Longitudinal investigation of the presence of different trajectories and associated health and socio-economic determinants, for participants who report suicidal ideation within a community-based public health survey.

OBJECTIVE: Given the paucity of evidence-based research investigating different suicidal ideation profiles and trajectories, this project sought to investigate health and socio-economic factors associated with the presence of suicidal ideation and changes in ideation over time. DESIGN: Longitudinal cohort design, using logistic regression analysis. SETTING: A public health survey was administered at two timepoints in a community setting across the North West of England. In the 2015/2016 survey, participants were recruited from high (n=20) and low (n=8) deprivation neighbourhoods. In the 2018 survey, only the 20 high-deprivation neighbourhoods were included. PARTICIPANTS: 4287 people were recruited in 2015/2016 and 3361 were recruited in 2018. The 2018 sample was subdivided into those who responded only in 2018 (n=2494: replication sample) and those who responded at both timepoints (n=867: longitudinal sample). PRIMARY OUTCOME MEASURES: Suicide ideation was the dependent variable which was assessed using item 9 of the Patient Health Questionnaire instrument. RESULTS: The prevalence of suicidal ideation was 11% (n=454/4319) at 2015/2016 and 16% (n=546/3361) at 2018.Replication study results highlighted: persistent debilitation from physical ill health and/or medication side effects; demographic factors (ie, middle-aged, single or never married); and personal coping strategies (ie, smoking) as risk factors for suicidal ideation. A static/improved financial position and high levels of empathy were protective factors.Longitudinal study results confirmed three suicidal ideation trajectories: 'onset', 'remission' and 'persistence'. Similar findings to the replication study were evidenced for the onset and persistence trajectories. Persistent suicidal ideation was synonymous with higher levels of practical support which may correspond to the higher levels of debilitation and functional disability reported within this group. Remission was characterised by fewer debilitating factors and higher levels of self-agency. CONCLUSION: A greater appreciation of the heterogeneity of suicidal trajectories should lead to the implementation of broad clinical assessments and targeted interventions.

Community Outpatient Psychotherapy Engagement Service for Self-harm (COPESS): a feasibility trial protocol.

BACKGROUND: People who self-harm are at high risk for future suicide and often suffer considerable emotional distress. Depression is common among people who self-harm and may be an underlying driver of self-harm behaviour. Self-harm is often repeated, and risk of repetition is highest immediately after an act of self-harm. Readily accessible brief talking therapies show promise in helping people who self-harm, but further evaluation of these approaches is needed. A brief talking therapy intervention for depression and self-harm has been designed for use in a community setting. This mixed methods feasibility study with repeated measures will examine the feasibility and acceptability of the Community Outpatient Psychological Engagement Service for Self-Harm (COPESS) for people with self-harm and depression in the community, compared to routine care. METHODS: Sixty participants with a history of self-harm within the last six months, who are also currently depressed, will be recruited to take part in a feasibility single-blind randomised controlled trial (RCT). Participants will be randomised 1:1 to receive COPESS plus treatment as usual (TAU) or TAU alone. Recruitment will be via General Practitioners (GP) and self-referral. Assessment of feasibility and acceptability will be assessed via quantitative and qualitative methods including measures of recruitment and retention to the feasibility trial, participants' experience of therapy, completion/completeness of outcome measures at relevant time-points and completion of a service use questionnaire. DISCUSSION: The results will indicate whether it is feasible to conduct a definitive full trial to determine whether COPESS is a clinically and cost effective intervention for people who self-harm in the community. Qualitative and quantitative data will in addition help identify potential strengths and/or challenges of implementing brief community-based interventions for people who self-harm. TRIAL REGISTRATION: NCT04191122 registered 9th December 2019.

Investigation to identify individual socioeconomic and health determinants of suicidal ideation using responses to a cross-sectional, community-based public health survey.

OBJECTIVES: To address a gap in knowledge by simultaneously assessing a broad spectrum of individual socioeconomic and potential health determinants of suicidal ideation (SI) using validated measures in a large UK representative community sample. DESIGN: In this cross-sectional design, participants were recruited via random area probability sampling to participate in a comprehensive public health survey. The questionnaire examined demographic, health and socioeconomic factors. Logistic regression analysis was employed to identify predictors of SI. SETTING: Community setting from high (n=20) and low (n=8) deprivation neighbourhoods across the North West of England, UK. PARTICIPANTS: 4319 people were recruited between August 2015 and January 2016. There were 809 participants from low-deprivation neighbourhoods and 3510 from high-deprivation neighbourhoods. The sample comprised 1854 (43%) men and 2465 (57%) women. PRIMARY OUTCOME MEASURES: SI was the dependent variable which was assessed using item 9 of the Patient Health Questionnaire-9 instrument. RESULTS: 454 (11%) participants reported having SI within the last 2 weeks. Model 1 (excluding mental health variables) identified younger age, black and minority ethnic (BME) background, lower housing quality and current smoker status as key predictors of SI. Higher self-esteem, empathy and neighbourhood belonging, alcohol abstinence and having arthritis were protective against SI. Model 2 (including mental health variables) found depression and having cancer as key health predictors for SI, while identifying as lesbian, gay, bisexual, transgender or queer (LGBTQ) and BME were significant demographic predictors. Alcohol abstinence, having arthritis and higher empathy levels were protective against SI. CONCLUSIONS: This study suggests that it could be useful to increase community support and sense of belonging using a public health approach for vulnerable groups (e.g. those with cancer) and peer support for people who identify as LGBTQ and/or BME. Also, interventions aimed at increasing empathic functioning may prove effective for reducing SI.

Pilot service evaluation of a brief psychological therapy for self-harm in an emergency department: Hospital Outpatient Psychotherapy Engagement Service.

BACKGROUND: Brief psychological therapies may be helpful for people who have recently self-harmed. The current paper reports on a service evaluation of a novel brief therapy service based within an Emergency Department, Hospital Outpatient Psychotherapy Engagement (HOPE) Service. This service combines elements of psychodynamic interpersonal and cognitive analytic therapy to help people who present with self-harm-related difficulties. The primary aim of this service evaluation was to ascertain the feasibility of HOPE in terms of attendance rates. The study also examined variables associated with engagement, and change over time in psychological distress for those attending the service. METHOD: The HOPE service was evaluated over a ten-month period. Consenting patients completed measures of psychological distress and working alliance across four therapy sessions and one follow-up session. Measures of emotion regulation style and self-harm function were also completed at the point of referral. RESULTS: Eight-nine patients were referred to the service (83 eligible referrals). Fifty-three (64%) attended at least one therapy session. Baseline variables did not distinguish people who attended and people who did not. Psychological distress decreased significantly across the sessions. Most people reported a good working alliance with their therapist. CONCLUSIONS: The results of this service evaluation support the feasibility of the HOPE service, demonstrating good engagement rates given the complexity of the population and context. Whilst there was evidence of reductions in distress, randomized controlled trials are needed to determine if HOPE has clinical efficacy. PRACTITIONER POINTS: Rates of engagement with HOPE suggest the service is feasible in an Emergency Department context Working alliance scores were positive for the majority of patients The HOPE service shows promise as a brief intervention for people who self-harm but requires further evaluation Randomized controlled trials are needed to determine the clinical efficacy of the HOPE service.

Montgomery in, Bolam out: are trainee surgeons 'material risks' when taking consent for cataract surgery?

Trainee involvement in cataract surgery is vital to allow proper training of the next generation of ophthalmic surgeons. However, recent changes in the UK Law, coupled with open publication of National Cataract Dataset results, lead us to conclude that the status of being a trainee is itself a material risk that now needs to be divulged to patients during the consent process. The opinions of current trainee surgeons in the UK were sampled via questionnaire and clinical negligence counsel was involved in the authorship of the paper in order to analyse the legal issues at stake. Attitudes towards consent regarding trainee involvement in UK cataract surgery need to change.

Quality assurance for care of the dying: engaging with clinical services to facilitate a regional cross-sectional survey of bereaved relatives' views.

BACKGROUND: Globally, having the 'patient and /or family voice' engaged when measuring quality of care for the dying is fundamentally important. This is particularly pertinent within the United Kingdom, where changes to national guidance about care provided to dying patients has heightened the importance of quality assurance and user-feedback. Our main aim was to engage with clinical services (hospice, hospital and community settings) within a specific English region and conduct a bereaved relatives' cross-sectional survey about quality of care. Our secondary aim was to explore levers and barriers to project participation as perceived by organisational representatives. METHODS: Each organisation identified a consecutive sample of next-of-kin to adult patients who died between 1st September and 30th November 2014. Those who had an unexpected death or were involved in a formal complaint were excluded. The 'Care Of the Dying Evaluation' (CODE™) questionnaire was posted out three months following the bereavement. One-to-one interviews were undertaken with a purposive sample of organisational representatives to explore experiences about project participation. RESULTS: Of the 30 invited organisations, 18 were able to participate comprising: 7 hospitals, 7 hospices and 4 community settings. There were 1774 deaths which met the inclusion criteria but 460 (26%) were excluded due to inaccurate next-of-kin details. Subsequently, 1283 CODE™ questionnaires were sent out, with 354 completed (27% response rate). Overall, most participants perceived good quality of care. A notable minority reported poor care for symptom control and communication especially within the hospital. Nine interviews were conducted - levers to project participation included the 'significance of user-feedback and the opportunity to use results in a meaningful way'; the main barrier was related to 'concern about causing distress to bereaved relatives'. CONCLUSIONS: Overall, being able to engage with 18 (60%) organisations within the region and conduct the bereaved relatives' survey showed success of this initiative and was supported by interview findings. The potential to be able to benchmark user-feedback against other organisations was thought to help focus on areas to develop services. This type of quality assurance project could form a template model and be replicated on a national and international level.

How well do we currently care for our dying patients in acute hospitals: the views of the bereaved relatives?

BACKGROUND: The National Care of the Dying Audit-Hospitals (NCDAH) is used as a method to evaluate care for dying patients in England. An additional component to the 2013/2014 audit was the Local Survey of Bereaved Relatives Views using the 'Care Of the Dying Evaluation' (CODE) questionnaire. AIM: Within the context of the NCDAH audit, to evaluate quality of care provided to dying patients and their families in acute hospitals from the perspective of bereaved relatives. DESIGN: Postbereavement survey to bereaved relatives. SETTING/PARTICIPANTS: For acute hospitals wishing to participate, consecutive 'expected' adult deaths occurring between 1 May and 30 June 2013 were identified and the CODE questionnaire was sent to the next-of-kin. RESULTS: From 3414 eligible next-of-kin, 95 (2.8%) were excluded due to being involved in a complaint procedure and 1006 (29.5%) due to insufficient next-of-kin details. From the remaining 2313 potential participants, 858 returned a completed CODE questionnaire (37.1% response rate). Generally, symptoms were perceived to be well controlled with 769 (91%) participants reporting that either no pain was present or only there 'some of the time'. Unmet information needs, however, was a recognised area for improvement, for example, 230 (29%) reporting having a discussion about hydration would have been beneficial. CONCLUSIONS: Adopting a postbereavement survey to NCDAH appears to be feasible, acceptable and a valuable addition. On the whole, the majority of participants reported good or excellent care. A small but significant minority, however, perceived poor quality of patient care with clear and timely communication urgently needed.

Vitamin D, calcium and dairy intake, and risk of oesophageal adenocarcinoma and its precursor conditions.

Evidence is accumulating that vitamin D may be protective against carcinogenesis, although exceptions have been observed for some digestive tract neoplasms. The aim of the present study was to explore the association between dietary vitamin D and related nutrients and the risk of oesophageal adenocarcinoma and its precursor conditions, Barrett's oesophagus and reflux oesophagitis. In an all-Ireland case-control study conducted between March 2002 and July 2005, 218 oesophageal adenocarcinoma patients, 212 Barrett's oesophagus patients, 208 reflux oesophagitis patients and 252 population-based controls completed a 101-item FFQ, and provided lifestyle and demographic information. Multiple logistic regression analysis was applied to examine the association between dietary intake and disease risk. Oesophageal adenocarcinoma risk was significantly greater for individuals with the highest compared with the lowest tertile of vitamin D intake (OR 1·99, 95 % CI 1·03, 3·86; P for trend = 0·02). The direct association could not be attributed to a particular vitamin D food source. Vitamin D intake was unrelated to Barrett's oesophagus and reflux oesophagitis risk. No significant associations were observed for Ca or dairy intake and oesophageal adenocarcinoma, Barrett's oesophagus or reflux oesophagitis development. High vitamin D intake may increase oesophageal adenocarcinoma risk but is not related to reflux oesophagitis and Barrett's oesophagus. Ca and dairy product intake did not influence the development of these oesophageal lesions. These findings suggest that there may be population subgroups at an increased risk of oesophageal adenocarcinoma if advice to improve vitamin D intake from foods is implemented. Limited work has been conducted in this area, and further research is required.

Can physical activity modulate pancreatic cancer risk? a systematic review and meta-analysis.

Numerous epidemiological studies have examined the association between physical activity and pancreatic cancer; however, findings from individual cohorts have largely not corroborated a protective effect. Among other plausible mechanisms, physical activity may reduce abdominal fat depots inducing metabolic improvements in glucose tolerance and insulin sensitivity, thereby potentially attenuating pancreatic cancer risk. We performed a systematic review to examine associations between physical activity and pancreatic cancer. Six electronic databases were searched from their inception through July 2009, including MEDLINE and EMBASE, seeking observational studies examining any physical activity measure with pancreatic cancer incidence/mortality as an outcome. A random effects model was used to pool individual effect estimates evaluating highest vs. lowest categories of activity. Twenty-eight studies were included. Pooled estimates indicated a reduction in pancreatic cancer risk with higher levels of total (five prospective studies, RR: 0.72, 95% CI: 0.52-0.99) and occupational activity (four prospective studies, RR: 0.75, 95% CI: 0.59-0.96). Nonsignificant inverse associations were seen between risks and recreational and transport physical activity. When examining exercise intensity, moderate activity appeared more protective (RR: 0.79, 95% CI: 0.52-1.20) than vigorous activity (RR: 0.97, 95% CI: 0.85-1.11), but results were not statistically significant and the former activity variable incorporated marked heterogeneity. Despite indications of an inverse relationship with higher levels of work and total activity, there was little evidence of such associations with recreational and other activity exposures.

Glycemic index, carbohydrate and fiber intakes and risk of reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma.

OBJECTIVE: To examine the association between dietary glycemic index (GI), glycemic load (GL), total carbohydrate, sugars, starch, and fiber intakes and the risk of reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. METHODS: In an all-Ireland study, dietary information was collected from patients with esophageal adenocarcinoma (n = 224), long-segment Barrett's esophagus (n = 220), reflux esophagitis (n = 219), and population-based controls (n = 256). Multiple logistic regression analysis examined the association between dietary variables and disease risk by tertiles of intake and as continuous variables, while adjusting for potential confounders. RESULTS: Reflux esophagitis risk was positively associated with starch intake and negatively associated with sugar intake. Barrett's esophagus risk was significantly reduced in people in the highest versus the lowest tertile of fiber intake (OR 0.44 95%CI 0.25-0.80). Fiber intake was also associated with a reduced risk of esophageal adenocarcinoma, as was total carbohydrate intake (OR 0.45 95%CI 0.33-0.61 per 50 g/d increase). However, an increased esophageal adenocarcinoma risk was detected per 10 unit increase in GI intake (OR 1.42 95%CI 1.07-1.89). CONCLUSIONS: Our findings suggest that fiber intake is inversely associated with Barrett's esophagus and esophageal adenocarcinoma risk. Esophageal adenocarcinoma risk is inversely associated with total carbohydrate consumption but positively associated with high GI intakes.

Glycemic index, glycemic load, and risk of digestive tract neoplasms: a systematic review and meta-analysis.

BACKGROUND: Habitual consumption of diets with a high glycemic index (GI) and a high glycemic load (GL) may influence cancer risk via hyperinsulinemia and the insulin-like growth factor axis. OBJECTIVE: The objective was to conduct a systematic review to assess the association between GI, GL, and risk of digestive tract cancers. DESIGN: Medline and Embase were searched for relevant publications from inception to July 2008. When possible, adjusted results from a comparison of cancer risk of the highest compared with the lowest category of GI and GL intake were combined by using random-effects meta-analyses. RESULTS: Cohort and case-control studies that examined the risk between GI or GL intake and colorectal cancer (n = 12) and adenomas (n = 2), pancreatic cancer (n = 6), gastric cancer (n = 2), and squamous-cell esophageal carcinoma (n = 1) were retrieved. Most case-control studies observed positive associations between GI and GL intake and these cancers. However, pooled cohort study results showed no associations between colorectal cancer risk and GI intake [relative risk (RR): 1.04; 95% CI: 0.92, 1.12; n = 7 studies] or GL intake (RR: 1.06; 95% CI: 0.95, 1.17; n = 8 studies). Furthermore, no significant associations were observed in meta-analyses of cohort study results of colorectal cancer subsites and GI and GL intake. Similarly, no significant associations emerged between pancreatic cancer risk and GI intake (RR: 0.99; 95% CI: 0.83, 1.19; n = 5 studies) or GL intake (RR: 1.01; 95% CI: 0.86, 1.19; n = 6 studies) in combined cohort studies. CONCLUSIONS: The findings from our meta-analyses indicate that GI and GL intakes are not associated with risk of colorectal or pancreatic cancers. There were insufficient data available regarding other digestive tract cancers to make any conclusions about GI or GL intake and risk.