Suicide and death by other causes among patients with a severe mental illness: cohort study comparing risks among patients discharged from inpatient care v. those treated in the community.

AIMS: People diagnosed with a severe mental illness (SMI) are at elevated risk of dying prematurely compared to the general population. We aimed to understand the additional risk among people with SMI after discharge from inpatient psychiatric care, when many patients experience an acute phase of their illness. METHODS: In the Clinical Practice Research Datalink (CPRD) GOLD and Aurum datasets, adults aged 18 years and older who were discharged from psychiatric inpatient care in England between 2001 and 2018 with primary diagnoses of SMI (schizophrenia, bipolar disorder, other psychoses) were matched by age and gender with up to five individuals with SMI and without recent hospital stays. Using survival analysis approaches, cumulative incidence and adjusted hazard ratios were estimated for all-cause mortality, external and natural causes of death, and suicide. All analyses were stratified by younger, middle and older ages and also by gender. RESULTS: In the year after their discharge, the risk of dying by all causes examined was higher than among individuals with SMI who had not received inpatient psychiatric care recently. Suicide risk was 11.6 times (95% CI 6.4-20.9) higher in the first 3 months and remained greater at 2-5 years after discharge (HR 2.3, 1.7-3.2). This risk elevation remained after adjustment for self-harm in the 6 months prior to the discharge date. The relative risk of dying by natural causes was raised in the first 3 months (HR 1.6, 1.3-1.9), with no evidence of elevation during the second year following discharge. CONCLUSIONS: There is an additional risk of death by suicide and natural causes for people with SMI who have been recently discharged from inpatient care over and above the general risk among people with the same diagnosis who have not recently been treated as an inpatient. This mortality gap shows the importance of continued focus, following discharge, on individuals who require inpatient care.

Managing loneliness: a qualitative study of older people's views.

Engaging with older people who self-identify as lonely may help professionals in mental health and other services understand how they deal with loneliness. The evidence-base for effective interventions to address loneliness is inconclusive. This study aimed to explore how community-dwelling lonely older people in England manage their experiences of loneliness. Twenty eight community-dwelling older people identifying as lonely, based on responses to two loneliness measures (self-report and a standardised instrument), participated in in-depth interviews between 2013 and 2014. Fifteen lived alone. Thematic analysis of transcribed interviews was conducted by a multidisciplinary team including older people.Participants drew on a range of strategies to ameliorate their distress which had been developed over their lives and shaped according to individual coping styles and contexts. Strategies included physical engagement with the world beyond their home, using technologies, planning, and engagement with purpose in an 'outside world', and acceptance, endurance, revealing and hiding, positive attitude and motivation, and distraction within an 'inside world'. Strategies of interests and hobbies, comparative thinking, religion and spirituality and use of alcohol straddled both the inside and outside worlds. Participants conveyed a personal responsibility for managing feelings of loneliness rather than relying on others. This study includes the experiences of those living with loneliness whilst also living with other people. When developing policy and practice responses to loneliness it is important to listen attentively to the views of those who may not be engaging with services designed for 'the lonely' and to consider their own strategies for managing it.

Depression predicts emergency care use in people with chronic obstructive pulmonary disease: a large cohort study in primary care.

Background: Depression is common in people with chronic obstructive pulmonary disease (COPD) and has been associated with a variety of poor outcomes. A large proportion of health care costs in the UK are spent on emergency care. This study examined the prospective relationship between depression and use of emergency care in patients with COPD managed in primary care. Methods: This was a twelve-month, prospective longitudinal study of 355 patients with COPD in six primary care practices in the UK. Baseline measures included demographic characteristics, depression and anxiety, severity of COPD, presence or absence of other chronic diseases, and prior use of emergency care. Outcome measures were (a) number of emergency department (ED) visits; or (b) an emergency hospital admission in the follow-up year. Results: Older age, number of comorbid physical health conditions, severity of COPD, prior use of emergency care, and depression were all independently associated with both ED attendance and an emergency hospital admission in the follow-up year. Subthreshold depression (HADS depression score 4-7) was associated with a 2.8 times increased odds of emergency hospital admission, and HADS depression >8 was associated with 4.8 times increased odds. Conclusion: Depression is a predictor of emergency care in COPD, independent of severity of disease or physical comorbidity. Even mild (subthreshold) symptoms of depression more than double the risk of using emergency care, suggesting there is a strong case to develop and deploy integrated preventive strategies in primary care that can promote mental health in people with COPD.

Assessing the severity of Type 2 diabetes using clinical data-based measures: a systematic review.

AIMS: To identify and critically appraise measures that use clinical data to grade the severity of Type 2 diabetes. METHODS: We searched MEDLINE, Embase and PubMed between inception and June 2018. Studies reporting on clinical data-based diabetes-specific severity measures in adults with Type 2 diabetes were included. We excluded studies conducted solely in participants with other types of diabetes. After independent screening, the characteristics of the eligible measures including design and severity domains, the clinical utility of developed measures, and the relationship between severity levels and health-related outcomes were assessed. RESULTS: We identified 6798 studies, of which 17 studies reporting 18 different severity measures (32 314 participants in 17 countries) were included: a diabetes severity index (eight studies, 44%); severity categories (seven studies, 39%); complication count (two studies, 11%); and a severity checklist (one study, 6%). Nearly 89% of the measures included diabetes-related complications and/or glycaemic control indicators. Two of the severity measures were validated in a separate study population. More severe diabetes was associated with increased healthcare costs, poorer cognitive function and significantly greater risks of hospitalization and mortality. The identified measures differed greatly in terms of the included domains. One study reported on the use of a severity measure prospectively. CONCLUSIONS: Health records are suitable for assessment of diabetes severity; however, the clinical uptake of existing measures is limited. The need to advance this research area is fundamental as higher levels of diabetes severity are associated with greater risks of adverse outcomes. Diabetes severity assessment could help identify people requiring targeted and intensive therapies and provide a major benchmark for efficient healthcare services.

Evidence flowers: An innovative, visual method of presenting "best evidence" summaries to health professional and lay audiences.

BACKGROUND & AIMS: Barriers to dissemination and engagement with evidence pose a threat to implementing evidence-based medicine. Understanding, retention, and recall can be enhanced by visual presentation of information. The aim of this exploratory research was to develop and evaluate the accessibility and acceptability of visual summaries for presenting evidence syntheses with multiple exposures or outcomes to professional and lay audiences. METHODS: "Evidence flowers" were developed as a visual method of presenting data from 4 case scenarios: 2 complex evidence syntheses with multiple outcomes, Cochrane reviews, and clinical guidelines. Petals of evidence flowers were coloured according to the GRADE evidence rating system to display key findings and recommendations from the evidence summaries. Application of evidence flowers was observed during stakeholder workshops. Evaluation and feedback were conducted via questionnaires and informal interviews. RESULTS: Feedback from stakeholders on the evidence flowers collected from workshops, questionnaires, and interviews was encouraging and helpful for refining the design of the flowers. Comments were made on the content and design of the flowers, as well as the usability and potential for displaying different types of evidence. CONCLUSIONS: Evidence flowers are a novel and visually stimulating method for presenting research evidence from evidence syntheses with multiple exposures or outcomes, Cochrane reviews, and clinical guidelines. To promote access and engagement with research evidence, evidence flowers may be used in conjunction with other evidence synthesis products, such as (lay) summaries, evidence inventories, rapid reviews, and clinical guidelines. Additional research on potential adaptations and applications of the evidence flowers may further bridge the gap between research evidence and clinical practice.

The feasibility and acceptability of a physical activity intervention for older people with chronic musculoskeletal pain: The iPOPP pilot trial protocol.

INTRODUCTION: This pilot trial will inform the design and methods of a future full-scale randomized controlled trial (RCT) and examine the feasibility, acceptability and fidelity of the Increasing Physical activity in Older People with chronic Pain (iPOPP) intervention, a healthcare assistant (HCA)-supported intervention to promote walking in older adults with chronic musculoskeletal pain in a primary care setting. METHODS AND ANALYSIS: The iPOPP study is an individually randomized, multicentre, three-parallel-arm pilot RCT. A total of 150 participants aged ≥65 years with chronic pain in one or more index sites will be recruited and randomized using random permuted blocks, stratified by general practice, to: (i) usual care plus written information; (ii) pedometer plus usual care and written information; or (iii) the iPOPP intervention. A theoretically informed mixed-methods approach will be employed using semi-structured interviews, audio recordings of the HCA consultations, self-reported questionnaires, case report forms and objective physical activity data collection (accelerometry). Follow-up will be conducted 12 weeks post-randomization. Collection of the quantitative data and statistical analysis will be performed blinded to treatment allocation, and analysis will be exploratory to inform the design and methods of a future RCT. Analysis of the HCA consultation recordings will focus on the use of a checklist to determine the fidelity of the iPOPP intervention delivery, and the interview data will be analysed using a constant comparison approach in order to generate conceptual themes focused around the acceptability and feasibility of the trial, and then mapped to the Theoretical Domains Framework to understand barriers and facilitators to behaviour change. A triangulation protocol will be used to integrate quantitative and qualitative data and findings.

'If it's a medical issue I would have covered it by now': learning about fibromyalgia through the hidden curriculum: a qualitative study.

BACKGROUND: Fibromyalgia syndrome (FMS) is a long-term condition that affects between 1 and 5% of the general population and lies within the spectrum of medically unexplained symptoms (MUS). FMS can be difficult to diagnose and is usually done so as a diagnosis of exclusion. There is continuing debate regarding its legitimacy excluding other causes of symptoms. It is known that the diagnosis and management of MUS, including FMS, receives little attention in medical curricula and attitudes towards patients with FMS amongst medical professionals and trainees can be negative. The purpose of this study was to investigate how attitudes and perspectives of undergraduate medical students towards FMS are acquired during their training. METHODS: Qualitative interviews with 21 medical students were conducted to explore their views on FMS, encounters with patients with FMS, and where learning about FMS occurs. Participants were recruited from two English medical schools and the study was approved by two University Ethics committees. Interviews were digitally recorded with consent and data analysed thematically, using principles of constant comparison. RESULTS: The data were organised within three themes: i) FMS is a complex, poorly understood condition; ii) multiple sources for learning about FMS; and iii) consequences of negative attitudes for patients with FMS. CONCLUSION: Undergraduate medical students have limited understanding of, and are sceptical over the existence of FMS. These attitudes are influenced by the 'hidden curriculum' and witnessing attitudes and actions of their clinical teachers. Students interpret a lack of formal curriculum teaching around FMS to mean that it is not serious and hence a low priority. Encountering a patient, friend or family member with FMS can increase knowledge and lead to altered perceptions of the condition. Teaching and learning about FMS needs to be consistent to improve knowledge and attitudes of clinicians. Undergraduate students should be exposed to patients with FMS so that they better understand patients with FMS.

Primary care-based screening for cardiovascular risk factors in patients with psoriasis.

BACKGROUND: Studies assessing cardiovascular disease (CVD) risk factors in patients with psoriasis have been limited by selection bias, inappropriate controls or a reliance on data collected for clinical reasons. OBJECTIVES: To investigate whether screening for CVD risk factors in patients with psoriasis in primary care augments the known prevalence of CVD risk factors in a cross-sectional study. METHODS: Patients listed as having psoriasis in primary care were recruited, screened and risk assessed by QRISK2. RESULTS: In total, 287 patients attended (mean age 53 years, 57% women, 94% white British, 22% severe disease, 33% self-reported psoriatic arthritis). The proportion with known and screen-detected (previously unknown) risk factors was as follows: hypertension 35% known and 13% screen-detected; hypercholesterolaemia 32% and 37%; diabetes 6·6% and 3·1% and chronic kidney disease 1·1% and 4·5%. At least one screen-detected risk factor was found in 48% and two or more risk factors were found in 21% of patients. One in three patients (37%) not previously known to be at high risk were found to have a high (> 10%) 10-year CVD risk. Among the participants receiving treatment for known CVD risk factors, nearly half had suboptimal levels for blood pressure (46%) and cholesterol (46%). CONCLUSIONS: Cardiovascular risk factor screening of primary care-based adults with psoriasis identified a high proportion of patients (i) at high CVD risk, (ii) with screen-detected risk factors and (iii) with suboptimally managed known risk factors. These findings need to be considered alongside reports that detected limited responses of clinicians to identified risk factors before universal CVD screening can be recommended.

Common and unique associated factors for medically unexplained chronic widespread pain and chronic fatigue.

OBJECTIVE: Chronic widespread pain and chronic fatigue share common associated factors but these associations may be explained by the presence of concurrent depression and anxiety. METHODS: We mailed questionnaires to a randomly selected sample of people in the UK to identify participants with chronic widespread pain (ACR 1990 definition) and those with chronic fatigue. The questionnaire assessed sociodemographic factors, health status, healthcare use, childhood factors, adult attachment, and psychological stress including anxiety and depression. To identify persons with unexplained chronic widespread pain or unexplained chronic fatigue; we examined participant's medical records to exclude medical illness that might cause these symptoms. RESULTS: Of 1443 participants (58.0% response rate) medical records of 990 were examined. 9.4% (N=93) had unexplained chronic widespread pain and 12.6% (N=125) had unexplained chronic fatigue. Marital status, childhood psychological abuse, recent threatening experiences and other somatic symptoms were commonly associated with both widespread pain and fatigue. No common effect was found for few years of education and current medical illnesses (more strongly associated with chronic widespread pain) or recent illness in a close relative, neuroticism, depression and anxiety scores (more strongly associated with chronic fatigue). Putative associated factors with a common effect were associated with unexplained chronic widespread pain or unexplained chronic fatigue only when there was concurrent anxiety and/or depression. DISCUSSION: This study suggests that the associated factors for chronic widespread pain and chronic fatigue need to be studied in conjunction with concurrent depression/anxiety. Clinicians should be aware of the importance of concurrent anxiety or depression.

Recognition of need in health care consultations: a qualitative study of people with psoriasis.

BACKGROUND: Psoriasis is a life-long inflammatory condition that can impact on quality of life, psychological and social functioning. Previous literature suggests patient dissatisfaction with psoriasis management; however, little is known about people's specific experiences of health care consultations. OBJECTIVES: The study aimed to explore in depth the perspectives of people living with psoriasis including coping responses, self-care strategies and how consultations with health care professionals in both primary and secondary care are experienced. METHODS: Qualitative semistructured interviews were carried out with a diverse sample of 29 people with psoriasis generated purposively and recruited from community sources in North West England. Interviews were coded using Framework Analysis to produce a thematic framework incorporating key emerging issues and concepts. RESULTS: Participants experienced psoriasis as a complex condition involving physical, psychological and social challenges, as well as issues of control, but perceived that these were largely unacknowledged by practitioners in health care consultations. Practitioners were perceived as lacking knowledge and expertise in the management of psoriasis, lacking empathy with the effects of psoriasis and failing to manage it as a long-term condition. This perceived lack of support resulted in some participants withdrawing from conventional health service providers and seeking alternative sources of help. CONCLUSIONS: Psoriasis needs to be recognized and managed as a complex long-term condition with emotional and social needs that are addressed alongside appropriate diagnosis and regular reviews of treatments which may involve referrals to specialist care.

Autoclave performance and operator knowledge of autoclave use in primary care: a survey of UK practices.

Changes in the delivery of health care have increased the demand for minor surgical and screening procedures in general practice. This has increased the risk of cross-infection with blood-borne viruses and the demand for sterile instruments. The aim of this study was to investigate the knowledge and training of medical personnel in England and Wales on aspects of autoclave use, and to test the effectiveness of their practice autoclaves. An anonymous postal questionnaire and autoclave performance survey using biological indicators was made of 700 general medical practitioners selected at random from FHSA lists from 12 Health Authorities in England and Wales. The overall response rate was 53.1% (N= 372) comprising 10% general practitioners and 90% practice nurses. Eighty-two percent of respondents used autoclaves with a mean age of 2.5 years, of which 91% had been serviced in the past year. While 35% of respondents made daily observation of gauges, 19% did not routinely monitor autoclave effectiveness. Six autoclaves failed to sterilize the spore test ampoules. Fourteen percent of respondents did not autoclave instruments after every patient. Only 33.1% reported wearing gloves during minor operations. Fifty five percent had training in cross-infection prevention. It was concluded that although there has been improvement in instrument decontamination procedures in general practice compared with previous surveys, further education of medical practitioners and practice nurses in the use of autoclaves and infection prevention and control is indicated. The failure of 2% of the autoclaves to kill spores suggests the need for increased monitoring of autoclave performance. Two-thirds of practitioners exposed themselves to increased risk of infection by carrying out minor surgery without the protection of gloves.