Just a phase? Causal probing reveals spurious phasic dependence of sustained attention

For over a decade, electrophysiological studies have reported correlations between attention / perception and the phase of spontaneous brain oscillations. To date, these findings have been interpreted as evidence that the brain uses neural oscillations to sample and predict upcoming stimuli. Yet, evidence from simulations have shown that analysis artefacts could also lead to spurious pre-stimulus oscillations that appear to predict future brain responses. To address this discrepancy, we conducted an experiment in which visual stimuli were presented in time to specific phases of spontaneous alpha and theta oscillations. This allowed us to causally probe the role of ongoing neural activity in visual processing independent of the stimulus-evoked dynamics. Our findings did not support a causal link between spontaneous alpha / theta rhythms and behaviour. However, spurious correlations between theta phase and behaviour emerged offline using gold-standard time-frequency analyses. These findings are a reminder that care should be taken when inferring causal relationships between neural activity and behaviour using acausal analysis methods.

1362 ANTICHOLINERGIC PRESCRIBING HABITS AND ITS ASSOCIATIONS IN A COMMUNITY POPULATION OF PEOPLE LIVING WITH DEMENTIA

Introduction

Many commonly prescribed medications have inadvertent anticholinergic effects. People with Dementia (PwD) are more vulnerable to these effects and at risk of adverse outcomes, the risk being higher with a greater degree of anticholinergic exposure. We investigated prescribing patterns and Anticholinergic burden (ACB) in a cohort of community-dwelling older adults with dementia and aimed to explore the effect of ACB on cognition, mood, and quality of life(QoL).

Method

The medication and demographic information for 87 (39 female) community-dwelling PwD were obtained from Electronic Care Summaries. We used the German Anticholinergic Burden Scale (GABS) to measure ACB. Additionally, we investigated associations between ACB and cognitive (ADAS-Cog), functional (BADL) and QoL (DemQoL) assessments.

Results

28.7% of participants had a clinically significant score (ACB> 2). The most commonly prescribed medications with ACB were Lansoprazole(18.3%), Mirtazapine(12.6%) and Codeine(12.6%). ACB was higher in males and negatively correlated with age, r(87)=-.21,p=.03. There was no association between ACB and cognition, QoL, functional independence, and neuropsychiatric symptoms. Over six months, PLWD with no ACB had a greater negative change in neuropsychiatric symptoms[t(18)=2.27,p=.04] and functional independence[t(23)=-3.8,p=.001], indicating greater dependence and worsening neuropsychiatric symptoms.

Conclusion

A third of PLWD in the community had clinically significant ACB. No ACB was associated with worsening neuropsychiatric symptoms and functional dependence over a six-month period. Community prescribers should consider regular medication reviews with PLWD and carers to ensure medications are prescribed safely and appropriately.

1415 NOVEL APPROACHES TO POST DISCHARGE CARE. REMOTE HEALTHCARE MONITORING SYSTEMS FOLLOWING TRAUMATIC BRAIN INJURY IN OLDER ADULTS

Introduction

Major trauma including Traumatic Brain Injury (TBI) is an increasingly common cause of hospitalisation in older adults (OAs). We studied post-discharge recovery from TBI using a remote healthcare monitoring system that captures data on activity and sleep. We aim to assess the feasibility and acceptability of this technology to monitor recovery at home following a significant acute health event in OAs.

Methods

We installed Minder, a remote healthcare monitoring system, in recently discharged patients >60 years with moderate-severe TBI. We present descriptive analyses of post-discharge recovery for two males, corroborating data from Minder against verified activities and events. We recorded semi-structured interviews assessing acceptability. Both participants have similar household set-up, multimorbidity profiles and clinical frailty scores; however, one participant has prior cognitive impairment (PAT1), and one does not (PAT2).

Results

We present 10 weeks of sleep and activity data from Minder and feedback from interviews. Data observed from PAT1 revealed habitual patterns of activity and sleep. These remained stable, despite discrete clinical events. Conversely, PAT2's data revealed irregular sleep patterns that became increasingly fragmented. Activity was detected in multiple rooms throughout the house at night, consistent with carer reports of night-time wandering. Increased overnight activity coincided with multiple falls, prompting increased care provision. Initial feedback from interviews was the technology helped participants and those involved in their care feel supported.

Conclusions

As pressure on services mounts, novel approaches to post-discharge care are of increasing importance. Remote healthcare monitoring can provide high temporal resolution data offering ‘real world’ insights into the effects of significant health events in OAs. Our provisional results support our hypothesis that use of this technology is feasible and acceptable for frail, multimorbid participants and highlights the substantial potential of this technology to help clinicians improve community-based care and more effectively monitor interventions and chronic conditions.

Brain charts for the human lifespan

Over the past few decades, neuroimaging has become a ubiquitous tool in basic research and clinical studies of the human brain. However, no reference standards currently exist to quantify individual differences in neuroimaging metrics over time, in contrast to growth charts for anthropometric traits such as height and weight1. Here we assemble an interactive open resource to benchmark brain morphology derived from any current or future sample of MRI data ( http://www.brainchart.io/ ). With the goal of basing these reference charts on the largest and most inclusive dataset available, acknowledging limitations due to known biases of MRI studies relative to the diversity of the global population, we aggregated 123,984 MRI scans, across more than 100 primary studies, from 101,457 human participants between 115 days post-conception to 100 years of age. MRI metrics were quantified by centile scores, relative to non-linear trajectories2 of brain structural changes, and rates of change, over the lifespan. Brain charts identified previously unreported neurodevelopmental milestones3, showed high stability of individuals across longitudinal assessments, and demonstrated robustness to technical and methodological differences between primary studies. Centile scores showed increased heritability compared with non-centiled MRI phenotypes, and provided a standardized measure of atypical brain structure that revealed patterns of neuroanatomical variation across neurological and psychiatric disorders. In summary, brain charts are an essential step towards robust quantification of individual variation benchmarked to normative trajectories in multiple, commonly used neuroimaging phenotypes.

A longitudinal study investigating change in BMI z-score in primary school-aged children and the association of child BMI z-score with parent BMI

Background

This paper aims to explore change in BMI z-score through childhood and the association between parent BMI and child BMI z-score. This is important to understand for the development of effective obesity interventions.

Methods

Data from the longitudinal B-ProAct1v study (1837 participants) were analysed. A paired sample t-test examined changes in child BMI z-score between Year 1 and 4. Multivariable linear regression models examined the cross-sectional associations between child BMI z-score and parent BMI in Year 1 and 4. The influence of change in parental BMI between Year 1 and Year 4 on child BMI z-score in Year 4 was explored through regression analyses, adjusted for baseline BMI z-score.

Results

There was a strong association between child BMI z-score at Year 1 and 4. Child mean BMI z-score score increased from 0.198 to 0.330 (p = < 0.005) between these timepoints. For every unit increase in parent BMI, there was an increase in child BMI z-score of 0.047 in Year 1 (p = < 0.005) and of 0.059 in Year 4 (p = < 0.005). Parental BMI change was not significantly associated with Year 4 child BMI z-score.

Conclusion

The key indicator of higher child BMI at Year 4 is high BMI at Year 1. Further studies are needed to explore the impact of parental weight change on child BMI z-score and whether interventions targeted at overweight or obese parents, can improve their child’s BMI z-score.

Antidepressant treatment with sertraline for adults with depressive symptoms in primary care: the PANDA research programme including RCT

Background

Despite a growing number of prescriptions for antidepressants (over 70 million in 2018), there is uncertainty about when people with depression might benefit from antidepressant medication and concern that antidepressants are prescribed unnecessarily.

Objectives

The main objective of the PANDA (What are the indications for Prescribing ANtiDepressAnts that will lead to a clinical benefit?) research programme was to provide more guidance about when antidepressants are likely to benefit people with depression. We aimed to estimate the minimal clinically important difference for commonly used self-administered scales for depression and anxiety, and to understand more about how patients respond to such assessments. We carried out an observational study of patients with depressive symptoms and a placebo-controlled randomised controlled trial of sertraline versus placebo to estimate the treatment effect in UK primary care. The hypothesis was that the severity and duration of symptoms were related to treatment response.

Design

The programme consisted of three phases. The first phase relied on the secondary analysis of existing data extracted from published trials. The second phase was the PANDA cohort study of patients with depressive symptoms who presented to primary care and were followed up 2, 4 and 6 weeks after a baseline assessment. Both quantitative and qualitative methods were used in the analysis. The third phase was a multicentre randomised placebo-controlled double-blind trial of sertraline versus placebo in patients presenting to primary care with depressive symptoms.

Setting

UK primary care in Bristol, London, Liverpool and York.

Participants

Patients aged 18–74 years who were experiencing depressive symptoms in primary care. Eligibility for the PANDA randomised controlled trial included that there was uncertainty about the benefits about treatment with an antidepressant.

Interventions

In the PANDA randomised controlled trial, patients were individually randomised to 100 mg daily of sertraline or an identical placebo. The PANDA cohort study was an observational study.

Main outcome measures

Depressive symptoms measured using the Patient Health Questionnaire were the primary outcome for the randomised controlled trial. Other outcomes included anxiety symptoms using the Generalised Anxiety Disorder-7; depressive symptoms using the Beck Depression Inventory, version 2; health-related quality of life; self-reported improvement; and cost-effectiveness.

Results

The secondary analysis of existing randomised controlled trials [GENetic and clinical Predictors Of treatment response in Depression (GenPod), TREAting Depression with physical activity (TREAD) and Clinical effectiveness and cost-effectiveness of cognitive Behavioural Therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care (CoBalT)] found evidence that the minimal clinically important difference increased as the initial severity of depressive symptoms rose. Our estimates of minimal clinically important difference were a 17% and 18% reduction in Beck Depression Inventory scores for GenPod and TREAD, respectively. In CoBalT, a 32% reduction corresponded to the minimal clinically important difference but the participants in this study had depression that had not responded to antidepressants. In the PANDA study cohort, and from our analyses in existing data, we found that the minimal clinically important difference varies considerably with the initial severity of depressive and anxiety symptoms. Expressing the minimal clinically important difference as a percentage reduction reduces this variation at higher scores, but at low scores the percentage reduction increased substantially. The results from the qualitative studies pointed out many limitations of the Patient Health Questionnaire-9 items in assessing change and recovery from depression. In the PANDA randomised controlled trial, there was no evidence that sertraline resulted in a reduction in depressive symptoms within 6 weeks of randomisation, but there was some evidence of a reduction by 12 weeks. However, sertraline led to a reduction in anxiety symptoms, an improvement of mental health-related quality of life and an increased likelihood of reporting improvement. The mean Patient Health Questionnaire-9 items score at 6 weeks was 7.98 (standard deviation 5.63) in the sertraline group and 8.76 (standard deviation 5.86) in the placebo group (5% relative reduction, 95% confidence interval –7% to 15%; p = 0.41). Of the secondary outcomes, there was strong evidence that sertraline reduced anxiety symptoms (Generalised Anxiety Disorder-7 score reduced by 17% (95% confidence interval 9% to 25%; p = 0.00005). Sertraline had a high probability (> 90%) of being cost-effective at 12 weeks. The PANDA randomised controlled trial found no evidence that treatment response or cost-effectiveness was related to severity or duration of depressive symptoms. The minimal clinically important difference estimates suggested that sertraline’s effect on anxiety, but not on depression, was likely to be clinically important.

Limitations

The results from the randomised controlled trial and the estimates of minimal clinically important difference were not sufficiently precise to provide specific clinical guidance for individuals. We had low power in testing whether or not initial severity and duration of depressive symptoms are related to treatment response.

Conclusions

The results of the trial support the use of sertraline and probably other selective serotonin reuptake inhibitors because of their action in reducing anxiety symptoms and the likelihood of longer-term benefit on depressive symptoms. Sertraline could be prescribed for anxiety symptoms that commonly occur with depression and many patients will experience a clinical benefit. The Patient Health Questionnaire-9 items and similar self-administered scales should not be used on their own to assess clinical outcome, but should be supplemented with further clinical assessment.

Future work

We need to examine the longer-term effects of antidepressant treatment. We need more precise estimates of the treatment effects and minimal clinically important difference at different severities to provide more specific guidance for individuals. However, the methods we have developed provide an approach towards providing such detailed guidance.

Trial registration

Current Controlled Trials ISRCTN84544741 and EudraCT number 2013-003440-22.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 10. See the NIHR Journals Library website for further project information.

Head trauma in sports - clinical characteristics, epidemiology and biomarkers

Traumatic brain injury (TBI) is clinically divided into a spectrum of severities, with mild TBI being the least severe form and a frequent occurrence in contact sports, such as ice hockey, American football, rugby, horse riding and boxing. Mild TBI is caused by blunt nonpenetrating head trauma that causes movement of the brain and stretching and tearing of axons, with diffuse axonal injury being a central pathogenic mechanism. Mild TBI is in principle synonymous with concussion; both have similar criteria in which the most important elements are acute alteration or loss of consciousness and/or post-traumatic amnesia following head trauma and no apparent brain changes on standard neuroimaging. Symptoms in mild TBI are highly variable and there are no validated imaging or fluid biomarkers to determine whether or not a patient with a normal computerized tomography scan of the brain has neuronal damage. Mild TBI typically resolves within a few weeks but 10-15% of concussion patients develop postconcussive syndrome. Repetitive mild TBI, which is frequent in contact sports, is a risk factor for a complicated recovery process. This overview paper discusses the relationships between repetitive head impacts in contact sports, mild TBI and chronic neurological symptoms. What are these conditions, how common are they, how are they linked and can they be objectified using imaging or fluid-based biomarkers? It gives an update on the current state of research on these questions with a specific focus on clinical characteristics, epidemiology and biomarkers.

Psychological advocacy towards healing (PATH): A randomized controlled trial of a psychological intervention in a domestic violence service setting

BACKGROUND

Experience of domestic violence and abuse (DVA) is associated with mental illness. Advocacy has little effect on mental health outcomes of female DVA survivors and there is uncertainty about the effectiveness of psychological interventions for this population.

OBJECTIVE

To test effectiveness of a psychological intervention delivered by advocates to DVA survivors.

DESIGN, MASKING, SETTING, PARTICIPANTS

Pragmatic parallel group individually randomized controlled trial of normal DVA advocacy vs. advocacy + psychological intervention. Statistician and researchers blinded to group assignment. Setting: specialist DVA agencies; two UK cities. Participants: Women aged 16 years and older accessing DVA services.

INTERVENTION

Eight specialist psychological advocacy (SPA) sessions with two follow up sessions.

MEASUREMENTS

Primary outcomes at 12 months: depression symptoms (PHQ-9) and psychological distress (CORE-OM). Primary analysis: intention to treat linear (logistic) regression model for continuous (binary) outcomes.

RESULTS

263 women recruited (78 in shelter/refuge, 185 in community), 2 withdrew (1 community, control group; 1 intervention, refuge group), 1 was excluded from the study for protocol violation (community, control group), 130 in intervention and 130 in control groups. Recruitment ended June 2013. 12-month follow up: 64%. At 12-month follow up greater improvement in mental health of women in the intervention group. Difference in average CORE-OM score between intervention and control groups: -3.3 points (95% CI -5.5 to -1.2). Difference in average PHQ-9 score between intervention and control group: -2.2 (95% CI -4.1 to -0.3). At 12 months, 35% of the intervention group and 55% of the control group were above the CORE-OM -2clinical threshold (OR 0.32, 95% CI 0.16 to 0.64); 29% of the intervention group and 46% of the control group were above the PHQ-9 clinical threshold (OR 0.41, 95% CI 0.21 to 0.81).

LIMITATIONS

64% retention at 12 months.

CONCLUSIONS

An eight-session psychological intervention delivered by DVA advocates produced clinically relevant improvement in mental health outcomes compared with normal advocacy care.

TRIAL REGISTRATION

ISRCTN registry ISRCTN58561170 Original Research 3675/3750.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

Prenatal maternal depression is associated with offspring inflammation at 25 years: a prospective longitudinal cohort study

Animal studies and a handful of prospective human studies have demonstrated that young offspring exposed to maternal prenatal stress show abnormalities in immune parameters and hypothalamic-pituitary-adrenal (HPA) axis function. No study has examined the effect of maternal prenatal depression on offspring inflammation and HPA axis activity in adulthood, nor the putative role of child maltreatment in inducing these abnormalities. High-sensitivity C-reactive protein (hs-CRP) and awakening cortisol were measured at age 25 in 103 young-adult offspring of the South London Child Development Study (SLCDS), a prospective longitudinal birth cohort of mother-offspring dyads recruited in pregnancy in 1986. Maternal prenatal depression was assessed in pregnancy at 20 and 36 weeks; offspring child maltreatment (birth 17 years) was assessed at offspring ages 11, 16 and 25; and offspring adulthood depression (18-25 years) was assessed at age 25. Exposure to maternal prenatal depression predicted significantly elevated offspring hs-CRP at age 25 (odds ratio=11.8, 95% confidence interval (CI) (1.1, 127.0), P=0.041), independently of child maltreatment and adulthood depression, known risk factors for adulthood inflammation. In contrast, maternal prenatal depression did not predict changes in offspring adulthood cortisol; however, offspring exposure to child maltreatment did, and was associated with elevated awakening cortisol levels (B=161.9, 95% CI (45.4, 278.4), P=0.007). Fetal exposure to maternal depression during pregnancy has effects on immune function that persist for up to a quarter of a century after birth. Findings are consistent with the developmental origins of health and disease (DOHaD) hypothesis for the biological embedding of gestational psychosocial adversity into vulnerability for future physical and mental illness.

Supportive care for men with prostate cancer: why are the trials not working? A systematic review and recommendations for future trials

Men with prostate cancer are likely to have a long illness and experience psychological distress for which supportive care may be helpful. This systematic review describes the evidence for effectiveness and cost-effectiveness of supportive care for men with prostate cancer, taking into account treatment pathway and components of interventions. MEDLINE, EMBASE, CINAHL, CENTRAL, and Psychinfo were searched from inception––July 2013 for randomized controlled trials and controlled trials. Two authors independently assessed risk of bias and extracted data. Twenty-six studies were included (2740 participants). Interventions were delivered pre and during (n = 12), short-term (n = 8), and longer term (18 months) (n = 5) after primary treatment. No interventions were delivered beyond this time. Few trials recruited ethnic minorities and none recruited men in same sex relationships. Intervention components included information, education, health professional discussion, homework, peer discussion, buddy support, cognitive behavioral therapy, cognitive restructuring, psychoeducation, Reiki and relaxation. Most interventions were delivered for 5–10 weeks. Risk of bias of trials was assessed as unclear for most domains due to lack of information. The majority of trials measuring quality of life and depression found no effect. Relatively few trials measured anxiety, coping skills and self-efficacy, and the majority found no effect. No cost data were available. Trials of supportive care for men with prostate cancer cover a range of interventions but are limited by population diversity, inconsistent measurement and reporting of outcomes, and inability to assess risk of bias. Recommendations on design and conduct of future trials are presented.

Changing eating behaviours to treat childhood obesity in the community using Mandolean: the Community Mandolean randomised controlled trial (ComMando)--a pilot study

BACKGROUND

Around one in five children in England is obese when they leave primary school. Thus far, it has not been demonstrated that primary care interventions to manage childhood obesity can achieve significant weight reduction. Training obese children to eat more slowly as an adjunct to other healthy lifestyle behaviour change has been shown to increase weight reduction in a hospital setting.

OBJECTIVES

This pilot study aimed to test recruitment strategies, treatment adherence, clinic attendance and participants' experiences of using a device [Mandolean® (previously Mandometer®, Mikrodidakt AB, Lund, Sweden)] to slow down speed of eating as an adjunct to dietary and activity advice in treating obesity in primary school-aged children.

DESIGN

A two-arm, parallel, randomised controlled trial with a qualitative study embedded within the pilot. Randomisation occurred after informed consent and baseline measures were collected. Participants were randomised by the Bristol Randomised Trials Collaboration randomisation service with allocation stratified by hub and minimised by age of the child, gender, and baseline body mass index (BMI) standard deviation score (BMI z-value) of the child, and by BMI of the study parent (obese/not obese).

SETTING

General practices across Bristol, North Somerset and South Gloucestershire primary care trusts.

PARTICIPANTS

Children (BMI ≥ 95th percentile) aged 5-11 years and their families.

INTERVENTION

Standard care comprised dietary and activity advice by trained practice nurses. Adjunctive Mandolean training (the intervention) educated participants to eat meals more slowly and to rate levels of fullness (satiety). Mandolean is a small computer device attached to a weighing scale that provides visual and oral feedback during meals while generating a visual representation of levels of satiety during the meal. Participants were encouraged to eat their main meal each day from the Mandolean. One parent was also given a Mandolean to use when eating with the child.

OUTCOME MEASURES

Outcomes for the pilot were recruitment of 36 families to the trial in the 9-month pilot phase, that meals would be eaten at least five times a week off a Mandolean by 90% of patients randomised to the intervention arm, that 80% of patients in both arms would attend the weight management clinic appointment 3 months post randomisation and that > 60% of children using Mandolean would demonstrate a reduction in speed of eating from baseline within 3 months of randomisation.

RESULTS

None of the criteria for progression to the main trial were reached. Despite numerous pathways being available for referral, only 21 (13 to standard care, eight to intervention arm; 58%) of the target 36 families were recruited in the pilot phase. Less than 20% of those randomised to Mandolean used the device at least five times a week. The > 60% target for slowing down of eating speed by 3 months was unmet. Attendance at the weight management clinic in general practice hubs for both arms of the study at 3 months was 44% against a target of 80%.

CONCLUSIONS

This pilot trial failed to meet its objectives in terms of recruitment, treatment adherence, demonstration of a reduction in speed of eating in sufficient numbers of children, and attendance at follow-up appointments. Despite a high prevalence of childhood obesity in the geographical area and practices signing up for the trial, this study, like many others, demonstrates a failure of families to engage with and respond to primary care weight management interventions. We need to understand why the target population seems inured to the health message that childhood obesity is a significant health-care issue and identify the barriers to seeking help and then acting on positive health behaviour retraining. Only when we have fully understood the general public's perceptions of childhood obesity and have identified ways of engaging target populations can we hope to develop interventions that can work in a primary or community-based setting.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN90561114.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 47. See the NIHR Journals Library website for further project information.

Prostate cancer and supportive care: a systematic review and qualitative synthesis of men's experiences and unmet needs

Prostate cancer is the second most common cancer in men worldwide, accounting for an estimated 1.1 million new cases diagnosed in 2012 (www.globocan.iarc.fr). Currently, there is a lack of specific guidance on supportive care for men with prostate cancer. This article describes a qualitative systematic review and synthesis examining men's experience of and need for supportive care. Seven databases were searched; 20 journal articles were identified and critically appraised. A thematic synthesis was conducted in which descriptive themes were drawn out of the data. These were peer support, support from partner, online support, cancer specialist nurse support, self‐care, communication with health professionals, unmet needs (emotional support, information needs, support for treatment‐induced side effects of incontinence and erectile dysfunction) and men's suggestions for improved delivery of supportive care. This was followed by the development of overarching analytic themes which were: uncertainty, reframing, and the timing of receiving treatment, information and support. Our results show that the most valued form of support men experienced following diagnosis was one‐to‐one peer support and support from partners. This review highlights the need for improved access to cancer specialist nurses throughout the care pathway, individually tailored supportive care and psychosexual support for treatment side effects.

Antibacterial validation of electrogenerated hypochlorite using carbon-based electrodes

This proof-of-concept study explores the novel use of carbon-based electrodes for the electrochemical generation of hypochlorite and compares the antimicrobial efficacy against commercial hypochlorite solution. Antimicrobial concentrations of hypochlorite were generated using pad-printed carbon and carbon fibre electrodes, yielding up to 0·027% hypochlorite in 60 min and 0·1% hypochlorite in 15 min, respectively, in a nondivided assembly. The minimum inhibitory concentration (MIC) of the electrogenerated hypochlorite produced using carbon fibre electrodes was established for four medically important bacteria (Pseudomonas aeruginosa and Staphylococcus aureus approx. 0·025%, Escherichia coli and Enterococcus faecalis approx. 0·012%) and found to be in agreement with those determined using commercial hypochlorite solution. Therefore, carbon-based electrodes, particularly carbon fibre, have proven effective for the generation of antimicrobial concentrations of hypochlorite. The similarity of the MIC values to commercial hypochlorite solutions suggests that the antimicrobial efficacy is derived from the quantified hypochlorite generated and not due to marked cogeneration of reactive oxygen species, as identified for other assemblies. As such, the application of carbon electrodes may be suitable for the local production of hypochlorite for healthcare antisepsis.

SIGNIFICANCE AND IMPACT OF THE STUDY

Carbon fibre electrodes can rapidly generate antimicrobial concentrations of hypochlorite; as such, these cheap and commercially available electrodes are proposed for the local production of hypochlorite for healthcare antisepsis. Importantly, the antimicrobial properties of the electrochemically generated hypochlorite mirror those of commercial hypochlorite, suggesting this is not enhanced by the cogeneration of reactive oxygen species. This illustrates the potential use of disposable carbon electrodes for localized small-volume production of hypochlorite for surface and skin cleansing, and opens a broader scope of research into the exploitation of carbon electrodes for this application.

Objectively assessed physical activity and subsequent health service use of UK adults aged 70 and over: a four to five year follow up study

Objectives

To examine the associations between volume and intensity of older peoples' physical activity, with their subsequent health service usage over the following four to five years.

Study Design

A prospective cohort design using baseline participant characteristics, objectively assessed physical activity and lower limb function provided by Project OPAL (Older People and Active Living). OPAL-PLUS provided data on numbers of primary care consultations, prescriptions, unplanned hospital admissions, and secondary care referrals, extracted from medical records for up to five years following the baseline OPAL data collection.

Participants and Data Collection

OPAL participants were a diverse sample of 240 older adults with a mean age of 78 years. They were recruited from 12 General Practitioner surgeries from low, middle, and high areas of deprivation in a city in the West of England. Primary care consultations, secondary care referrals, unplanned hospital admissions, number of prescriptions and new disease diagnoses were assessed for 213 (104 females) of the original 240 OPAL participants who had either consented to participate in OPAL-PLUS or already died during the follow-up period.

Results

In regression modelling, adjusted for socio-economic variables, existing disease, weight status, minutes of moderate-to-vigorous physical activity (MVPA) per day predicted subsequent numbers of prescriptions. Steps taken per day and MVPA also predicted unplanned hospital admissions, although the strength of the effect was reduced when further adjustment was made for lower limb function.

Conclusions

Community-based programs are needed which are successful in engaging older adults in their late 70s and 80s in more walking, MVPA and activity that helps them avoid loss of physical function. There is a potential for cost savings to health services through reduced reliance on prescriptions and fewer unplanned hospital admissions.

Psychological advocacy toward healing (PATH): study protocol for a randomized controlled trial

Background

Domestic violence and abuse (DVA), defined as threatening behavior or abuse by adults who are intimate partners or family members, is a key public health and clinical priority. The prevalence of DVA in the United Kingdom and worldwide is high, and its impact on physical and mental health is detrimental and persistent. There is currently little support within healthcare settings for women experiencing DVA. Psychological problems in particular may be difficult to manage outside specialist services, as conventional forms of therapy such as counseling that do not address the violence may be ineffective or even harmful. The aim of this study is to assess the overall effectiveness and cost-effectiveness of a novel psychological intervention tailored specifically for survivors of DVA and delivered by domestic violence advocates based in third-sector organizations.

Methods and study design

This study is an open, pragmatic, parallel group, individually randomized controlled trial. Women ages 16 years and older experiencing domestic violence are being enrolled and randomly allocated to receive usual DVA agency advocacy support (control) or usual DVA agency support plus psychological intervention (intervention). Those in the intervention group will receive eight specialist psychological advocacy (SPA) sessions weekly or fortnightly, with two follow-up sessions, 1 month and then 3 months later. This will be in addition to any advocacy support sessions each woman receives. Women in the control group will receive usual DVA agency support but no additional SPA sessions. The aim is to recruit 250 women to reach the target sample size. The primary outcomes are psychological well-being and depression severity at 1 yr from baseline, as measured by the Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM) and the Patient Health Questionnaire (PHQ-9), respectively. Secondary outcome measures include anxiety, posttraumatic stress, severity and frequency of abuse, quality of life and cost-effectiveness of the intervention. Data from a subsample of women in both groups will contribute to a nested qualitative study with repeat interviews during the year of follow-up.

Discussion

This study will contribute to the evidence base for management of the psychological needs of women experiencing DVA. The findings will have important implications for healthcare commissioners and providers, as well as third sector specialist DVA agencies providing services to this client group.

Trial registration

ISRCTN58561170

A randomized double-blind crossover study of indoor air filtration and acute changes in cardiorespiratory health in a First Nations community

Few studies have examined indoor air quality in First Nations communities and its impact on cardiorespiratory health. To address this need, we conducted a crossover study on a First Nations reserve in Manitoba, Canada, including 37 residents in 20 homes. Each home received an electrostatic air filter and a placebo filter for 1 week in random order, and lung function, blood pressure, and endothelial function measures were collected at the beginning and end of each week. Indoor air pollutants were monitored throughout the study period. Indoor PM2.5 decreased substantially during air filter weeks relative to placebo (mean difference: 37 μg/m(3) , 95% CI: 10, 64) but remained approximately five times greater than outdoor concentrations owing to a high prevalence of indoor smoking. On average, air filter use was associated with a 217-ml (95% CI: 23, 410) increase in forced expiratory volume in 1 s, a 7.9-mm Hg (95% CI: -17, 0.82) decrease in systolic blood pressure, and a 4.5-mm Hg (95% CI: -11, 2.4) decrease in diastolic blood pressure. Consistent inverse associations were also observed between indoor PM2.5 and lung function. In general, our findings suggest that reducing indoor PM2.5 may contribute to improved lung function in First Nations communities.

PRACTICAL IMPLICATIONS

Indoor air quality is known to contribute to adverse cardiorespiratory health, but few studies have examined indoor air quality in First Nations communities. Our findings suggest that indoor PM2.5 may contribute to reduced lung function and that portable air filters may help to alleviate these effects by effectively reducing indoor levels of particulate matter.

A pilot randomised controlled trial of cognitive behavioural therapy for antenatal depression

BACKGROUND

Few trials have evaluated the effectiveness of psychological treatment in improving depression by the end of pregnancy. This is the first pilot randomised controlled trial (RCT) of individual cognitive behavioural therapy (CBT) looking at treating depression by the end of pregnancy. Our aim was to assess the feasibility of delivering a CBT intervention modified for antenatal depression during pregnancy.

METHODS

Women in North Bristol, UK between 8-18 weeks pregnant were recruited through routine contact with midwives and randomised to receive up to 12 sessions of individual CBT in addition to usual care or to continue with usual care only. Women were eligible for randomisation if they screened positive on a 3-question depression screen used routinely by midwives and met ICD-10 criteria for depression assessed using the clinical interview schedule - revised version (CIS-R). Two CBT therapists delivered the intervention. Follow-up was at 15 and 33 weeks post-randomisation when assessments of mental health were made using measures which included the CIS-R.

RESULTS

Of the 50 women assessed for the trial, 36 met ICD-10 depression criteria and were randomised: 18 to the intervention and 18 to usual care. Thirteen of the 18 (72%) women who were allocated to receive the intervention completed 9 or more sessions of CBT before the end of pregnancy. Follow-up rates at 15 and 33 weeks post-randomisation were higher in the group who received the intervention (89% vs. 72% at 15 weeks and 89% vs. 61% at 33 weeks post-randomisation). At 15 weeks post-randomisation (the end of pregnancy), there were more women in the intervention group (11/16; 68.7%) who recovered (i.e. no longer met ICD-10 criteria for depression), than those receiving only usual care (5/13; 38.5%).

CONCLUSIONS

This pilot trial shows the feasibility of conducting a large RCT to assess the effectiveness of CBT for treating antenatal depression before the end of pregnancy. The intervention could be delivered during the antenatal period and there was some evidence to suggest that it could be effective.

TRIAL REGISTRATION

ISRCTN44902048.

Developing a model of decision-making about complementary therapy use for patients with cancer: a qualitative study

OBJECTIVE

To improve our understanding of patient participation in health care consultations and decision-making by exploring a consultation that lies at the interface between mainstream care and complementary therapies.

METHODS

Thirty-four holistic consultations were observed at centres offering complementary therapies for cancer, followed by interviews with patients and focus groups with professionals.

RESULTS

A model of decision-making about complementary therapy use emerged from the data: 'Advice: Assessor led decision', 'Confirmation: Joint decision', 'Access: Patient-led decision' and 'Informed: Patient-led decision'. Decision-making style was contingent on identifiable communication strategies in the preceding information-sharing and discussion phases of the consultation.

CONCLUSION

This study confirms the importance of gauging patients' preferences for level of participation in decision-making. Models of consultations are generally based on the assumption that a greater degree of patient participation is a good thing that access to information and decision-making power is sought by all patients. Data from this study suggest that, in this context at least, this is not necessarily the case. The study also stresses the dynamic nature of the consultation, in which roles are fluid rather than fixed.

PRACTICE IMPLICATIONS

Insight were gained into professionals' communication strategies and patients' role preferences in decision-making, which may be applicable more widely.

Contrasting Beliefs About Screening for Mental Disorders Among Uk Military Personnel Returning from Deployment to Afghanistan

Objective

The objective of the study was to elicit beliefs and experiences of the value of a screening programme for mental illness among UK military personnel.

Method

Three months after returning from Afghanistan 21 army personnel participated in a qualitative study about mental health screening. One-to-one interviews were conducted and recorded. Data-driven thematic analysis was used. Researchers identified master themes represented by extracts of text from the 21 complete transcripts.

Results

Participants made positive remarks on the advantages of screening. Noted barriers to seeking help included: unwillingness to receive advice, a wish to deal with any problems themselves and a belief that military personnel should be strong enough to cope with any difficulties. Participants believed that overcoming barriers to participating in screening and seeking help would be best achieved by making screening compulsory.

Conclusions

Although respondents were positive about a screening programme for mental illness, the barriers to seeking help for mental illness appear deep rooted and reinforced by the value ascribed to hardiness.

Domestic violence: knowledge, attitudes, and clinical practice of selected UK primary healthcare clinicians

BACKGROUND

Domestic violence affects one in four women and has significant health consequences. Women experiencing abuse identify doctors and other health professionals as potential sources of support. Primary care clinicians agree that domestic violence is a healthcare issue but have been reluctant to ask women if they are experiencing abuse.

AIM

To measure selected UK primary care clinicians' current levels of knowledge, attitudes, and clinical skills in this area.

DESIGN AND SETTING

Prospective observational cohort in 48 general practices from Hackney in London and Bristol, UK.

METHOD

Administration of the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS), comprising five sections: responder profile, background (perceived preparation and knowledge), actual knowledge, opinions, and practice issues.

RESULTS

Two hundred and seventy-two (59%) clinicians responded. Minimal previous domestic violence training was reported by participants. Clinicians only had basic knowledge about domestic violence but expressed a positive attitude towards engaging with women experiencing abuse. Many clinicians felt poorly prepared to ask relevant questions about domestic violence or to make appropriate referrals if abuse was disclosed. Forty per cent of participants never or seldom asked about abuse when a woman presented with injuries. Eighty per cent said that they did not have an adequate knowledge of local domestic violence resources. GPs were better prepared and more knowledgeable than practice nurses; they also identified a higher number of domestic violence cases.

CONCLUSION

Primary care clinicians' attitudes towards women experiencing domestic violence are generally positive but they only have basic knowledge of the area. Both GPs and practice nurses need more comprehensive training on assessment and intervention, including the availability of local domestic violence services.

Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial

BACKGROUND

Most clinicians have no training about domestic violence, fail to identify patients experiencing abuse, and are uncertain about management after disclosure. We tested the effectiveness of a programme of training and support in primary health-care practices to increase identification of women experiencing domestic violence and their referral to specialist advocacy services.

METHODS

In this cluster randomised controlled trial, we selected general practices in two urban primary care trusts, Hackney (London) and Bristol, UK. Practices in which investigators from this trial were employed or those who did not use electronic records were excluded. Practices were stratified by proportion of female doctors, postgraduate training status, number of patients registered, and percentage of practice population on low incomes. Within every primary care trust area, we randomised practices with a computer-minimisation programme with a random component to intervention or control groups. The intervention programme included practice-based training sessions, a prompt within the medical record to ask about abuse, and a referral pathway to a named domestic violence advocate, who also delivered the training and further consultancy. The primary outcome was recorded referral of patients to domestic violence advocacy services. The prespecified secondary outcome was recorded identification of domestic violence in the electronic medical records of the general practice. Poisson regression analyses accounting for clustering were done for all practices receiving the intervention. Practice staff and research associates were not masked and patients were not aware they were part of a study. This study is registered at Current Controlled Trials, ISRCTN74012786.

FINDINGS

We randomised 51 (61%) of 84 eligible general practices in Hackney and Bristol. Of these, 24 received a training and support programme, 24 did not receive the programme, and three dropped out before the trial started. 1 year after the second training session, the 24 intervention practices recorded 223 referrals of patients to advocacy and the 24 control practices recorded 12 referrals (adjusted intervention rate ratio 22·1 [95% CI 11·5-42·4]). Intervention practices recorded 641 disclosures of domestic violence and control practices recorded 236 (adjusted intervention rate ratio 3·1 [95% CI 2·2-4·3). No adverse events were recorded.

INTERPRETATION

A training and support programme targeted at primary care clinicians and administrative staff improved referral to specialist domestic violence agencies and recorded identification of women experiencing domestic violence. Our findings reduce the uncertainty about the benefit of training and support interventions in primary care settings for domestic violence and show that screening of women patients for domestic violence is not a necessary condition for improved identification and referral to advocacy services.

FUNDING

Health Foundation.

Emergency respiratory admissions: influence of practice, population and hospital factors

OBJECTIVE

To determine the influence of population, hospital and general practice characteristics on practice admission rates for asthma and chronic obstructive pulmonary disease (COPD) in England.

METHODS

Cross sectional study using Hospital Episode Statistics (HES), routine population data and primary care data. Admissions for all general practices in England during 2005-06, adjusted for age and sex composition of practice population. Univariable analysis of population, practice and hospital care provision variables, including prevalence and quality data. Significant factors included in multiple regression Poisson model.

RESULTS

Admissions from 8169 practices were included. Risk of admission for each condition increased with deprivation, prevalence and smoking. Admission rates were higher in urban than rural practices. Hospital bed availability and distance to the nearest emergency department were also significantly associated with risk of admission. The associations with practice factors including practice size and quality markers varied across conditions.

CONCLUSIONS

Practice population, geographic and hospital supply factors are consistently associated with asthma and COPD admissions. Higher smoking rates among such patients in a practice are associated with higher admission rates. There is little evidence from this study that other modifiable general practice factors are important in influencing admission rates.

The diagnostic performance of scoring systems to identify symptomatic colorectal cancer compared to current referral guidance

OBJECTIVES

To determine the discrimination characteristics of a new algorithm and two existing symptom scoring systems for identification of patients with suspected colorectal cancer.

DESIGN

Derivation of algorithm by a case-control study and assessment of discrimination characteristics using receiver operating characteristics (ROC) curves. Three colorectal cancer scoring systems were investigated. The Bristol-Birmingham (BB) equation, which we derived from a large primary care dataset; the CAPER score, previously derived from a primary care case-control study and a symptom score derived from National Institute of Clinical Excellence (NICE) guidance for urgent referral of symptomatic patients. Their discrimination characteristics were investigated in two datasets: the BB derivation dataset and the CAPER score derivation dataset. The main analyses were ROC curves and the areas under them for all three algorithms in both datasets. Setting Electronic primary care databases. Main outcome measures Diagnosis of colorectal cancer.

RESULTS

In the BB dataset, areas under the curve were: BB equation 0.83 (95% CI 0.82 to 0.84); CAPER 0.79 (95% CI 0.79 to 0.80); the NICE guidelines 0.65 (95% CI 0.64 to 0.66). In the CAPER dataset, areas under the curve were: BB 0.92 (95% CI 0.91 to 0.94); CAPER 0.91 (95% CI 0.89 to 0.93); NICE guidelines 0.75 (95% CI 0.72 to 0.79). In subjects under 50 the discrimination characteristics of NICE referral guidelines were no better than chance.

CONCLUSIONS

Both multivariable symptom scoring systems performed significantly better than NICE referral guidelines.

Antenatal domestic violence, maternal mental health and subsequent child behaviour: a cohort study

OBJECTIVE

To investigate the long-term impact of antenatal domestic violence on maternal psychiatric morbidity and child behaviour.

DESIGN

Cohort study.

SETTING

Avon, UK.

POPULATION OR SAMPLE

A birth cohort of 13,617 children and mother dyads were followed to 42 months of age.

METHODS

Experiences of domestic violence and depressive symptoms were gathered at 18 weeks of gestation and up to 33 months after birth, together with maternal, paternal and child characteristics.

MAIN OUTCOME MEASURES

Child behavioural problems were assessed at 42 months using the Revised Rutter Questionnaire.

ANALYSIS

Logistic regression with the use of multiple imputation employing chained equations for missing data.

RESULTS

Antenatal domestic violence was associated with high levels of maternal antenatal (odds ratio [OR], 4.02; 95% confidence interval [CI], 3.4-4.8) and postnatal (OR, 1.29; 95% CI, 1.02-1.63) depressive symptoms after adjustment for potential confounders. Antenatal domestic violence predicted future behavioural problems at 42 months in the child before adjustment for possible confounding and mediating factors (OR, 1.87; 95% CI, 1.45-2.40); this association was not significant after adjustment for high levels of maternal antenatal depressive symptoms, postnatal depressive symptoms or domestic violence since birth.

CONCLUSIONS

Antenatal domestic violence is associated with high levels of both maternal antenatal and postnatal depressive symptoms. It is also associated with postnatal violence, and both are associated with future behavioural problems in the child at 42 months. This is partly mediated by maternal depressive symptoms in the ante- or postnatal period.

Neighbourhood deprivation and physical activity in UK older adults

The benefits of regular physical activity for older adults are now well-established but this group remain the least active sector of the population. In this paper, the association between levels of neighbourhood deprivation and physical activity was assessed. A sample of 125 males with a mean age of 77.5 (±5.6) years, and 115 females with a mean age of age 78.6 (±8.6) underwent 7-day accelerometry, a physical performance battery, and completed a daily journeys log. Univariate associations between physical activity parameters and level of deprivation of neighbourhood were extinguished in regression models controlling for age, gender, and level of educational attainment. Age, gender, educational attainment, body mass index, physical function, and frequency of journeys from the home explained between 50% and 54% of variance in activity parameters. These results suggest the importance of strategies to help older adults maintain physical function, healthy weight, and remain active in their communities.

Developing quality indicators for community services: the case of district nursing

BACKGROUND

Quality indicators exist for the acute and primary care sectors in the National Health Service (NHS), but until recently little attention has been given to measuring the quality of community services. The innovative project described in this paper attempted to address that gap.

OBJECTIVES

To produce a framework for developing quality indicators for Bristol Community Health services. To develop a set of initial indicators for Bristol Community Health services using the proposed framework.

METHOD

After familiarising ourselves with community services and NHS policy, gathering the views of stakeholders and consulting the literature on quality indicators, we designed a framework for indicator development, using the 'test' case of the district nursing service. The long list of possible indicators came from best practice guidelines for wound, diabetes and end of life care, the three conditions most commonly treated by district nurses. To narrow down this list we surveyed and held workshops with district nurses, interviewed service users by telephone and met with commissioners and senior community health managers.

RESULTS

The final set of quality indicators for district nurses included 23 organisational and clinical process and outcome indicators and eight patient experience indicators. These indicators are now being piloted, together with two potential tools identified to capture patient reported outcomes.

CONCLUSION

Developing quality indicators for community services is time consuming and resource intensive. A range of skills are needed including clinical expertise, project management and skills in evidence-based medicine. The commitment and involvement of front-line professionals is crucial.