaction and quality of life following post-mastectomy breast reconstruction. METHODS: Women who underwent post-mastectomy breast reconstruction between 2010 and 2016 received a postal questionnaire consisting of The BREAST-Q Patient Reported Outcomes Instrument, The European Organisation for Research and Treatment of Cancer QLQ-30 Questionnaire, The Patient and Observer Scar Assessment Scale, and a series of Visual-Analogue Scales. One hundredforty-eight women completed the questionnaire, a 56% response rate. RESULTS: Hierarchical multiple regression analyses revealed psychosocial factors accounted for 75% of the variance in breast satisfaction, 68% for outcome satisfaction, and 46% forquality of life. Psychosocial well-being emerged as a significant predictor of satisfaction with breast appearance (ß = .322) and outcome satisfaction (ß = .406). Deep inferior epigastric perforator flap patients reported greater satisfaction with breast appearance (ß = .120) and outcome satisfaction (ß = .167). CONCLUSIONS: This study extends beyond the limited research by distinguishing between satisfaction with breast appearance and outcome satisfaction. The study provides evidence for the role of psychosocial factors predicting key patient reported outcomes and demonstrates the importance of psychosocial well-being and reconstruction type. The findings also highlight the need for healthcare providers to consider the psychosocial well-being of patients both preoperatively and post operatively and provide preliminary evidence for the use of deep inferior epigastric perforator reconstructions over other types of reconstructive procedures.

The efficacy of interventions to improve psychosocial outcomes following surgical treatment for breast cancer: a systematic review and meta-analysis.

OBJECTIVE: Breast cancer is the most commonly diagnosed cancer in women across the world. The majority of women diagnosed with the disease undergo surgery, which is often associated with significant psychosocial morbidity. The aim of this meta-analysis was to identify the efficacy of psychosocial interventions for women following breast cancer surgery. METHOD: A comprehensive literature search was undertaken using keyword and subject headings within 7 databases. Included studies employed a quantitative methodology presenting empirical findings focusing on interventions for female breast cancer patients following surgery. RESULTS: Thirty-two studies were included and based on conventional values of effect sizes. Small effects emerged for the efficacy of psychosocial interventions in relation to anxiety (Hedges g = 0.31), depression (0.38), quality of life (0.40), mood disturbance (0.31), distress (0.27), body image (0.40), self-esteem (0.35), and sexual functioning (0.22). A moderate to large effect emerged for the efficacy of interventions in promoting improvements in sleep disturbance (0.67). Clear evidence emerged for the efficacy of cognitive behavioral therapy in promoting improvements in anxiety, depression, and quality of life. CONCLUSION: This is the first meta-analysis to demonstrate the efficacy of interventions on a range of psychosocial outcomes following breast cancer surgery. The meta-analysis highlighted that cognitive behavioral therapy was consistently the most effective psychosocial intervention promoting improvements in anxiety, depression, and quality of life. However, there are shortcomings in existing studies; the length of the follow-up period is typically short and the generalizability of findings was limited by small samples, both of which should be addressed in future studies.

'Dropped from the system': the experiences and challenges of long-term breast cancer survivors.

AIMS: The aim of this study was to explore breast cancer patients' experiences during survivorship. Particular attention is given to the role of specialist breast care nurses in supporting women throughout this phase. BACKGROUND: There is a relative lack of research involving long-term breast cancer survivors. Yet, many survivors experience substantial psychosocial and iatrogenic harms created by diagnosis, symptoms of disease and treatment. A more comprehensive understanding may assist in supporting the needs of breast cancer survivors. DESIGN: An exploratory qualitative approach was used to collect data on breast cancer survivors' experiences during 2013. METHODS: Semi-structured interview data were collected from seven British women aged 38-80 years exploring the support received during survivorship. Data were analysed using Interpretive Phenomenological Analysis. FINDINGS: Breast cancer survivors perceived a systemic absence in support from oncology teams and rapid deterioration of support from personal support networks. Despite this, survivors were able to find benefits from the cancer experience. This allowed for adjustment and enabled patients to assume a new identity as a breast cancer survivor. We recommend specialist breast care nurses would be suitably placed to provide extended support allowing for a salient transition from treatment to survivorship. CONCLUSION: This study yields insights into breast cancer survivorship and specifically the role of specialist breast care nurses. Given the growing cohort of breast cancer survivors and the increased importance on promoting and supporting optimal psychosocial adjustment, we advise the cost-effectiveness of providing continuing nursing support and the mode of administration requires further research.

Caught between compassion and control: exploring the challenges associated with inpatient adolescent mental healthcare in an independent hospital.

AIM: To extend our understanding of how healthcare assistants construct and manage demanding situations in a secure mental health setting and to explore the effects on their health and well-being, to provide recommendations for enhanced support. BACKGROUND: Contemporary literature acknowledges high rates of occupational stress and burnout among healthcare assistants, suggesting the context in which they work places them at elevated risk of physical harm and psychological distress. Yet, there is a deficit of qualitative research exploring the experiences of healthcare assistants in adolescent inpatient facilities. DESIGN: An exploratory multi-method qualitative approach was used to collect data about the challenges faced by healthcare assistants working on secure adolescent mental health wards in an independent hospital during 2014. METHOD: Fifteen sets of data were collected. Ten participants completed diary entries and five participants were also interviewed allowing for triangulation. Data were analysed using Interpretive Phenomenological Analysis. FINDINGS: The findings illustrated how inpatient mental healthcare is a unique and distinctive area of nursing, where disturbing behaviour is often normalized and detached from the outside world. Healthcare assistants often experienced tension between their personal moral code which orientate them towards empathy and support and the emotional detachment and control expected by the organization, contributing to burnout and moral distress. CONCLUSIONS: This study yielded insights into mental health nursing and specifically the phenomenon of moral distress. Given the ever-increasing demand for healthcare professionals, the effects of moral distress on both the lives of healthcare assistants and patient care, merits further study.