Patient stratification for determining optimal second-line and third-line therapy for type 2 diabetes: the TriMaster study

Precision medicine aims to treat an individual based on their clinical characteristics. A differential drug response, critical to using these features for therapy selection, has never been examined directly in type 2 diabetes. In this study, we tested two hypotheses: (1) individuals with body mass index (BMI) > 30 kg/m², compared to BMI ≤ 30 kg/m², have greater glucose lowering with thiazolidinediones than with DPP4 inhibitors, and (2) individuals with estimated glomerular filtration rate (eGFR) 60-90 ml/min/1.73 m², compared to eGFR >90 ml/min/1.73 m², have greater glucose lowering with DPP4 inhibitors than with SGLT2 inhibitors. The primary endpoint for both hypotheses was the achieved HbA1c difference between strata for the two drugs. In total, 525 people with type 2 diabetes participated in this UK-based randomized, double-blind, three-way crossover trial of 16 weeks of treatment with each of sitagliptin 100 mg once daily, canagliflozin 100 mg once daily and pioglitazone 30 mg once daily added to metformin alone or metformin plus sulfonylurea. Overall, the achieved HbA1c was similar for the three drugs: pioglitazone 59.6 mmol/mol, sitagliptin 60.0 mmol/mol and canagliflozin 60.6 mmol/mol (P = 0.2). Participants with BMI > 30 kg/m², compared to BMI ≤ 30 kg/m², had a 2.88 mmol/mol (95% confidence interval (CI): 0.98, 4.79) lower HbA1c on pioglitazone than on sitagliptin (n = 356, P = 0.003). Participants with eGFR 60-90 ml/min/1.73 m², compared to eGFR >90 ml/min/1.73 m², had a 2.90 mmol/mol (95% CI: 1.19, 4.61) lower HbA1c on sitagliptin than on canagliflozin (n = 342, P = 0.001). There were 2,201 adverse events reported, and 447/525 (85%) randomized participants experienced an adverse event on at least one of the study drugs. In this precision medicine trial in type 2 diabetes, our findings support the use of simple, routinely available clinical measures to identify the drug class most likely to deliver the greatest glycemic reduction for a given patient. (ClinicalTrials.gov registration: NCT02653209 ; ISRCTN registration: 12039221 .).

A randomised controlled trial to investigate the clinical effectiveness and cost effectiveness of Mindfulness-Based Cognitive Therapy (MBCT) for depressed non-responders to Increasing Access to Psychological Therapies (IAPT) high-intensity therapies: study protocol

BACKGROUND

Major depression represents a pressing challenge for health care. In England, Increasing Access to Psychological Therapies (IAPT) services provide evidence-based psychological therapies in a stepped-care approach to patients with depression. While introduction of these services has successfully increased access to therapy, estimates suggest that about 50% of depressed patients who have come to the end of the IAPT pathway still show significant levels of symptoms. This study will investigate whether Mindfulness-Based Cognitive Therapy (MBCT), a group intervention combining training in mindfulness meditation and elements from cognitive therapy, can have beneficial effects in depressed patients who have not responded to high-intensity therapy in IAPT. It will seek to establish the effectiveness and cost-effectiveness of MBCT as compared to the treatment these patients would usually receive.

METHODS

In a 2-arm randomised controlled trial, patients who currently meet the criteria for major depressive disorder and who have not sufficiently responded to at least 12 sessions of IAPT high-intensity therapy will be allocated, at a ratio of 1:1, to receive either MBCT (in addition to treatment as usual [TAU]) or continue with TAU only. Assessments will take place at baseline, 10 weeks and 34 weeks post-randomisation. The primary outcome will be reduction in depression symptomatology 34 weeks post-randomisation as assessed using the Public Health Questionnaire-9 (PHQ-9). Secondary outcomes will include depressive symptomatology at 10 weeks post-randomisation and other clinical outcomes measured at 10-week and 34-week follow-up, along with a series of binarised outcomes to indicate clinically significant and reliable change. Evaluations of cost-effectiveness will be based on assessments of service use costs collected using the Adult Service Use Schedule and health utilities derived from the EQ-5D.

DISCUSSION

This trial will add to the evidence base for the use of MBCT in depressed treatment non-responders. It will constitute the first trial to test MBCT following non-response to psychological therapy, with results providing a direct estimate of efficacy within the IAPT pathway. As such, its results will offer an important basis for decisions regarding the adoption of MBCT for non-responders within IAPT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05236959. Registered on 11 February 2022. ISRCTN 17755571. Registered on 2 February 2021.

How well do Cognitive Behavioural Therapy and Behavioural Activation for depression repair anhedonia? A secondary analysis of the COBRA randomized controlled trial

A secondary analysis of the COBRA randomized controlled trial was conducted to examine how well Cognitive Behavioural Therapy (CBT) and Behavioural Activation (BA) repair anhedonia. Patients with current major depressive disorder (N = 440) were randomized to receive BA or CBT, and anhedonia and depression outcomes were measured after acute treatment (six months) and at two further follow up intervals (12 and 18 months). Anhedonia was assessed using the Snaith Hamilton Pleasure Scale (SHAPS; a measure of consummatory pleasure). Both CBT and BA led to significant improvements in anhedonia during acute treatment, with no significant difference between treatments. Participants remained above healthy population averages of anhedonia at six months, and there was no further significant improvement in anhedonia at 12-month or 18-month follow up. Greater baseline anhedonia severity predicted reduced repair of depression symptoms and fewer depression-free days across the follow-up period in both the BA and CBT arms. The extent of anhedonia repair was less marked than the extent of depression repair across both treatment arms. These findings demonstrate that CBT and BA are similarly and only partially effective in treating anhedonia. Therefore, both therapies should be further refined or novel treatments should be developed in order better to treat anhedonia.

Time trends in autism diagnosis over 20 years: a UK population-based cohort study

BACKGROUND

Autism spectrum disorder is a diagnosis that is increasingly applied; however, previous studies have conflicting findings whether rates of diagnosis rates continue to grow in the UK. This study tested whether the proportion of people receiving a new autism diagnosis has been increasing over a twenty-year period, both overall and by subgroups.

METHOD

Population-based study utilizing the Clinical Practice Research Datalink (CPRD) primary care database, which contains patients registered with practices contributing data to the CPRD between 1998 and 2018 (N = 6,786,212 in 1998 to N = 9,594,598 in 2018). 65,665 patients had a diagnosis of autism recorded in 2018. Time trend of new (incident) cases of autism diagnosis was plotted for all, and stratified by gender, diagnostic subtypes, and developmental stage: infancy and preschool, 0-5 years old; childhood, 6-11 years old; adolescence, 12-19 years old; adults, over 19 years old.

RESULTS

There was a 787%, exponential increase in recorded incidence of autism diagnoses between 1998 and 2018; R²  = 0.98, exponentiated coefficient = 1.07, 95% CI [1.06, 1.08], p < .001. The increase in diagnoses was greater for females than males (exponentiated interaction coefficient = 1.02, 95% CI [1.01, 1.03], p < .001) and moderated by age band, with the greatest rises in diagnostic incidence among adults (exponentiated interaction coefficient = 1.06, 95% CI [1.04, 1.07], p < .001).

CONCLUSIONS

Increases could be due to growth in prevalence or, more likely, increased reporting and application of diagnosis. Rising diagnosis among adults, females and higher functioning individuals suggest augmented recognition underpins these changes.

An Observational Cohort Study on the Incidence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection and B.1.1.7 Variant Infection in Healthcare Workers by Antibody and Vaccination Status

BACKGROUND

Natural and vaccine-induced immunity will play a key role in controlling the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. SARS-CoV-2 variants have the potential to evade natural and vaccine-induced immunity.

METHODS

In a longitudinal cohort study of healthcare workers (HCWs) in Oxfordshire, United Kingdom, we investigated the protection from symptomatic and asymptomatic polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection conferred by vaccination (Pfizer-BioNTech BNT162b2, Oxford-AstraZeneca ChAdOx1 nCOV-19) and prior infection (determined using anti-spike antibody status), using Poisson regression adjusted for age, sex, temporal changes in incidence and role. We estimated protection conferred after 1 versus 2 vaccinations and from infections with the B.1.1.7 variant identified using whole genome sequencing.

RESULTS

In total, 13 109 HCWs participated; 8285 received the Pfizer-BioNTech vaccine (1407 two doses), and 2738 the Oxford-AstraZeneca vaccine (49 two doses). Compared to unvaccinated seronegative HCWs, natural immunity and 2 vaccination doses provided similar protection against symptomatic infection: no HCW vaccinated twice had symptomatic infection, and incidence was 98% lower in seropositive HCWs (adjusted incidence rate ratio 0.02 [95% confidence interval {CI} < .01-.18]). Two vaccine doses or seropositivity reduced the incidence of any PCR-positive result with or without symptoms by 90% (0.10 [95% CI .02-.38]) and 85% (0.15 [95% CI .08-.26]), respectively. Single-dose vaccination reduced the incidence of symptomatic infection by 67% (0.33 [95% CI .21-.52]) and any PCR-positive result by 64% (0.36 [95% CI .26-.50]). There was no evidence of differences in immunity induced by natural infection and vaccination for infections with S-gene target failure and B.1.1.7.

CONCLUSIONS

Natural infection resulting in detectable anti-spike antibodies and 2 vaccine doses both provide robust protection against SARS-CoV-2 infection, including against the B.1.1.7 variant.

Economic evaluation of a complex intervention (Engager) for prisoners with common mental health problems, near to and after release: a cost-utility and cost-consequences analysis

BACKGROUND

People in prison experience a range of physical and mental health problems. Evaluating the effectiveness and efficiency of prison-based interventions presents a number of methodological challenges. We present a case study of an economic evaluation of a prison-based intervention ("Engager") to address common mental health problems.

METHODS

Two hundred and eighty people were recruited from prisons in England and randomised to Engager plus usual care or usual care. Participants were followed up for 12 months following release from prison. The primary analysis is the cost per quality-adjusted life year (QALY) gained of Engager compared to usual care from a National Health Service (NHS) perspective with QALYs calculated using the CORE 6 Dimension. A cost-consequences analysis evaluated cross-sectoral costs and a range of outcomes.

RESULTS

From an NHS perspective, Engager cost an additional £2737 per participant (95% of iterations between £1029 and £4718) with a mean QALY difference of - 0.014 (95% of iterations between - 0.045 and 0.017). For the cost-consequences, there was evidence of improved access to substance misuse services 12 months post-release (odds ratio 2.244, 95% confidence Interval 1.304-3.861).

CONCLUSION

Engager provides a rare example of a cost-utility analysis conducted in prisons and the community using patient-completed measures. Although the results from this trial show no evidence that Engager is cost-effective, the results of the cost-consequences analysis suggest that follow-up beyond 12 months post-release using routine data may provide additional insights into the effectiveness of the intervention and the importance of including a wide range of costs and outcomes in prison-based economic evaluations.

TRIAL REGISTRATION

(ISRCTN11707331).

Adjunctive Ketamine With Relapse Prevention-Based Psychological Therapy in the Treatment of Alcohol Use Disorder

OBJECTIVE

Early evidence suggests that ketamine may be an effective treatment to sustain abstinence from alcohol. The authors investigated the safety and efficacy of ketamine compared with placebo in increasing abstinence in patients with alcohol use disorder. An additional aim was to pilot ketamine combined with mindfulness-based relapse prevention therapy compared with ketamine and alcohol education as a therapy control.

METHODS

In a double-blind placebo-controlled phase 2 clinical trial, 96 patients with severe alcohol use disorder were randomly assigned to one of four conditions: 1) three weekly ketamine infusions (0.8 mg/kg i.v. over 40 minutes) plus psychological therapy, 2) three saline infusions plus psychological therapy, 3) three ketamine infusions plus alcohol education, or 4) three saline infusions plus alcohol education. The primary outcomes were self-reported percentage of days abstinent and confirmed alcohol relapse at 6-month follow-up.

RESULTS

Ninety-six participants (35 women; mean age, 44.07 years [SD=10.59]) were included in the intention-to-treat analysis. The treatment was well tolerated, and no serious adverse events were associated with the study drug. Although confidence intervals were wide, consistent with a proof-of-concept study, there were a significantly greater number of days abstinent from alcohol in the ketamine group compared with the placebo group at 6-month follow-up (mean difference=10.1%, 95% CI=1.1, 19.0), with the greatest reduction in the ketamine plus therapy group compared with the saline plus education group (15.9%, 95% CI=3.8, 28.1). There was no significant difference in relapse rate between the ketamine and placebo groups.

CONCLUSIONS

This study demonstrated that treatment with three infusions of ketamine was well tolerated in patients with alcohol use disorder and was associated with more days of abstinence from alcohol at 6-month follow-up. The findings suggest a possible beneficial effect of adding psychological therapy alongside ketamine treatment.

Time of Day of Vaccination Affects SARS-CoV-2 Antibody Responses in an Observational Study of Health Care Workers

The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a global crisis with unprecedented challenges for public health. Vaccinations against SARS-CoV-2 have slowed the incidence of new infections and reduced disease severity. As the time of day of vaccination has been reported to influence host immune responses to multiple pathogens, we quantified the influence of SARS-CoV-2 vaccination time, vaccine type, participant age, sex, and days post-vaccination on anti-Spike antibody responses in health care workers. The magnitude of the anti-Spike antibody response is associated with the time of day of vaccination, vaccine type, participant age, sex, and days post-vaccination. These results may be relevant for optimising SARS-CoV-2 vaccine efficacy.

'Rich' and 'poor' in mentalizing: Do expert mentalizers exist?

Mentalization theory is concerned with the capacity to notice, and make sense of, thoughts and feelings in self and others. This development may be healthy or impaired and therefore, by extension, it may be theorized that expertise in mentalizing can exist. Furthermore, a continuum from impairment to expertise should exist within separate dimensions of mentalizing: of self and of others. This study hypothesized that three groups would be distinguishable on the basis of their mentalizing capacities. In a cross-sectional design, Psychological Therapists (‘expert’ mentalizers; n = 51), individuals with a diagnosis of Borderline Personality Disorder (‘poor’ mentalizers; n = 43) and members of the general population (‘non-clinical controls’; n = 35) completed a battery of self-report measures. These assessed the mentalizing of self and of others (using an extended version of the Reflective Function Questionnaire (RFQ18)), alexithymia and cognitive empathy. As hypothesized, Psychological Therapists’ scores were higher than controls on self-mentalizing and control group scores were higher than those with BPD. Cognitive empathy scores in the BPD group indicated markedly lower capacities than the other two groups. Contrary to predictions, no significant differences were found between groups on mentalizing others in RFQ18 scores. The Psychological Therapist and BPD profiles were characterized by differential impairment with regards to mentalizing self and others but in opposing directions. Results suggest that the RFQ18 can identify groups with expertise in mentalizing. Implications of these results for the effectiveness of psychological therapy and of Psychological Therapists are discussed.

Epidemiological data and genome sequencing reveals that nosocomial transmission of SARS-CoV-2 is underestimated and mostly mediated by a small number of highly infectious individuals

OBJECTIVES

Despite robust efforts, patients and staff acquire SARS-CoV-2 infection in hospitals. We investigated whether whole-genome sequencing enhanced the epidemiological investigation of healthcare-associated SARS-CoV-2 acquisition.

METHODS

From 17-November-2020 to 5-January-2021, 803 inpatients and 329 staff were diagnosed with SARS-CoV-2 infection at four Oxfordshire hospitals. We classified cases using epidemiological definitions, looked for a potential source for each nosocomial infection, and evaluated genomic evidence supporting transmission.

RESULTS

Using national epidemiological definitions, 109/803(14%) inpatient infections were classified as definite/probable nosocomial, 615(77%) as community-acquired and 79(10%) as indeterminate. There was strong epidemiological evidence to support definite/probable cases as nosocomial. Many indeterminate cases were likely infected in hospital: 53/79(67%) had a prior-negative PCR and 75(95%) contact with a potential source. 89/615(11% of all 803 patients) with apparent community-onset had a recent hospital exposure. Within 764 samples sequenced 607 genomic clusters were identified (>1 SNP distinct). Only 43/607(7%) clusters contained evidence of onward transmission (subsequent cases within ≤ 1 SNP). 20/21 epidemiologically-identified outbreaks contained multiple genomic introductions. Most (80%) nosocomial acquisition occurred in rapid super-spreading events in settings with a mix of COVID-19 and non-COVID-19 patients.

CONCLUSIONS

Current surveillance definitions underestimate nosocomial acquisition. Most nosocomial transmission occurs from a relatively limited number of highly infectious individuals.

Antibody Status and Incidence of SARS-CoV-2 Infection in Health Care Workers

BACKGROUND

The relationship between the presence of antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the risk of subsequent reinfection remains unclear.

METHODS

We investigated the incidence of SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR) in seropositive and seronegative health care workers attending testing of asymptomatic and symptomatic staff at Oxford University Hospitals in the United Kingdom. Baseline antibody status was determined by anti-spike (primary analysis) and anti-nucleocapsid IgG assays, and staff members were followed for up to 31 weeks. We estimated the relative incidence of PCR-positive test results and new symptomatic infection according to antibody status, adjusting for age, participant-reported gender, and changes in incidence over time.

RESULTS

A total of 12,541 health care workers participated and had anti-spike IgG measured; 11,364 were followed up after negative antibody results and 1265 after positive results, including 88 in whom seroconversion occurred during follow-up. A total of 223 anti-spike-seronegative health care workers had a positive PCR test (1.09 per 10,000 days at risk), 100 during screening while they were asymptomatic and 123 while symptomatic, whereas 2 anti-spike-seropositive health care workers had a positive PCR test (0.13 per 10,000 days at risk), and both workers were asymptomatic when tested (adjusted incidence rate ratio, 0.11; 95% confidence interval, 0.03 to 0.44; P = 0.002). There were no symptomatic infections in workers with anti-spike antibodies. Rate ratios were similar when the anti-nucleocapsid IgG assay was used alone or in combination with the anti-spike IgG assay to determine baseline status.

CONCLUSIONS

The presence of anti-spike or anti-nucleocapsid IgG antibodies was associated with a substantially reduced risk of SARS-CoV-2 reinfection in the ensuing 6 months. (Funded by the U.K. Government Department of Health and Social Care and others.).

Randomised feasibility trial and embedded qualitative process evaluation of a new intervention to facilitate the involvement of older patients with multimorbidity in decision-making about their healthcare during general practice consultations: the VOLITION study protocol

BACKGROUND

The number of older people with multiple health problems is increasing worldwide. This creates a strain on clinicians and the health service when delivering clinical care to this patient group, who themselves carry a large treatment burden. Despite shared decision-making being acknowledged by healthcare organisations as a priority feature of clinical care, older patients with multimorbidity are less often involved in decision-making when compared with younger patients, with some evidence suggesting associated health inequalities. Interventions aimed at facilitating shared decision-making between doctors and patients are outdated in their assessments of today's older patient population who need support in prioritising complex care needs in order to maximise quality of life and day-to-day function.

AIMS

To undertake feasibility testing of an intervention ('VOLITION') aimed at facilitating the involvement of older patients with more than one long-term health problem in shared decision-making about their healthcare during GP consultations.To inform the design of a fully powered trial to assess intervention effectiveness.

METHODS

This study is a cluster randomised controlled feasibility trial with qualitative process evaluation interviews. Participants are patients, aged 65 years and above with more than one long-term health problem (multimorbidity), and the GPs that they consult with. This study aims to recruit 6 GP practices, 18 GPs and 180 patients. The intervention comprises two components: (i) a half-day training workshop for GPs in shared decision-making; and (ii) a leaflet for patients that facilitate their engagement with shared decision-making. Intervention implementation will take 2 weeks (to complete delivery of both patient and GP components), and follow-up duration will be 12 weeks (from index consultation and commencement of data collection to final case note review and process evaluation interview). The trial will run from 01/01/20 to 31/01/21; 1 year 31 days.

DISCUSSION

Shared decision-making for older people with multimorbidity in general practice is under-researched. Emerging clinical guidelines advise a patient-centred approach, to reduce treatment burden and focus on quality of life alongside disease control. The systematic development, testing and evaluation of an intervention is warranted and timely. This study will test the feasibility of implementing a new intervention in UK general practice for future evaluation as a part of routine care.

TRIAL REGISTRATION

CLINICAL TRIALS.GOV registration number NCT03786315, registered 24/12/18.

Exercise-based cardiac rehabilitation for chronic heart failure: the EXTRAMATCH II individual participant data meta-analysis

BACKGROUND

Current national and international guidelines on the management of heart failure (HF) recommend exercise-based cardiac rehabilitation (ExCR), but do not differentiate this recommendation according to patient subgroups.

OBJECTIVES

(1) To obtain definitive estimates of the impact of ExCR interventions compared with no exercise intervention (control) on mortality, hospitalisation, exercise capacity and health-related quality of life (HRQoL) in HF patients; (2) to determine the differential (subgroup) effects of ExCR in HF patients according to their age, sex, left ventricular ejection fraction, HF aetiology, New York Heart Association class and baseline exercise capacity; and (3) to assess whether or not the change in exercise capacity mediates for the impact of the ExCR on final outcomes (mortality, hospitalisation and HRQoL), and determine if this is an acceptable surrogate end point.

DESIGN

This was an individual participant data (IPD) meta-analysis.

SETTING

An international literature review.

PARTICIPANTS

HF patients in randomised controlled trials (RCTs) of ExCR.

INTERVENTIONS

ExCR for at least 3 weeks compared with a no-exercise control, with 6 months' follow-up.

MAIN OUTCOME MEASURES

All-cause and HF-specific mortality, all-cause and HF-specific hospitalisation, exercise capacity and HRQoL.

DATA SOURCES

IPD from eligible RCTs.

REVIEW METHODS

RCTs from the Exercise Training Meta-Analysis of Trials for Chronic Heart Failure (ExTraMATCH/ExTraMATCH II) IPD meta-analysis and a 2014 Cochrane systematic review of ExCR (Taylor RS, Sagar VA, Davies EJ, Briscoe S, Coats AJ, Dalal H, et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev 2014;4:CD003331).

RESULTS

Out of the 23 eligible RCTs (4398 patients), 19 RCTs (3990 patients) contributed data to this IPD meta-analysis. There was a wide variation in exercise programme prescriptions across included studies. Compared with control, there was no statistically significant difference in pooled time-to-event estimates in favour of ExCR, although confidence intervals (CIs) were wide: all-cause mortality had a hazard ratio (HR) of 0.83 (95% CI 0.67 to 1.04); HF-related mortality had a HR of 0.84 (95% CI 0.49 to 1.46); all-cause hospitalisation had a HR of 0.90 (95% CI 0.76 to 1.06); and HF-related hospitalisation had a HR of 0.98 (95% CI 0.72 to 1.35). There was a statistically significant difference in favour of ExCR for exercise capacity and HRQoL. Compared with the control, improvements were seen in the 6-minute walk test (6MWT) (mean 21.0 m, 95% CI 1.57 to 40.4 m) and Minnesota Living with Heart Failure Questionnaire score (mean -5.94, 95% CI -1.0 to -10.9; lower scores indicate improved HRQoL) at 12 months' follow-up. No strong evidence for differential intervention effects across patient characteristics was found for any outcomes. Moderate to good levels of correlation (R ² _trial > 50% and p > 0.50) between peak oxygen uptake (VO₂peak) or the 6MWT with mortality and HRQoL were seen. The estimated surrogate threshold effect was an increase of 1.6 to 4.6 ml/kg/minute for VO₂peak.

LIMITATIONS

There was a lack of consistency in how included RCTs defined and collected the outcomes: it was not possible to obtain IPD from all includable trials for all outcomes and patient-level data on exercise adherence was not sought.

CONCLUSIONS

In comparison with the no-exercise control, participation in ExCR improved the exercise and HRQoL in HF patients, but appeared to have no effect on their mortality or hospitalisation. No strong evidence was found of differential intervention effects of ExCR across patient characteristics. VO₂peak and 6MWT may be suitable surrogate end points for the treatment effect of ExCR on mortality and HRQoL in HF. Future studies should aim to achieve a consensus on the definition of outcomes and promote reporting of a core set of HF data. The research team also seeks to extend current policies to encourage study authors to allow access to RCT data for the purpose of meta-analysis.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014007170.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Differential occupational risks to healthcare workers from SARS-CoV-2 observed during a prospective observational study

We conducted voluntary Covid-19 testing programmes for symptomatic and asymptomatic staff at a UK teaching hospital using naso-/oro-pharyngeal PCR testing and immunoassays for IgG antibodies. 1128/10,034 (11.2%) staff had evidence of Covid-19 at some time. Using questionnaire data provided on potential risk-factors, staff with a confirmed household contact were at greatest risk (adjusted odds ratio [aOR] 4.82 [95%CI 3.45-6.72]). Higher rates of Covid-19 were seen in staff working in Covid-19-facing areas (22.6% vs. 8.6% elsewhere) (aOR 2.47 [1.99-3.08]). Controlling for Covid-19-facing status, risks were heterogenous across the hospital, with higher rates in acute medicine (1.52 [1.07-2.16]) and sporadic outbreaks in areas with few or no Covid-19 patients. Covid-19 intensive care unit staff were relatively protected (0.44 [0.28-0.69]), likely by a bundle of PPE-related measures. Positive results were more likely in Black (1.66 [1.25-2.21]) and Asian (1.51 [1.28-1.77]) staff, independent of role or working location, and in porters and cleaners (2.06 [1.34-3.15]).

Workforce predictive risk modelling: development of a model to identify general practices at risk of a supply-demand imbalance

OBJECTIVE

This study aimed to develop a risk prediction model identifying general practices at risk of workforce supply-demand imbalance.

DESIGN

This is a secondary analysis of routine data on general practice workforce, patient experience and registered populations (2012 to 2016), combined with a census of general practitioners' (GPs') career intentions (2016).

SETTING/PARTICIPANTS

A hybrid approach was used to develop a model to predict workforce supply-demand imbalance based on practice factors using historical data (2012-2016) on all general practices in England (with over 1000 registered patients n=6398). The model was applied to current data (2016) to explore future risk for practices in South West England (n=368).

PRIMARY OUTCOME MEASURE

The primary outcome was a practice being in a state of workforce supply-demand imbalance operationally defined as being in the lowest third nationally of access scores according to the General Practice Patient Survey and the highest third nationally according to list size per full-time equivalent GP (weighted to the demographic distribution of registered patients and adjusted for deprivation).

RESULTS

Based on historical data, the predictive model had fair to good discriminatory ability to predict which practices faced supply-demand imbalance (area under receiver operating characteristic curve=0.755). Predictions using current data suggested that, on average, practices at highest risk of future supply-demand imbalance are currently characterised by having larger patient lists, employing more nurses, serving more deprived and younger populations, and having considerably worse patient experience ratings when compared with other practices. Incorporating findings from a survey of GP's career intentions made little difference to predictions of future supply-demand risk status when compared with expected future workforce projections based only on routinely available data on GPs' gender and age.

CONCLUSIONS

It is possible to make reasonable predictions of an individual general practice's future risk of undersupply of GP workforce with respect to its patient population. However, the predictions are inherently limited by the data available.

Cost and Outcome of BehaviouRal Activation (COBRA): a randomised controlled trial of behavioural activation versus cognitive-behavioural therapy for depression

BACKGROUND

Depression is a common, debilitating and costly disorder. The best-evidenced psychological therapy - cognitive-behavioural therapy (CBT) - is complex and costly. A simpler therapy, behavioural activation (BA), may be an effective alternative.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of BA compared with CBT for depressed adults at 12 and 18 months' follow-up, and to investigate the processes of treatments.

DESIGN

Randomised controlled, non-inferiority trial stratified by depression severity, antidepressant use and recruitment site, with embedded process evaluation; and randomisation by remote computer-generated allocation.

SETTING

Three community mental health services in England.

PARTICIPANTS

Adults aged ≥ 18 years with major depressive disorder (MDD) recruited from primary care and psychological therapy services.

INTERVENTIONS

BA delivered by NHS junior mental health workers (MHWs); CBT by NHS psychological therapists.

OUTCOMES

Primary: depression severity (as measured via the Patient Health Questionnaire-9; PHQ-9) at 12 months. Secondary: MDD status; number of depression-free days; anxiety (as measured via the Generalised Anxiety Disorder-7); health-related quality of life (as measured via the Short Form questionnaire-36 items) at 6, 12 and 18 months; and PHQ-9 at 6 and 18 months, all collected by assessors blinded to treatment allocation. Non-inferiority margin was 1.9 PHQ-9 points. We undertook intention-to-treat (ITT) and per protocol (PP) analyses. We explored cost-effectiveness by collecting direct treatment and other health- and social-care costs and calculating quality-adjusted life-years (QALYs) using the EuroQol-5 Dimensions, three-level version, at 18 months.

RESULTS

We recruited 440 participants (BA, n = 221; CBT, n = 219); 175 (79%) BA and 189 (86%) CBT participants provided ITT data and 135 (61%) BA and 151 (69%) CBT participants provided PP data. At 12 months we found that BA was non-inferior to CBT {ITT: CBT 8.4 PHQ-9 points [standard deviation (SD) 7.5 PHQ-9 points], BA 8.4 PHQ-9 points (SD 7.0 PHQ-9 points), mean difference 0.1 PHQ-9 points, 95% confidence interval (CI) -1.3 to 1.5 PHQ-9 points, p = 0.89; PP: CBT 7.9 PHQ-9 points (SD 7.3 PHQ-9 points), BA 7.8 PHQ-9 points (SD 6.5 PHQ-9 points), mean difference 0.0 PHQ-9 points, 95% CI -1.5 to 1.6 PHQ-9 points, p = 0.99}. We found no differences in secondary outcomes. We found a significant difference in mean intervention costs (BA, £975; CBT, £1235; p < 0.001), but no differences in non-intervention (hospital, community health, social care and medication costs) or total (non-intervention plus intervention) costs. Costs were lower and QALY outcomes better in the BA group, generating an incremental cost-effectiveness ratio of -£6865. The probability of BA being cost-effective compared with CBT was almost 80% at the National Institute for Health and Care Excellence's preferred willingness-to-pay threshold of £20,000-30,000 per QALY. There were no trial-related adverse events.

LIMITATIONS

In this pragmatic trial many depressed participants in both groups were also taking antidepressant medication, although most had been doing so for a considerable time before entering the trial. Around one-third of participants chose not to complete a PP dose of treatment, a finding common in both psychotherapy trials and routine practice.

CONCLUSIONS

We found that BA is as effective as CBT, more cost-effective and can be delivered by MHWs with no professional training in psychological therapies.

FUTURE WORK

Settings and countries with a paucity of professionally qualified psychological therapists, might choose to investigate the delivery of effective psychological therapy for depression without the need to develop an extensive and costly professional infrastructure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN27473954.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 46. See the NIHR Journals Library website for further project information.

Assessing the effectiveness of Enhanced Psychological Care for patients with depressive symptoms attending cardiac rehabilitation compared with treatment as usual (CADENCE): a pilot cluster randomised controlled trial

BACKGROUND

Around 17% of people attending UK cardiac rehabilitation programmes have depression. Optimising psychological wellbeing is a rehabilitation goal, but provision of psychological care is limited. We developed and piloted an Enhanced Psychological Care (EPC) intervention embedded within cardiac rehabilitation, aiming to test key areas of uncertainty to inform the design of a definitive randomised controlled trial (RCT) and economic evaluation.

METHODS

An external pilot randomised controlled trial (RCT) randomised eight cardiac rehabilitation teams (clusters) to either usual care of cardiac rehabilitation provision (UC), or EPC in addition to UC. EPC comprised mental health care coordination and patient-led behavioural activation with nurse support. Adults eligible for cardiac rehabilitation following an acute coronary syndrome and identified with new-onset depressive symptoms during an initial nurse assessment were eligible. Measures were performed at baseline and 5- and 8-month follow-ups and compared between EPC and UC. Team and participant recruitment and retention rates, and participant outcomes (clinical events, depression, anxiety, health-related quality of life, patient experiences, and resource use) were assessed.

RESULTS

Eight out of twenty teams were recruited and randomised. Of 614 patients screened, 55 were eligible and 29 took part (5%, 95% CI 3 to 7% of those screened), with 15 patient participants cluster randomised to EPC and 14 to UC. Nurse records revealed that 8/15 participants received the maximum number of EPC sessions offered; and 4/15 received no sessions. Seven out of fifteen EPC participants were referred to another NHS psychological service compared to none in UC. We followed up 27/29 participants at 5 months and 17/21 at 8 months. The mean difference (EPC minus UC) in depressive symptoms (Beck Depression Inventory) at follow-up (adjusting for baseline score) was 1.7 (95% CI - 3.8 to 7.3; N = 26) at 5 months and 4.4 (95% CI - 1.4 to 10.2; N = 17) at 8 months.

DISCUSSION

While valued by patients and nurses, organisational and workload constraints are significant barriers to EPC implementation. There remains a need to develop and test new models of psychological care within cardiac rehabilitation. Our study offers important data to inform the design of future trials of similar interventions.

TRIAL REGISTRATION

ISRCTN34701576 . Registered on 29 May 2014. Funding details: UK NIHR HTA Programme (project 12/189/09).

Ethnic diversity and equality of access to specialist therapeutic community treatment for severe personality disorder

Aims and Method

All mental health services are expected to aim for equality of access to people from minority ethnic groups. Psychotherapy services typically have a low proportion of ethnic minority clients. Specialist services such as therapeutic communities are no exception. It is also possible that ethnic minority residents are more likely to leave group treatments early if they are clearly in the minority. The study examined records between 1996–2000 to ascertain whether ethnic minorities show a different pattern of exit from the process than people from other backgrounds.

Results

Just over 9% of referrals to Henderson Hospital were from ethnic minorities. Ethnic minority referrals were less likely to be invited to a selection interview. However, there was no difference in length of stay in treatment. There was a trend towards ethnic minority referrals having more severe symptomatology and histories than those from White backgrounds.

Clinical Implications

Ethnic background should be taken into account when considering referral for specialist psychotherapy. Routine monitoring of the processing of ethnic minority referrals should be conducted in all psychotherapy services.

Improving patient experience in primary care: a multimethod programme of research on the measurement and improvement of patient experience

Background

There has been an increased focus towards improving quality of care within the NHS in the last 15 years; as part of this, there has been an emphasis on the importance of patient feedback within policy, through National Service Frameworks and the Quality and Outcomes Framework. The development and administration of large-scale national patient surveys to gather representative data on patient experience, such as the national GP Patient Survey in primary care, has been one such initiative. However, it remains unclear how the survey is used by patients and what impact the data may have on practice.

Objectives

Our research aimed to gain insight into how different patients use surveys to record experiences of general practice; how primary care staff respond to feedback; and how to engage primary care staff in responding to feedback.

Methods

We used methods including quantitative survey analyses, focus groups, interviews, an exploratory trial and an experimental vignette study.

Results

(1)Understanding patient experience data. Patients readily criticised their care when reviewing consultations on video, although they were reluctant to be critical when completing questionnaires. When trained raters judged communication during a consultation to be poor, a substantial proportion of patients rated the doctor as ‘good’ or ‘very good’. Absolute scores on questionnaire surveys should be treated with caution; they may present an overoptimistic view of general practitioner (GP) care. However, relative rankings to identify GPs who are better or poorer at communicating may be acceptable, as long as statistically reliable figures are obtained. Most patients have a particular GP whom they prefer to see; however, up to 40% of people who have such a preference are unable regularly to see the doctor of their choice. Users of out-of-hours care reported worse experiences when the service was run by a commercial provider than when it was run by a not-for profit or NHS provider. (2)Understanding patient experience in minority ethnic groups. Asian respondents to the GP Patient Survey tend to be registered with practices with generally low scores, explaining about half of the difference in the poorer reported experiences of South Asian patients than white British patients. We found no evidence that South Asian patients used response scales differently. When viewing the same consultation in an experimental vignette study, South Asian respondents gave higher scores than white British respondents. This suggests that the low scores given by South Asian respondents in patient experience surveys reflect care that is genuinely worse than that experienced by their white British counterparts. We also found that service users of mixed or Asian ethnicity reported lower scores than white respondents when rating out-of-hours services. (3)Using patient experience data. We found that measuring GP–patient communication at practice level masks variation between how good individual doctors are within a practice. In general practices and in out-of-hours centres, staff were sceptical about the value of patient surveys and their ability to support service reconfiguration and quality improvement. In both settings, surveys were deemed necessary but not sufficient. Staff expressed a preference for free-text comments, as these provided more tangible, actionable data. An exploratory trial of real-time feedback (RTF) found that only 2.5% of consulting patients left feedback using touch screens in the waiting room, although more did so when reminded by staff. The representativeness of responding patients remains to be evaluated. Staff were broadly positive about using RTF, and practices valued the ability to include their own questions. Staff benefited from having a facilitated session and protected time to discuss patient feedback.

Conclusions

Our findings demonstrate the importance of patient experience feedback as a means of informing NHS care, and confirm that surveys are a valuable resource for monitoring national trends in quality of care. However, surveys may be insufficient in themselves to fully capture patient feedback, and in practice GPs rarely used the results of surveys for quality improvement. The impact of patient surveys appears to be limited and effort should be invested in making the results of surveys more meaningful to practice staff. There were several limitations of this programme of research. Practice recruitment for our in-hours studies took place in two broad geographical areas, which may not be fully representative of practices nationally. Our focus was on patient experience in primary care; secondary care settings may face different challenges in implementing quality improvement initiatives driven by patient feedback. Recommendations for future research include consideration of alternative feedback methods to better support patients to identify poor care; investigation into the factors driving poorer experiences of communication in South Asian patient groups; further investigation of how best to deliver patient feedback to clinicians to engage them and to foster quality improvement; and further research to support the development and implementation of interventions aiming to improve care when deficiencies in patient experience of care are identified.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Development and Validation of a Self-Report Measure of Mentalizing: The Reflective Functioning Questionnaire

Reflective functioning or mentalizing is the capacity to interpret both the self and others in terms of internal mental states such as feelings, wishes, goals, desires, and attitudes. This paper is part of a series of papers outlining the development and psychometric features of a new self-report measure, the Reflective Functioning Questionnaire (RFQ), designed to provide an easy to administer self-report measure of mentalizing. We describe the development and initial validation of the RFQ in three studies. Study 1 focuses on the development of the RFQ, its factor structure and construct validity in a sample of patients with Borderline Personality Disorder (BPD) and Eating Disorder (ED) (n = 108) and normal controls (n = 295). Study 2 aims to replicate these findings in a fresh sample of 129 patients with personality disorder and 281 normal controls. Study 3 addresses the relationship between the RFQ, parental reflective functioning and infant attachment status as assessed with the Strange Situation Procedure (SSP) in a sample of 136 community mothers and their infants. In both Study 1 and 2, confirmatory factor analyses yielded two factors assessing Certainty (RFQ_C) and Uncertainty (RFQ_U) about the mental states of self and others. These two factors were relatively distinct, invariant across clinical and non-clinical samples, had satisfactory internal consistency and test-retest stability, and were largely unrelated to demographic features. The scales discriminated between patients and controls, and were significantly and in theoretically predicted ways correlated with measures of empathy, mindfulness and perspective-taking, and with both self-reported and clinician-reported measures of borderline personality features and other indices of maladaptive personality functioning. Furthermore, the RFQ scales were associated with levels of parental reflective functioning, which in turn predicted infant attachment status in the SSP. Overall, this study lends preliminary support for the RFQ as a screening measure of reflective functioning. Further research is needed, however, to investigate in more detail the psychometric qualities of the RFQ.

Western medical acupuncture in a group setting for knee osteoarthritis: results of a pilot randomised controlled trial

Background

Evidence suggests acupuncture may be effective for treating the symptoms of knee osteoarthritis. Offering this in a group setting may offer cost savings. The aim of this study was to establish the feasibility of a definitive trial to assess the clinical and cost-effectiveness of Western medical acupuncture given in groups, or given individually, for adults with severe knee pain attributable to osteoarthritis.

Methods

A pilot randomised controlled trial (RCT) was conducted. Participants were recruited from seven general practices in Plymouth, Devon. Acupuncture was provided, at a dosage that increased up to and including electroacupuncture if no pain relief was reported, by one experienced acupuncturist in a community clinic. Potentially eligible adults aged at least 45 years with knee osteoarthritis were identified from practice registers, screened and randomised to either: (1) standardised advice and exercise booklet alone (‘standard’); (2) booklet plus group acupuncture (‘group’); and (3) booklet plus individual acupuncture (‘individual’). Both acupuncture arms received up to ten treatments over 12 weeks.

Recruitment, retention and data completion rates were recorded, and participants completed questionnaires on acceptability. We collected pain, stiffness and function data (using the Western Ontario McMaster Universities Osteoarthritis Index; WOMAC) and general health (EQ-5D) and economic measures at baseline and 14 weeks post-randomisation.

Results

We screened 149 people and randomised 60 (40 %), 20 per arm. The overall 14 week follow-up rate was 77 %, but only 70 % in the ‘standard’ group; 4.1 % of data points were missing. The study was acceptable to participants.

Changes in WOMAC pain score (intention to treat complete case analysis) from baseline to 14 week follow-up were: ‘standard’, 0.4 (95 % confidence interval (CI) −1.4, 2.2, n = 14); ‘group’ −3.2 (95 % CI −5.1, −1.4, n = 17); ‘individual’ −2.4 (95 % CI −4.1, −0.7, n = 15).

Conclusions

A definitive three-arm trial is feasible. Further follow-up reminders, minimum data collection and incentives should be considered to improve participant retention in the follow-up processes in the standardised advice and exercise booklet arm.

Trial registration

ISRCTN05305406

Electronic supplementary material

The online version of this article (doi:10.1186/s40814-016-0051-5) contains supplementary material, which is available to authorized users.

Assessing the effectiveness of enhanced psychological care for patients with depressive symptoms attending cardiac rehabilitation compared with treatment as usual (CADENCE): study protocol for a pilot cluster randomised controlled trial

BACKGROUND

Around 17% of people eligible for UK cardiac rehabilitation programmes following an acute coronary syndrome report moderate or severe depressive symptoms. While maximising psychological health is a core goal of cardiac rehabilitation, psychological care can be fragmented and patchy. This study tests the feasibility and acceptability of embedding enhanced psychological care, composed of two management strategies of proven effectiveness in other settings (nurse-led mental health care coordination and behavioural activation), within the cardiac rehabilitation care pathway.

METHODS/DESIGN

This study tests the uncertainties associated with a large-scale evaluation by conducting an external pilot trial with a nested qualitative study. We aim to recruit and randomise eight comprehensive cardiac rehabilitation teams (clusters) to intervention (embedding enhanced psychological care into routine cardiac rehabilitation programmes) or control (routine cardiac rehabilitation programmes alone) arms. Up to 64 patients (eight per team) identified with depressive symptoms upon initial assessment by the cardiac rehabilitation team will be recruited, and study measures will be administered at baseline (before starting rehabilitation) and at 5 months and 8 months post baseline. Outcomes include depressive symptoms, cardiac mortality and morbidity, anxiety, health-related quality of life and service resource use. Trial data on cardiac team and patient recruitment, and the retention and flow of patients through treatment will be used to assess intervention feasibility and acceptability. Qualitative interviews will be undertaken to explore trial participants' and cardiac rehabilitation nurses' views and experiences of the trial methods and intervention, and to identify reasons why patients declined to take part in the trial. Outcome data will inform a sample size calculation for a definitive trial.

DISCUSSION

The pilot trial and qualitative study will inform the design of a fully powered cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of the provision of enhanced psychological care within cardiac rehabilitation programmes.

TRIAL REGISTRATION

ISRCTN34701576 (Registered 29 May 2014).

Development of Measures to Assess Personal Recovery in Young People Treated in Specialist Mental Health Services

BACKGROUND

Recovery has become a central concept in mental health service delivery, and several recovery-focused measures exist for adults. The concept's applicability to young people's mental health experience has been neglected, and no measures yet exist. Aim The aim of this work is to develop measures of recovery for use in specialist child and adolescent mental health services.

METHOD

On the basis of 21 semi-structured interviews, three recovery measures were devised, one for completion by the young person and two for completion by the parent/carer. Two parent/carer measures were devised in order to assess both their perspective on their child's recovery and their own recovery process. The questionnaires were administered to a UK sample of 47 young people (10-18 years old) with anxiety and depression and their parents, along with a measure used to routinely assess treatment progress and outcome and a measure of self-esteem.

RESULTS

All three measures had high internal consistency (alpha ≥ 0.89). Young people's recovery scores were correlated negatively with scores on a measure used to routinely assess treatment progress and outcome (r = -0.75) and positively with self-esteem (r = 0.84). Parent and young persons' reports of the young person's recovery were positively correlated (r = 0.61). Parent report of the young person's recovery and of their own recovery process were positively correlated (r = 0.75).

CONCLUSION

The three measures have the potential to be used in mental health services to assess recovery processes in young people with mental health difficulties and correspondence with symptomatic improvement. The measures provide a novel way of capturing the parental/caregiver perspective on recovery and caregivers' own wellbeing.

KEY PRACTITIONER MESSAGE

No tools exist to evaluate recovery-relevant processes in young people treated in specialist mental health services. This study reports on the development and psychometric evaluation of three self-report recovery-relevant assessments for young people and their caregivers. Findings indicate a high degree of correspondence between young person and caregiver reports of recovery in the former. The recovery assessments correlate inversely with a standardized symptom-focused measure and positively with self-esteem.

A written self-help intervention for depressed adults comparing behavioural activation combined with physical activity promotion with a self-help intervention based upon behavioural activation alone: study protocol for a parallel group pilot randomised controlled trial (BAcPAc)

BACKGROUND

Challenges remain to find ways to support patients with depression who have low levels of physical activity (PA) to overcome perceived barriers and enhance the perceived value of PA for preventing future relapse. There is an evidence-base for behavioural activation (BA) for depression, which focuses on supporting patients to restore activities that have been avoided, but practitioners have no specific training in promoting PA. We aimed to design and evaluate an integrated BA and PA (BAcPAc) practitioner-led, written, self-help intervention to enhance both physical and mental health.

METHODS/DESIGN

This study is informed by the Medical Research Council Complex Intervention Framework and describes a protocol for a pilot phase II randomised controlled trial (RCT) to test the feasibility and acceptability of the trial methods to inform a definitive phase III RCT. Following development of the augmented written self-help intervention (BAcPAc) incorporating behavioural activation with physical activity promotion, depressed adults are randomised to receive up to 12 sessions over a maximum of 4 months of either BAcPAc or behavioural activation alone within a written self-help format, which represents treatment as usual. The study is located within two 'Improving Access to Psychological Therapies' services in South West England, with both written self-help interventions supported by mental health paraprofessionals. Measures assessed at 4, 9, and 12 month follow-up include the following: CIS-R, PHQ-9, accelerometer recorded (4 months only) and self-reported PA, body mass index, blood pressure, Insomnia Severity Index, quality of life, and health and social care service use. Process evaluation will include analysis of recorded support sessions and patient and practitioner interviews. At the time of writing the study has recruited 60 patients.

DISCUSSION

The feasibility outcomes will inform a definitive RCT to assess the clinical and cost-effectiveness of the augmented BAcPAc written self-help intervention to reduce depression and depressive relapse, and bring about improvements across a range of physical health outcomes.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN74390532, 26.03.2013.

Do difficulties in accessing in-hours primary care predict higher use of out-of-hours GP services? Evidence from an English National Patient Survey

Introduction

It is believed that some patients are more likely to use out-of-hours primary care services because of difficulties in accessing in-hours care, but substantial evidence about any such association is missing.

Methods

We analysed data from 567 049 respondents to the 2011/2012 English General Practice Patient Survey who reported at least one in-hours primary care consultation in the preceding 6 months. Of those respondents, 7% also reported using out-of-hours primary care. We used logistic regression to explore associations between use of out-of-hours primary care and five measures of in-hours access (ease of getting through on the telephone, ability to see a preferred general practitioner, ability to get an urgent or routine appointment and convenience of opening hours). We illustrated the potential for reduction in use of out-of-hours primary care in a model where access to in-hours care was made optimal.

Results

Worse in-hours access was associated with greater use of out-of-hours primary care for each access factor. In multivariable analysis adjusting for access and patient characteristic variables, worse access was independently associated with increased out-of-hours use for all measures except ease of telephone access. Assuming these associations were causal, we estimated that an 11% relative reduction in use of out-of-hours primary care services in England could be achievable if access to in-hours care were optimal.

Conclusions

This secondary quantitative analysis provides evidence for an association between difficulty in accessing in-hours care and use of out-of-hours primary care services. The findings can motivate the development of interventions to improve in-hour access.

What is the clinical effectiveness and cost-effectiveness of using drugs in treating obese patients in primary care? A systematic review

BACKGROUND

Obesity [defined as a body mass index (BMI) ≥ 30 kg/m(2)] represents a considerable public health problem and is associated with a significant range of comorbidities and an increased mortality risk. The primary aim of the management of obesity is to achieve weight reduction in the interests of health. For obese patients who cannot achieve or maintain a healthy weight by non-pharmacological means, drug therapy is recommended in combination with non-pharmacological interventions such as dietary modifications and exercise.

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of three pharmacological interventions in obese patients.

DATA SOURCES

Clinical effectiveness data used in the meta-analysis were sourced from articles identified in a systematic review of the literature. Data used to inform transitions to obesity-related comorbidities were derived from the General Practice Research Database (GPRD). The results of the meta-analysis and GPRD analyses informed the economic model supplemented by data from the Health Survey for England and other UK-specific data sourced from the literature.

REVIEW METHODS

A systematic literature review was conducted of the clinical effectiveness and cost-effectiveness of orlistat, sibutramine and rimonabant within their licensed indications for the treatment of obese patients. Electronic bibliographic databases including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library databases and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched in January 2009, and the reference lists of relevant articles were checked. Studies were included if they compared orlistat, sibutramine or rimonabant with lifestyle and/or exercise advice (standard care), placebo or metformin.

RESULTS

Overall, 94 studies involving 24,808 individuals were included in the clinical meta-analysis. Eighty-three trials included data on weight change, 41 included data on BMI change and 45 and 36 studies reported on 5% and 10% body weight loss, respectively. Overall, the results show that the active drug interventions are all effective at reducing weight and BMI compared with placebo. In the case of sibutramine, the higher dose (15 mg) resulted in a greater reduction than the lower dose (10 mg). Generally, the data quality of the trials included was low with poor reporting of standard errors and standard deviations. Results from the BMI risk models derived from the GPRD showed consistent increases in risk with increasing BMI. Adjustments for key confounders, such as age, sex and smoking status, were found to be statistically significant at the 5% level, in all risk models. Applying linear models to estimate BMI trajectories, for the diabetic cohort, an average increase in BMI of 0.040 per year for both men and women was observed. The non-diabetic cohort model showed an increase in BMI of 0.175 per year for women and 0.145 per year for men. The results of the cost-effectiveness analyses suggest that sibutramine 15 mg dominates the other three active interventions and the net benefit analyses show that sibutramine 15 mg is the most cost-effective alternative for thresholds > £2000 per quality-adjusted life-year (QALY). However, both sibutramine and rimonabant have been withdrawn because of safety concerns relating to potential treatment-induced fatal adverse events. If the proportion of patients who experienced a fatal adverse event was > 1.8% (1.5%, 1.0%) for sibutramine 15 mg (sibutramine 10 mg, rimonabant) the treatment would not be considered cost-effective when using a threshold of £20,000 per QALY.

LIMITATIONS

The clinical review did not include all possible lifestyle comparators, with the inclusion limited to only those trials included one of the active drug interventions. We also excluded all studies not reported in English. Although the clinical review included data from 94 studies, the quality of data was generally low, particularly in terms of the reporting of standard deviation. There was also inconsistency between the results of the mixed-treatment comparison (MTC) and the pair-wise analyses.

CONCLUSION

The MTC of anti-obesity treatments shows that all the active treatments are effective at reducing weight and BMI. The economic results show that, compared with placebo, the treatments are all cost-effective when using a threshold of £20,000 per QALY, and, within the limitations of the data available, sibutramine 15 mg dominates the other three interventions. This work has highlighted many areas of methodological research that could be explored, including assessing inconsistencies within a network to determine differences between the results of pair-wise and MTC analyses; the use of meta-regression methods to look for effect modifiers; exploring the effect of local publication bias; and the use of joint models to analyse the repeated measures of BMI and the time-to-event processes simultaneously.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

'Neutralizing the patient': therapists' accounts of sexual boundary violations

Sexual contact between psychological therapists and their clients is regarded as highly damaging, both to the clients and to the professions, and regulatory bodies impose increasingly severe sanctions upon those practitioners who are disciplined. The present study captured therapists' accounts of sexual boundary violations through interpretative phenomenological analysis of interviews with three disciplined practitioners about their relationships with clients and former clients. The results highlighted two key themes relating to (i) therapists' efforts to neutralize the power imbalances between themselves and the clients by minimizing the clients' mental health problems, stressing the conventionality of the relationships and not testing the appropriateness of the relationship with their supervisors, and (ii) a shifting identity of the therapist between hero, victim, perpetrator, which permeated their accounts as the relationship moved from success to failure. In order for a sexual boundary violation to occur, the therapist needed to generate a sense of equivalent status between themselves and the client. As the relationships failed, the therapists' accounts of the clients shifted and the inequality of the relationship re-emerged. The results are discussed in terms of implicit theories and the implications for both training and supervision in the prevention of sexual boundary violations.

Postnatal debriefing: have we thrown the baby out with the bath water?

Postnatal debriefing is offered by 78% of maternity services in the UK despite little evidence from randomised controlled trials (RCTs) that it is effective. RCTs in this area have applied debriefing as a prophylactic to all or high risk women, rather than as a treatment for women who request it. This pragmatic trial therefore evaluated existing postnatal debriefing services that provide debriefing as a treatment for women who request it. Forty-six women who met criterion A for posttraumatic stress disorder (PTSD) and requested debriefing 1.3-72.2 months (median 16 weeks) postpartum completed measures of depression, PTSD, support and negative appraisals of the birth before and one month after debriefing. Women were compared with others who gave birth in the same hospitals during the same time period (n=34), who met criterion A for PTSD but had not requested debriefing. Results showed PTSD symptoms reduced over time in both groups but greater decreases were observed in women who attended debriefing. Debriefing also led to reduction in negative appraisals but did not affect symptoms of depression. Therefore, results suggest providing debriefing as a treatment to women who request or are referred to it may help to reduce symptoms of PTSD.

Meta-analysis of mortality and cancer incidence among workers in the synthetic rubber-producing industry

Production of synthetic rubber involves exposure to several potentially harmful chemicals. The authors carried out a systematic review and meta-analysis of cohort studies of workers in the rubber-producing industry. Data were obtained from computerized literature searches of several databases from their inception through December 2003. The reference lists of identified articles were inspected for further relevant articles. The authors conducted random-effects meta-analyses of log standardized mortality ratios (SMRs)/standardized incidence ratios. Heterogeneity between study results was explored through subgroup analyses and meta-regression on cohort demographic factors and study quality indicators. The authors identified 36 published articles reporting information on 31 different cohort groups. The meta-SMR was 0.86 (95% confidence interval (CI): 0.82, 0.91) for all-cause mortality (28 cohorts) and 0.94 (95% CI: 0.89, 1.01) for all malignant neoplasms (27 cohorts). Heterogeneity was observed for these endpoints and for the majority of disease-specific outcomes. Statistically significant excesses were observed for diabetes (meta-SMR=1.36, 95% CI: 1.17, 1.59) (five cohorts) and leukemia (meta-SMR=1.21, 95% CI: 1.03, 1.43) (16 cohorts), the latter particularly for persons working exclusively in nontire manufacturing (meta-SMR=1.70, 95% CI: 1.14, 2.54) (four cohorts). Excesses highlighted in previous narrative reviews were not substantiated. Interpretation of these results is complicated by substantial unexplainable heterogeneity; small excesses in specific mortality outcomes may have been disguised by the healthy worker effect.

Towards evidence-based practice in medical training: making evaluations more meaningful

CONTEXT

The evaluation of training is problematic and the evidence base inconclusive. This situation may arise for 2 main reasons: training is not understood as a complex intervention and, related to this, the evaluation methods applied are often overly simplistic.

METHOD

This paper makes the case for construing training, especially in the field of specialist medical education, as a complex intervention. It also selectively reviews the available literature in order to match evaluative techniques with the demonstrated complexity.

CONCLUSIONS

Construing training as a complex intervention can provide a framework for selecting the most appropriate methodology to evaluate a given training intervention and to appraise the evidence base for training fairly, choosing from among both quantitative and qualitative approaches and applying measurement at multiple levels of training impact.

The properties of self-report research measures: beyond psychometrics

Self-report measures pertinent for personality disorder are widely used and many are available. Their relative merits are usually assessed on nomothetic psychometrics and acceptability to users is neglected. We report reactions of lay, patient and professional groups to the Personality Diagnostic Questionnaire (PDQ-IV); Millon Clinical Multiaxial Inventory (MCMI-III); the Borderline Syndrome Index (BSI); Rosenberg's Self-Esteem Scale (RSE) and the Social Functioning Questionnaire (SFQ). These were sent to 148 professionals, ex-patients and lay people for comment. Thirty-six per cent were returned. Pattern-coding by three raters revealed problematic themes across all measures, including inappropriate length, vague items and language, cultural assumptions and slang, state-bias and response-set. Measures can be depressing and upsetting for some participants (both patients and non-patients), hence administration of measures should be sensitive. Treatment may make people more self-aware, which may compromise validity for outcome research. This evaluation raises issues and concerns, which are missed in traditional psychometric evaluation.

The possible effects on health, comfort and safety of aircraft cabin environments

A consultation was undertaken to investigate the views and concerns of stakeholders in the aircraft industry about the possible harmful effects on personal health, comfort and safety of aircraft cabin environments. Stakeholders were identified from a variety of sources including Government agencies, the Internet, House of Lords inquiry, and suggestions of interviewees. They represented: aircraft crews, aircraft constructors and engineers, government departments and authorities, holiday/flight companies, insurance companies, non-governmental organisations, occupational health physicians, passenger representatives, and independent researchers and consultants. Eighty-seven were contacted of which 57 were interviewed over the telephone using a semi-structured questionnaire. Their concerns were transcribed into a standard format and analysed qualitatively. Key stakeholders, along with Government officials, were invited to a workshop to discuss and prioritize the issues raised during the interviews. The main concerns expressed by the participants fell into five main areas: deep vein thrombosis, air quality, infection, cosmic radiation, and jet lag and work patterns. In addition, a number of safety concerns were raised as well as comments on the provision of appropriate advice to passengers. It was generally felt that further research was required on each of these subjects, as well as an improvement in the quality, quantity and availability of information provided for passengers prior to boarding a flight.

Change in borderline symptoms one year after therapeutic community treatment for severe personality disorder

BACKGROUND

The view that severe personality disorder (SPD) is untreatable derives from poor-quality studies of treatment outcome which use indirect measures of SPD pathology. This study evaluates the impact of psychotherapeutic in-patient treatment on core personality disorder symptoms.

METHOD

137 SPD patients completed the Borderline Syndrome Index (BSI) on referral and one year post-treatment ('admitted', n = 70) or one year post-referral ('non-admitted', n = 67); 22 of the non-admitted group were refused extra-contractual referral funding for their treatment.

RESULTS

There was a significantly greater reduction in BSI scores in the treated than in the non-admitted group. Changes in BSI scores were significantly positively correlated with length of treatment. Assessment of the reliability and clinical significance of changes in individual subjects showed that the magnitude of this change was reliable and clinically significant in 42.9% of the admitted sample, compared with only 17.9% of the non-admitted sample (18.2% of the unfunded group).

CONCLUSIONS

Specialist in-patient treatment is effective in reducing core SPD psychopathology.

Beneficial effects of corticosteroids on ocular myasthenia gravis

OBJECTIVE

To determine if moderate-or low-dose corticosteroid therapy can reduce the diplopia and frequency of deterioration to generalized disease in ocular myasthenia gravis.

DESIGN

Retrospective record review.

SETTING

Two university-based neuro-ophthalmology services.

PATIENTS

All 32 patients with ocular myasthenia gravis, treated with prednisone, followed up for a minimum of 2 years were included. Patients were treated with 1 or more courses of daily prednisone (highest initial dose, 40-80 mg) gradually withdrawn over 4 to 6 weeks. Subsequently, in 6 patients, 2.5 to 20 mg of prednisone was given on alternate day.

OUTCOME MEASURES

Diplopia in the primary position or downgaze diplopia and generalized myasthenia gravis after 2 years of follow-up.

RESULTS

Diplopia, which was initially found in the primary position in 29 patients and in the downgaze position in 26 patients, was absent in 21 patients at 2 years. Generalized myasthenia gravis occurred in 3 patients at 2 years. Elevated serum acetylcholine receptor antibody levels and abnormal electromyography findings were not predictive of worsening. No patient experienced a major steroid complication.

CONCLUSIONS

Moderate-dose daily prednisone for 4 to 6 weeks, followed by low-dose alternate-day therapy as needed, can control the diplopia in patients with ocular myasthenia gravis. The frequency of deterioration to generalized myasthenia gravis at 2 years may be reduced; 9.4% in this study compared with more than 40% previously reported frequency. Corticosteroids may be useful even when ocular motor dysfunction is not normalized.

Venous obstruction as the cause of retinal/choroidal dysfunction associated with arteriovenous shunts in the cavernous sinus

OBJECTIVE

To determine the hemodynamic abnormalities that result in visual acuity loss because of retinal or choroidal dysfunction associated with arteriovenous shunts (AVS) that involve the cavernous sinus.

METHODS

Retrospective study of the records of 250 patients with either a carotid cavernous fistula or dural arteriovenous malformation revealed a total of 10 patients with vision loss secondary to retinopathy (group I) or choroidal effusion (group II). The cerebral angiograms of these 10 patients and 10 additional patients with visual dysfunction due to elevated intraocular pressure (group III) were evaluated to determine whether the three groups could be distinguished by a specific vasculopathic pattern. Particular attention was given to the extent of thrombosis in the ophthalmic venous system and cavernous sinus.

RESULTS

There were angiographic signs of severe thrombosis in the ophthalmic vein in nine patients and in the cavernous sinus in seven patients ipsilateral to the retinal or choroidal lesion. In contrast, in group III, severe thrombosis in the ipsilateral ophthalmic vein and in the cavernous sinus occurred in one and two patients, respectively. Closure of the AVS improved the visual acuity in 1 of 4 patients in group I and in 4 of 5 patients in group II, and normalized the intraocular pressure in all patients.

CONCLUSIONS

Ophthalmic vein thrombosis, rather than arterialization of the venous system or an arterial "steal, " is the principal cause of retinal or choroidal dysfunction associated with AVS to the cavernous sinus. Following AVS closure, visual recovery is more frequent with choroidal effusion or detachment rather than with retinopathy.

Medical applications of single-chain antibodies

A single-chain antibody or single-chain Fv (sFv) incorporates the complete antibody binding site in a single polypeptide chain of minimal size, with an approximate molecular weight of 26,000. In antibodies, the antigen combining site is part of the Fv region, which is composed of the VH and VL variable domains on separate heavy and light chains. Efforts over nearly two decades have indicated that Fv fragments can only rarely be prepared from IgG and IgA antibodies by proteolytic dissection. Beginning in 1988, single-chain analogues of Fv fragments and their fusion proteins have been reliably generated by antibody engineering methods. The first step involves obtaining the genes encoding VH and VL domains with desired binding properties; these V genes may be isolated from a specific hybridoma cell line, selected from a combinatorial V-gene library, or made by V gene synthesis. The single-chain Fv is formed by connecting the component V genes with an oligonucleotide that encodes an appropriately designed linker peptide, such as (Gly4-Ser)3. The linker bridges the C-terminus of the first V region and N-terminus of the second, ordered as either VH-linker-VL or VL-linker-VH. In principle, the sFv binding site can faithfully replicate both the affinity and specificity of its parent antibody combining site, as demonstrated in our model studies with the 26-10 anti-digoxin sFv. Furthermore, the sFv remains stable at low concentrations that promote VH and VL dissociation from the Fv heterodimer, resulting in loss of Fv binding. Intravenously administered sFv proteins exhibit accelerated biodistribution and exceptionally fast clearance compared to IgG or Fab. These pharmacokinetic properties allow rapid imaging by sFv, which therefore may be labeled with a short-lived isotope such as Tc-99m. Expression of a single gene product from fused sFv and effector genes facilitates immunotargeting of the effector protein, as shown for single-chain Fv toxin fusion proteins.