Mediators of change in psychological interventions for adult offenders with personality disorders: A scoping review of the literature.

Offenders with personality disorder cause disproportionate harm to society and pose significant challenges for those responsible for their care and rehabilitation. Personality disorders are heterogeneous in terms of symptoms, as well as their pathways to offending behaviour. Thus, there is limited evidence regarding effective interventions. One solution might be to focus on how interventions are delivered as well as what is delivered. Within the non-offender personality disorder literature, the identification of potential mediators of change has enabled interventions to focus on 'how' they are delivered (e.g., therapeutic alliance) rather than the intervention itself. We explore the evidence and present a scoping review of the available literature on the mechanisms of change in psychological treatments for offenders with personality disorder. Only one study was found in the scoping review, highlighting a significant gap in the evidence base. We discuss the implications of this finding and potential future directions.

Frailty is associated with long-term outcomes in older trauma patients: A prospective cohort study.

BACKGROUND: Most major trauma admissions are older adults, many of whom are living with frailty - a recognised risk factor for post-injury mortality. OBJECTIVES: To describe the effect of frailty, and geriatrician review on mortality up to 4-years after hospitalisation following trauma. METHODS: This prospective cohort study included patients 65 years or older admitted to North Bristol NHS Trusts' Major Trauma Centre from November 2018 to September 2019. The primary outcome was time-to-mortality, assessed with an adjusted multivariable Cox regression model. Analyses were adjusted for factors known to be associated with mortality including age, sex, comorbidities, injury factors, surgical procedure, and complications. RESULTS: 573 patients were included: median age was 81 years; 67.5 % were living with frailty (Clinical Frailty Scale, CFS 4-8). Mortality was 45.2 % at the end of the study. Compared to fit patients (CFS 1-2), risk of death increased in those living with very mild frailty (CFS 4; aHR 3.22 [95 % CI 1.53-6.77]), mild frailty (CFS 5; aHR 4.97 [95 % CI 2.40-10.28]), moderate frailty (CFS 6; aHR 5.94 [95 % CI 2.83-12.44]), and moderate to severe frailty (CFS 7-8; aHR 9.63 [95 % CI 4.35-21.32]). Geriatrician review was associated with less mortality (aHR 0.55, 95 % CI 0.38-0.79). CONCLUSIONS: Frailty predicts long-term mortality in older trauma. Our findings have implications for clinician-patient discussions of prognosis and therapy goals. Furthermore, our results lend support to the routine provision of geriatrician input in trauma pathways.

A national study of 23 major trauma centres to investigate the effect of frailty on clinical outcomes in older people admitted with serious injury in England (FiTR 1): a multicentre observational study.

BACKGROUND: Older people are the largest group admitted to hospital with serious injuries. Many older people are living with frailty, a risk factor for poor recovery. We aimed to examine the effect of preinjury frailty on outcomes. METHODS: In this multicentre observational study (FiTR 1), we extracted prospectively collected data from all 23 adult major trauma centres in England on older people (aged ≥65 years) admitted with serious injuries over a 2·5 year period from the Trauma Audit and Research Network (TARN) database. Geriatricians assessed the preinjury Clinical Frailty Scale (CFS), a 9-point scale of fitness and frailty, with a score of 1 indicating a patient is very fit and a score of 9 indicating they are terminally ill. The primary outcome was inpatient mortality, with patients censored at hospital discharge. We used a multi-level Cox regression model fitted with adjusted hazards ratios (aHRs) to assess the association between CFS and mortality, with CFS scores being grouped as follows: a score of 1-2 indicated patients were fit; a score of 3 indicated patients were managing well; and a score of 4-8 indicated patients were living with frailty (4 being very mild, 5 being mild, 6 being moderate, and 7-8 being severe). FINDINGS: Between March 31, 2019, and Oct 31, 2021, 193 156 patients had records were held by TARN, of whom 16 504 had eligible records. Median age was 81·9 years (IQR 74·7-88·0), 9200 (55·7%) were women, and 7304 (44·3%) were men. Of 16 438 patients with a CFS score of 1-8, 11 114 (67·6%) were living with frailty (CFS of 4-8). 1660 (10·1%) patients died during their hospital stay, with a median time from admission to death of 9 days (IQR 4-18). Compared in patients with a CFS score of 1-2, risk of inpatient death was increased in those managing well (CFS score of 3; aHR 1·82 [95% CI 1·39-2·40]), living with very mild frailty (CFS score of 4: 1·99 [1·51-2·62]), living with mild frailty (CFS score of 5: 2·61 [1·99-3·43]), living with moderate frailty (CFS score of 6: 2·97 [2·26-3·90]), and living with severe frailty (CFS score of 7-8: 4·03 [3·04-5·34]). INTERPRETATION: Our findings support inclusion of the CFS in trauma pathways to aid patient management. Additionally, people who exercise regularly (CFS of 1-2) have better outcomes than those with lower activity levels (CFS of ≥3), supporting exercise as an intervention to improve trauma outcomes. FUNDING: None.

A national study of 23 major trauma centres to investigate the effect of a geriatrician assessment on clinical outcomes in older people admitted with serious injury in England (FiTR 2): a multicentre observational cohort study.

BACKGROUND: Older people are at the greatest risk of poor outcomes after serious injury. Evidence is limited for the benefit of assessment by a geriatrician in trauma care. We aimed to determine the effect of geriatrician assessment on clinical outcomes for older people admitted to hospital with serious injury. METHODS: In this multicentre observational study (FiTR 2), we extracted prospectively collected data on older people (aged ≥65 years) admitted to the 23 major trauma centres in England over a 2·5 year period from the Trauma Audit and Research Network (TARN) database. We examined the effect of a geriatrician assessment within 72 h of admission on the primary outcome of inpatient mortality in older people admitted to hospital with serious injury, with patients censored at discharge. We analysed data using a multi-level Cox regression model and estimated adjusted hazard ratios (aHRs). FINDINGS: Between March 31, 2019, and Oct 31, 2021, 193 156 patients had records held by TARN, of whom 35 490 were included in these analyses. Median age was 81·4 years (IQR 74·1-87·6), 19 468 (54·9%) were female, and 16 022 (45·1%) were male. 28 208 (79·5%) patients had experienced a fall from less than 2 m. 16 504 (46·5%) people received a geriatrician assessment. 4419 (12·5%) patients died during hospital stay, with a median time from admission to death of 6 days (IQR 2-14). Of those who died, 1660 (37·6%) had received a geriatrician assessment and 2759 (62·4%) had not (aHR 0·43 [95% CI 0·40-0·46]; p<0·0001). INTERPRETATION: Geriatrician assessment was associated with a reduced risk of death for seriously injured older people. These data support routine provision of geriatrician assessment in trauma care. Future research should explore the key components of a geriatrician assessment paired with a health economic evaluation. FUNDING: None.

Comparison between first and second wave of COVID-19 outbreak in older people: the COPE multicentre European observational cohort study.

BACKGROUND: Effective shielding measures and virus mutations have progressively modified the disease between the waves, likewise healthcare systems have adapted to the outbreak. Our aim was to compare clinical outcomes for older people with COVID-19 in Wave 1 (W1) and Wave 2 (W2). METHODS: All data, including the Clinical Frailty Scale (CFS), were collected for COVID-19 consecutive patients, aged ≥65, from 13 hospitals, in W1 (February-June 2020) and W2 (October 2020-March 2021). The primary outcome was mortality (time to mortality and 28-day mortality). Data were analysed with multilevel Cox proportional hazards, linear and logistic regression models, adjusted for wave baseline demographic and clinical characteristics. RESULTS: Data from 611 people admitted in W2 were added to and compared with data collected during W1 (N = 1340). Patients admitted in W2 were of similar age, median (interquartile range), W2 = 79 (73-84); W1 = 80 (74-86); had a greater proportion of men (59.4% vs. 53.0%); had lower 28-day mortality (29.1% vs. 40.0%), compared to W1. For combined W1-W2 sample, W2 was independently associated with improved survival: time-to-mortality adjusted hazard ratio (aHR) = 0.78 [95% confidence interval (CI) 0.65-0.93], 28-day mortality adjusted odds ratio = 0.80 (95% CI 0.62-1.03). W2 was associated with increased length of hospital stay aHR = 0.69 (95% CI 0.59-0.81). Patients in W2 were less frail, CFS [adjusted mean difference (aMD) = -0.50, 95% CI -0.81, -0.18], as well as presented with lower C-reactive protein (aMD = -22.52, 95% CI -32.00, -13.04). CONCLUSIONS: COVID-19 older adults in W2 were less likely to die than during W1. Patients presented to hospital during W2 were less frail and with lower disease severity and less likely to have renal decline.

Intimate partner violence and abuse experience and perpetration in UK military personnel compared to a general population cohort: A cross-sectional study.

Background: Research exploring prevalence of, and factors associated with, increased risk of experiencing or perpetrating Intimate Partner Violence and Abuse (IPVA) in military communities is limited. This study aimed to describe IPVA prevalence in a military sample, explore the role of military-specific risk factors, and draw comparisons with a general population cohort. Methods: We utilised data from a sample of military personnel participating in a cohort study of the health and wellbeing of UK military personnel who reported having an intimate relationship in the previous 12 months (n = 5557). To allow for comparison with civilian populations, participants from a general population cohort study in England (n = 6075) were matched on age and sex to the military cohort (n = 8093). Findings: The 12-month prevalences of IPVA experience and perpetration in the military sample were 12.80% (95% CI 11.72-13.96%) and 9.40% (8.45-10.45%), respectively. Factors associated with both increased IPVA experience and perpetration included childhood adversity, relationship dissatisfaction, military trauma, and recent mental health and alcohol misuse problems. Compared to the civilian cohort, adjusted odds (95% CI) of IPVA experience and perpetration were higher in the military: 2.94 (2.15-4.01) and 3.41 (1.79-6.50), respectively. Interpretation: This study found higher prevalences of IPVA experience and perpetration in the military compared to the general population cohort and highlighted both non-military and military factors associated with increased risk of both. Relationship dissatisfaction, military trauma and mental health difficulties mark key areas for IPVA prevention and management efforts to target. Funding: Funded by the UK Ministry of Defence and National Institute of Health Research.

Relationship conflict and partner violence by UK military personnel following return from deployment in Iraq and Afghanistan.

PURPOSE: Risk of violence by UK military personnel, both towards non-family and family, has been found to be higher post-deployment. However, no UK research to date has attempted to examine relationship conflict and intimate partner violence (IPV) in this period. This study estimated the prevalence of and risk factors for post-deployment relationship conflict and partner violence in UK military personnel. METHODS: We utilised data on military personnel who had deployed to Iraq and/or Afghanistan (n = 5437), drawn from a large cohort study into the health and well-being of UK military personnel. RESULTS: 34.7% reported relationship conflict (arguing with partner) and 3.4% reported perpetrating physical IPV post-deployment. Males were more likely than females to report relationship conflict. There were similar rates of self-reported physical IPV perpetration among males and females. Among our male sample, factors associated with both relationship conflict and physical IPV perpetration post-deployment included being in the Army compared with the Royal Air Force, higher levels of childhood adversity, higher levels of military trauma exposure and recent mental health and alcohol misuse problems. Being over 40 at time of deployment (vs being under 25) and having deployed in a combat role were also associated with relationship conflict, but not physical IPV perpetration. CONCLUSIONS: Deployment-related variables and mental health and alcohol misuse problems were found to be key factors associated with post-deployment relationship conflict and IPV. Services providing health or welfare support to military personnel must collaborate with mental health services and consider history of deployment, and particularly deployment-related trauma, in their assessments to improve identification and management of intimate partner violence and abuse in military communities.

Frailty is associated with poor mental health 1 year after hospitalisation with COVID-19.

BACKGROUND: Frailty is associated with long-term physical deterioration after COVID-19. Mental health recovery has been less well investigated. Early studies have shown minimal effect from the virus, although studies have not focused on whether people living with frailty may have different psychiatric outcomes. We aimed to examine the effect of living with frailty on mental health outcomes one year after hospital with COVID-19. METHODS: We undertook a multicentre cross-sectional study of people admitted with COVID-19. We assessed quality of life (ICECAP-O and MRC), psychiatric symptoms including: generalised anxiety (GAD-7), depression (Patient Health Questionnaire-9), and trauma (Trauma Screening Questionnaire). Frailty was measured using the Clinical Frailty Scale (CFS). We used a multivariable mixed-effects logistic and linear regression to examine the adjusted odds ratio (aOR) and adjusted mean difference (aMD). RESULTS: From eight hospitals 224 participants consented. Median follow-up time from admission 358 days (IQR 153-418), mean age 63.8 (SD = 13.7), 34.8% female (n = 78), and 43.7% living with frailty (n = 98 CFS 4-8). People living with frailty were significantly more likely to have symptoms of anxiety aOR = 5.72 (95% CI 1.71-19.13), depression aOR = 2.52 (95% CI 1.59-14.91), post-traumatic stress disorder aMD = 1.16 (95% CI 0.47, 1.85), and worse quality of life aMD = 1.06 (95% CI 0.76-1.36). LIMITATIONS: Patient-rated symptoms were captured rather than formal mental health diagnoses. CFS has not been validated in under 65-year-olds. CONCLUSIONS: Living with frailty is associated with significant psychiatric morbidity and reduced wellbeing one year after COVID-19 hospital admission. We recommend clinical follow-up after COVID-19 for people living with frailty should include a psychiatric assessment.

Prognostic value of estimated glomerular filtration rate in hospitalised older patients (over 65) with COVID-19: a multicentre, European, observational cohort study.

BACKGROUND: The reduced renal function has prognostic significance in COVID-19 and it has been linked to mortality in the general population. Reduced renal function is prevalent in older age and thus we set out to better understand its effect on mortality. METHODS: Patient clinical and demographic data was taken from the COVID-19 in Older People (COPE) study during two periods (February-June 2020 and October 2020-March 2021, respectively). Kidney function on admission was measured using estimated glomerular filtration rate (eGFR). The primary outcomes were time to mortality and 28-day mortality. Secondary outcome was length of hospital stay. Data were analysed with multilevel Cox proportional hazards regression, and multilevel logistic regression and adjusted for individual patient clinical and demographic characteristics. RESULTS: One thousand eight hundred two patients (55.0% male; median [IQR] 80 [73-86] years) were included in the study. 28-day mortality was 42.3% (n = 742). 48% (n = 801) had evidence of renal impairment on admission. Using a time-to-event analysis, reduced renal function was associated with increased in-hospital mortality (compared to eGFR ≥ 60 [Stage 1&2]): eGFR 45-59 [Stage 3a] aHR = 1.26 (95%CI 1.02-1.55); eGFR 30-44 [Stage 3b] aHR = 1.41 (95%CI 1.14-1.73); eGFR 1-29 [Stage 4&5] aHR = 1.42 (95%CI 1.13-1.80). In the co-primary outcome of 28-day mortality, mortality was associated with: Stage 3a adjusted odds ratio (aOR) = 1.18 (95%CI 0.88-1.58), Stage 3b aOR = 1.40 (95%CI 1.03-1.89); and Stage 4&5 aOR = 1.65 (95%CI 1.16-2.35). CONCLUSION: eGFR on admission is a good independent predictor of mortality in hospitalised older patients with COVID-19 population. We found evidence of a dose-response between reduced renal function and increased mortality.

Predicting 1 year mortality after traumatic injury using the Clinical Frailty Scale.

BACKGROUND: Frailty is known to affect how people admitted with traumatic injuries recover during their inpatient stay and shortly after discharge. However, few studies have examined the effect of frailty on long-term mortality when adjusted for significant factors including age. We aimed to determine the effect of frailty on 1-year morality in older adults admitted with traumatic injuries. METHODS: We undertook an observational study at the Severn Major Trauma Network's major trauma centre based in South West England. Patients ≥65 years old admitted between November 2018 and September 2019 with traumatic injuries were included. Isolated hip fractures and inpatient injuries were excluded. A geriatrician assessed all patients for frailty using the Clinical Frailty Scale. Follow-up occurred at 1 year. A multivariable Cox proportional baseline hazards model assessed the effect of frailty on time-to-mortality. The adjusted model included age, sex, multimorbidity, surgery, most injured site, injury severity, postinjury complications, and geriatrician review. RESULTS: Five hundred and eighty-five patients were included. Median age was 81 years old (IQR 74-88), and median injury severity score was 13 (IQR 9-25). At 1 year 147 (25.1%) patients had died. Living with frailty was associated with mortality. The risk of dying increased with frailty severity. Compared to CFS 1-3: CFS 4 aHR = 1.73 (95% CI 0.89-3.36, p = 0.11); CFS 5 aHR = 3.82 (95% CI 2.11-6.93, p < 0.001); CFS 6 aHR = 4·05 (95% CI 2.21-7.45, p < 0.001); CFS 7-8 aHR = 6.57 (95% CI 3.43-12.59, p < 0.001). CONCLUSION: This study is the first to demonstrate a consistent effect of frailty, at all levels of severity and independent of age, on older peoples' survival 1 year after traumatic injury. These data support performing an admission frailty assessment to aid long-term management decisions and provide opportunity to modify frailty to improve outcomes.

Routine use of immunosuppressants is associated with mortality in hospitalised patients with COVID-19.

BACKGROUND: Whilst there is literature on the impact of SARS viruses in the severely immunosuppressed, less is known about the link between routine immunosuppressant use and outcome in COVID-19. Consequently, guidelines on their use vary depending on specific patient populations. METHODS: The study population was drawn from the COPE Study (COVID-19 in Older People), a multicentre observational cohort study, across the UK and Italy. Data were collected between 27 February and 28 April 2020 by trained data-collectors and included all unselected consecutive admissions with COVID-19. Load (name/number of medications) and dosage of immunosuppressant were collected along with other covariate data. Primary outcome was time-to-mortality from the date of admission (or) date of diagnosis, if diagnosis was five or more days after admission. Secondary outcomes were Day-14 mortality and time-to-discharge. Data were analysed with mixed-effects, Cox proportional hazards and logistic regression models using non-users of immunosuppressants as the reference group. RESULTS: In total 1184 patients were eligible for inclusion. The median (IQR) age was 74 (62-83), 676 (57%) were male, and 299 (25.3%) died in hospital (total person follow-up 15,540 days). Most patients exhibited at least one comorbidity, and 113 (~10%) were on immunosuppressants. Any immunosuppressant use was associated with increased mortality: aHR 1.87, 95% CI: 1.30, 2.69 (time to mortality) and aOR 1.71, 95% CI: 1.01-2.88 (14-day mortality). There also appeared to be a dose-response relationship. CONCLUSION: Despite possible indication bias, until further evidence emerges we recommend adhering to public health measures, a low threshold to seek medical advice and close monitoring of symptoms in those who take immunosuppressants routinely regardless of their indication. However, it should be noted that the inability to control for the underlying condition requiring immunosuppressants is a major limitation, and hence caution should be exercised in interpretation of the results. PLAIN LANGUAGE SUMMARY: Regular Use of Immune Suppressing Drugs is Associated with Increased Risk of Death in Hospitalised Patients with COVID-19 Background: We do not have much information on how the COVID-19 virus affects patients who use immunosuppressants, drugs which inhibit or reduce the activity of the immune system. There are various conflicting views on whether immune-suppressing drugs are beneficial or detrimental in patients with the disease. Methods: This study collected data from 10 hospitals in the UK and one in Italy between February and April 2020 in order to identify any association between the regular use of immunosuppressant medicines and survival in patients who were admitted to hospital with COVID-19. Results: 1184 patients were included in the study, and 10% of them were using immunosuppressants. Any immunosuppressant use was associated with increased risk of death, and the risk appeared to increase if the dose of the medicine was higher. Conclusion: We therefore recommend that patients who take immunosuppressant medicines routinely should carefully adhere to social distancing measures, and seek medical attention early during the COVID-19 pandemic.

Risk and protective factors for offending among UK Armed Forces personnel after they leave service: a data linkage study.

BACKGROUND: A proportion of ex-military personnel who develop mental health and social problems end up in the Criminal Justice System. A government review called for better understanding of pathways to offending among ex-military personnel to improve services and reduce reoffending. We utilised data linkage with criminal records to examine the patterns of offending among military personnel after they leave service and the associated risk (including mental health and alcohol problems) and socio-economic protective factors. METHOD: Questionnaire data from a cohort study of 13 856 randomly selected UK military personnel were linked with national criminal records to examine changes in the rates of offending after leaving service. RESULTS: All types of offending increased after leaving service, with violent offending being the most prevalent. Offending was predicted by mental health and alcohol problems: probable PTSD, symptoms of common mental disorder and aggressive behaviour (verbal, property and threatened or actual physical aggression). Reduced risk of offending was associated with post-service socio-economic factors: absence of debt, stable housing and relationship satisfaction. These factors were associated with a reduced risk of offending in the presence of mental health risk factors. CONCLUSIONS: Ex-military personnel are more likely to commit violent offences after leaving service than other offence-types. Mental health and alcohol problems are associated with increased risk of post-service offending, and socio-economic stability is associated with reduced risk of offending among military veterans with these problems. Efforts to reduce post-service offending should encompass management of socio-economic risk factors as well as mental health.

The influence of ACE inhibitors and ARBs on hospital length of stay and survival in people with COVID-19.

OBJECTIVE: During the COVID-19 pandemic the continuation or cessation of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) has been contentious. Mechanisms have been proposed for both beneficial and detrimental effects. Recent studies have focused on mortality with no literature having examined length of hospital stay. The aim of this study was to determine the influence of ACEi and ARBs on COVID-19 mortality and length of hospital stay. METHODS: COPE (COVID-19 in Older People) is a multicenter observational study including adults of all ages admitted with either laboratory or clinically confirmed COVID-19. Routinely generated hospital data were collected. Primary outcome: mortality; secondary outcomes: Day-7 mortality and length of hospital stay. A mixed-effects multivariable Cox's proportional baseline hazards model and logistic equivalent were used. RESULTS: 1371 patients were included from eleven centres between 27th February to 25th April 2020. Median age was 74 years [IQR 61-83]. 28.6% of patients were taking an ACEi or ARB. There was no effect of ACEi or ARB on inpatient mortality (aHR = 0.85, 95%CI 0.65-1.11). For those prescribed an ACEi or ARB, hospital stay was significantly reduced (aHR = 1.25, 95%CI 1.02-1.54, p = 0.03) and in those with hypertension the effect was stronger (aHR = 1.39, 95%CI 1.09-1.77, p = 0.007). CONCLUSIONS: Patients and clinicians can be reassured that prescription of an ACEi or ARB at the time of COVID-19 diagnosis is not harmful. The benefit of prescription of an ACEi or ARB in reducing hospital stay is a new finding.

The Clinical Frailty Scale: Estimating the Prevalence of Frailty in Older Patients Hospitalised with COVID-19. The COPE Study.

Frailty assessed using Clinical Frailty Scale (CFS) is a good predictor of adverse clinical events including mortality in older people. CFS is also an essential criterion for determining ceilings of care in people with COVID-19. Our aims were to assess the prevalence of frailty in older patients hospitalised with COVID-19, their sex and age distribution, and the completion rate of the CFS tool in evaluating frailty. Methods: Data were collected from thirteen sites. CFS was assessed routinely at the time of admission to hospital and ranged from 1 (very fit) to 9 (terminally ill). The completion rate of the CFS was assessed. The presence of major comorbidities such as diabetes and cardiovascular disease was noted. Results: A total of 1277 older patients with COVID-19, aged ≥ 65 (79.9 ± 8.1) years were included in the study, with 98.5% having fully completed CFS. The total prevalence of frailty (CFS ≥ 5) was 66.9%, being higher in women than men (75.2% vs. 59.4%, p < 0.001). Frailty was found in 161 (44%) patients aged 65-74 years, 352 (69%) in 75-84 years, and 341 (85%) in ≥85 years groups, and increased across the age groups (<0.0001, test for trend). Conclusion: Frailty was prevalent in our cohort of older people admitted to hospital with COVID-19. This indicates that older people who are also frail, who go on to contract COVID-19 may have disease severity significant enough to warrant hospitalization. These data may help inform health care planners and targeted interventions and appropriate management for the frail older person.

Prior Routine Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Important Outcomes in Hospitalised Patients with COVID-19.

Coronavirus disease 2019 (COVID-19) infection causes acute lung injury, resulting from aggressive inflammation initiated by viral replication. There has been much speculation about the potential role of non-steroidal inflammatory drugs (NSAIDs), which increase the expression of angiotensin-converting enzyme 2 (ACE2), a binding target for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to enter the host cell, which could lead to poorer outcomes in COVID-19 disease. The aim of this study was to examine the association between routine use of NSAIDs and outcomes in hospitalised patients with COVID-19. This was a multicentre, observational study, with data collected from adult patients with COVID-19 admitted to eight UK hospitals. Of 1222 patients eligible to be included, 54 (4.4%) were routinely prescribed NSAIDs prior to admission. Univariate results suggested a modest protective effect from the use of NSAIDs, but in the multivariable analysis, there was no association between prior NSAID use and time to mortality (adjusted HR (aHR) = 0.89, 95% CI 0.52-1.53, p = 0.67) or length of stay (aHR 0.89, 95% CI 0.59-1.35, p = 0.58). This study found no evidence that routine NSAID use was associated with higher COVID-19 mortality in hospitalised patients; therefore, patients should be advised to continue taking these medications until further evidence emerges. Our findings suggest that NSAID use might confer a modest benefit with regard to survival. However, as this finding was underpowered, further research is required.

The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study.

BACKGROUND: The COVID-19 pandemic has placed unprecedented strain on health-care systems. Frailty is being used in clinical decision making for patients with COVID-19, yet the prevalence and effect of frailty in people with COVID-19 is not known. In the COVID-19 in Older PEople (COPE) study we aimed to establish the prevalence of frailty in patients with COVID-19 who were admitted to hospital and investigate its association with mortality and duration of hospital stay. METHODS: This was an observational cohort study conducted at ten hospitals in the UK and one in Italy. All adults (≥18 years) admitted to participating hospitals with COVID-19 were included. Patients with incomplete hospital records were excluded. The study analysed routinely generated hospital data for patients with COVID-19. Frailty was assessed by specialist COVID-19 teams using the clinical frailty scale (CFS) and patients were grouped according to their score (1-2=fit; 3-4=vulnerable, but not frail; 5-6=initial signs of frailty but with some degree of independence; and 7-9=severe or very severe frailty). The primary outcome was in-hospital mortality (time from hospital admission to mortality and day-7 mortality). FINDINGS: Between Feb 27, and April 28, 2020, we enrolled 1564 patients with COVID-19. The median age was 74 years (IQR 61-83); 903 (57·7%) were men and 661 (42·3%) were women; 425 (27·2%) had died at data cutoff (April 28, 2020). 772 (49·4%) were classed as frail (CFS 5-8) and 27 (1·7%) were classed as terminally ill (CFS 9). Compared with CFS 1-2, the adjusted hazard ratios for time from hospital admission to death were 1·55 (95% CI 1·00-2·41) for CFS 3-4, 1·83 (1·15-2·91) for CFS 5-6, and 2·39 (1·50-3·81) for CFS 7-9, and adjusted odds ratios for day-7 mortality were 1·22 (95% CI 0·63-2·38) for CFS 3-4, 1·62 (0·81-3·26) for CFS 5-6, and 3·12 (1·56-6·24) for CFS 7-9. INTERPRETATION: In a large population of patients admitted to hospital with COVID-19, disease outcomes were better predicted by frailty than either age or comorbidity. Our results support the use of CFS to inform decision making about medical care in adult patients admitted to hospital with COVID-19. FUNDING: None.

Relative effectiveness of augmentation treatments for treatment-resistant depression: a systematic review and network meta-analysis.

Most interventions for treatment-resistant depression (TRD) are added as augmenters. We aimed to determine the relative effectiveness of augmentation treatments for TRD. This systematic review and network meta-analysis (NMA) sought all randomized trials of pharmacological and psychological augmentation interventions for adults meeting the most common clinical criteria for TRD. The NMA compared the intervention effectiveness of depressive symptoms for TRD augmentation. Of 36 included trials, 27 were suitable for inclusion in NMA, and no psychological trials could be included in the absence of a common comparator. Antipsychotics (13 trials), mood stabilizers (three trials), NMDA-targeting medications (five trials), and other mechanisms (3 trials) were compared against placebo. NMDA treatments were markedly superior to placebo (ES = 0.91, 95% CI 0.67 to 1.16) and head-to-head NMA suggested that NMDA therapies had the highest chance of being an effective treatment option compared to other pharmacological classes. This study provides the most comprehensive evidence of augmenters' effectiveness for TRD, and our GRADE recommendations can be used to guide guidelines to optimize treatment choices. Although conclusions are limited by paucity of, and heterogeneity between, trials as well as inconsistent reports of treatment safety. This work supports the use of NMDA-targeting medications such as ketamine.

Offending behaviour, health and wellbeing of military veterans in the criminal justice system.

BACKGROUND: A small but significant proportion of military veterans become involved in the criminal justice system (CJS) after leaving service. Liaison and Diversion (L&D) services aim to identify vulnerable offenders in order to provide them with the health/welfare support they need, and (where possible) divert them away from custody. An administrative database of L&D service-users was utilised to compare the needs of veterans with those of non-veteran L&D service-users. METHOD: National data collected from 29 L&D services in 2015-2016 was utilised. Of the 62,397 cases, 1,067 (2%) reported previous service in the Armed Forces, and 48,578 had no previous service history. The associations between veteran status and socio-demographic characteristics, offending behaviour, health- and mental health-problems were explored. The associations between specific types of offending and mental health problems within the veterans in the sample were also investigated. RESULTS: Veterans tended to be older, and less likely to be unemployed than non-veterans, but just as likely to have unstable living arrangements (including homelessness). Veteran status was associated with increased levels of interpersonal violence, motoring offences, anxiety disorders and hazardous drinking patterns. Veteran status was associated with decreased levels of acquisitive offending, schizophrenia, ADHD, and substance misuse. Among veterans, the presence of an anxiety disorder (umbrella term which included GAD, Phobias, PTSD etc.) was associated with increased interpersonal violence, alcohol misuse was associated with increased motoring offences, and substance use was associated with increased acquisitive offending. CONCLUSIONS: Our study indicates that among offenders in the CJS who have been identified as needing health or welfare support, veterans differ from non-veterans in terms of their health and welfare needs and offending behaviour. These differences may be influenced by the impact of military service and the transition into civilian life. Our findings support the identification of military personnel within the CJS to provide appropriate interventions and support to improve outcomes and reduce offending.

Does comorbid anxiety counteract emotion recognition deficits in conduct disorder?

BACKGROUND: Previous research has reported altered emotion recognition in both conduct disorder (CD) and anxiety disorders (ADs) - but these effects appear to be of different kinds. Adolescents with CD often show a generalised pattern of deficits, while those with ADs show hypersensitivity to specific negative emotions. Although these conditions often cooccur, little is known regarding emotion recognition performance in comorbid CD+ADs. Here, we test the hypothesis that in the comorbid case, anxiety-related emotion hypersensitivity counteracts the emotion recognition deficits typically observed in CD. METHOD: We compared facial emotion recognition across four groups of adolescents aged 12-18 years: those with CD alone (n = 28), ADs alone (n = 23), cooccurring CD+ADs (n = 20) and typically developing controls (n = 28). The emotion recognition task we used systematically manipulated the emotional intensity of facial expressions as well as fixation location (eye, nose or mouth region). RESULTS: Conduct disorder was associated with a generalised impairment in emotion recognition; however, this may have been modulated by group differences in IQ. AD was associated with increased sensitivity to low-intensity happiness, disgust and sadness. In general, the comorbid CD+ADs group performed similarly to typically developing controls. CONCLUSIONS: Although CD alone was associated with emotion recognition impairments, ADs and comorbid CD+ADs were associated with normal or enhanced emotion recognition performance. The presence of comorbid ADs appeared to counteract the effects of CD, suggesting a potentially protective role, although future research should examine the contribution of IQ and gender to these effects.