Cancer prevention: setting the scene.

Each year in the United Kingdom there are over 300,000 new cases of cancer and nearly 165,000 deaths from cancer. It is widely believed that as many as four fifths of all cancers are preventable by means that are already available. The Health of the Nation and the Europe Against Cancer programme have set targets and strategies for reducing the risk of cancer. An approach based on the whole population will achieve the greatest reductions in morbidity and mortality. Complementary to this is the individual approach, which can be based in primary care and targeted at high risk subjects. Health promotion and screening in primary care are not in themselves self evidently valuable. Their effectiveness must be tested rigorously and scientifically. Furthermore, because of limited time and resources, health education in primary care should be focused on interventions that are likely to achieve the greatest benefit, such as helping people to stop smoking.     

What Interrupts Suicide Attempts in Men: A Qualitative Study

Despite higher rates of suicide in men, there is a dearth of research examining the perspectives and experiences of males at risk of suicide, particularly in terms of understanding how interventions can be tailored to men’s specific needs. The current study aimed to examine factors assisting, complicating or inhibiting interventions for men at risk, as well as outlining the roles of family, friends and others in male suicide prevention. Thirty-five male suicide survivors completed one-to-one interviews, and forty-seven family and friends of male suicide survivors participated in eight focus groups. Thematic analysis revealed five major themes: (1) development of suicidal behaviours tends to follow a common path associated with specific types of risk factors (disrupted mood, unhelpful stoic beliefs and values, avoidant coping strategies, stressors), (2) men at risk of suicide tend to systematically misinterpret changes in their behaviour and thinking, (3) understanding mood and behavioural changes in men enables identification of opportunities to interrupt suicide progression, (4) distraction, provision of practical and emotional supports, along with professional intervention may effectively interrupt acute risk of harm, and (5) suicidal ideation may be reduced through provision of practical help to manage crises, and helping men to focus on obligations and their role within families. Findings suggest that interventions for men at risk of suicidal behaviours need to be tailored to specific risk indicators, developmental factors, care needs and individuals’ preferences. To our knowledge this is the first qualitative study to explore the experiences of both suicidal men and their family/friends after a suicide attempt, with the view to improve understanding of the processes which are effective in interrupting suicide and better inform interventions for men at risk.     

Suicide and Social Change in China

Using recently available data from China's Disease Surveillance Points system, we estimate that there are over 300,000 suicides in China per year; this makes suicide one of the most important causes of death in the country and makes the suicide rate in China one of the highest in the world. Moreover, the pattern of suicides in China is quite different than in other parts of the world – there are more completed suicides among females than males and rural rates are three-fold urban rates. The lack of reliable suicide data prior to 1987 makes it difficult to determine whether the rates are currently rising, falling, or staying constant. However, reports of suicides in the Chinese press and case studies conducted by the authors suggest (but do not prove) that the high rates of suicide currently experienced are related to the social changes that have occurred with the economic reforms (which started in 1978). Another possible explanation for the high rates of suicide is the large numbers of persons with depressive illness in China who remain untreated. Single-cause models of suicide (i.e., social factors or mental illness) do not do justice to the complexity of the processes involved and, therefore, do not provide useful information about the etiology and prevention of suicide in China or elsewhere. We describe our own dynamic model of suicide that includes five interacting factors which, we believe, collectively determine the suicide rates in a community.     

A Systematic Assessment of Smartphone Tools for Suicide Prevention

BackgroundSuicide is a leading cause of death globally, and there has been a rapid growth in the use of new technologies such as mobile health applications (apps) to help identify and support those at risk. However, it is not known whether these apps are evidence-based, or indeed contain potentially harmful content. This review examines the concordance of features in publicly available apps with current scientific evidence of effective suicide prevention strategies.MethodsApps referring to suicide or deliberate self-harm (DSH) were identified on the Android and iOS app stores. Systematic review methodology was employed to screen and review app content. App features were labelled using a coding scheme that reflected the broad range of evidence-based medical and population-based suicide prevention interventions. Best-practice for suicide prevention was based upon a World Health Organization report and supplemented by other reviews of the literature.ResultsOne hundred and twenty-three apps referring to suicide were identified and downloaded for full review, 49 of which were found to contain at least one interactive suicide prevention feature. Most apps focused on obtaining support from friends and family (n = 27) and safety planning (n = 14). Of the different suicide prevention strategies contained within the apps, the strongest evidence in the literature was found for facilitating access to crisis support (n = 13). All reviewed apps contained at least one strategy that was broadly consistent with the evidence base or best-practice guidelines. Apps tended to focus on a single suicide prevention strategy (mean = 1.1), although safety plan apps provided the opportunity to provide a greater number of techniques (mean = 3.9). Potentially harmful content, such as listing lethal access to means or encouraging risky behaviour in a crisis, was also identified.DiscussionMany suicide prevention apps are available, some of which provide elements of best practice, but none that provide comprehensive evidence-based support. Apps with potentially harmful content were also identified. Despite the number of apps available, and their varied purposes, there is a clear need to develop useful, pragmatic, and multifaceted mobile resources for this population. Clinicians should be wary in recommending apps, especially as potentially harmful content can be presented as helpful. Currently safety plan apps are the most comprehensive and evidence-informed, for example, “Safety Net” and “MoodTools—Depression Aid”.     

Are current management recommendations for saproxylic invertebrates effective? A systematic review

Conservation management recommendations for saproxylic invertebrates advocate the continuous provision of the dead and decaying wood microhabitats that they require for survival. Accepted site-based management practices include leaving fallen dead and decaying wood in situ, providing supplementary coarse woody material (CWM), inducing decay in mature trees and strategic planting in order to maintain a balanced age structure of trees in both space and time. Here we examine the empirical evidence regarding the effectiveness of such interventions using rigorous systematic review methodology. Systematic searching yielded 27 studies containing pertinent information. The evidence presently available is insufficient to critically appraise the utility of any specific intervention for conserving saproxylic species, or assemblages, in the long-term. However, there are a range of studies, conducted over relatively short periods of time, which do describe changes in saproxylic fauna in response to management practices. In the absence of robust, high quality evidence, recommendations relating to the use of specific site-based conservation interventions should only be regarded as speculative. Nonetheless, general proposals for the maintenance of suitable microhabitats, such as the protection of veteran trees within the landscape, are based on sound ecological principles and should be encouraged even though experimentally controlled and replicated evidence is lacking. Further primary research and long-term monitoring are required to fill the gaps in our ecological knowledge that potentially weaken the case for the effectiveness of current saproxylic invertebrate conservation action and would enable practitioners to make better informed decisions with regard to dead wood protection and provision.     

Evidence‐Based Medicine and Women: Do the Principles and Practice of EBM Further Women's Health?

Clinicians and policy makers the world over are embracing evidence-based medicine (EBM). The promise of EBM is to use summaries of research evidence to determine which healthcare interventions are effective and which are not, so that patients may benefit from effective interventions and be protected from useless or harmful ones. EBM provides an ostensibly rational objective means of deciding whether or not an intervention should be provided on the basis of its effectiveness, in theory leading to fair and effective healthcare for all. In this paper I closely examine these claims from the perspective of healthcare for women, using relevant examples. I argue that the current processes of evidence-based medicine contain a number of biases against women. These biases occur in the production of research that informs evidence-based medicine, in the methods used to analyse and synthesise the evidence, and in the application of EBM through the use of guidelines. Finally, the biomedical model of health that underpins most of the medical research used by EBM ignores the social and political context which contributes so much to the ill-health of women.     

Health promotion priorities for general practice: constructing and using "indicative prevalences".

OBJECTIVE--To construct indicative prevalences for a range of diseases and risk markers and use them in planning health promotion interventions in primary health care. DESIGN--Indicative prevalences comprised point prevalence, incidence, and mortality measures. Use of data from Office of Population Censuses and Surveys, Northern Regional Health Authority, and Newcastle health and lifestyle survey 1991, and research papers to determine prevalence adjusted for age and sex in a hypothetical practice with a list of 10,000 patients. SETTING--Newcastle upon Tyne, England. RESULTS--Indicative prevalences were highest for common risk markers such as failure to achieve exercise targets (6871), moderate to extreme obesity (2785), and smoking (2689); moderate for overt disease such as angina (175) and stroke (20/year); and low for events such as suicide (1/year) and deaths from malignant melanoma (2/10 years). CONCLUSIONS--Given limited time and resources, brief interventions to reduce smoking and the systematic case finding and management of patients with hypertension, angina, and previous myocardial infarction are likely to be the highest priorities for health promotion in primary care.     

Mortality and Suicide Risk in Treatment-Resistant Depression: An Observational Study of the Long-Term Impact of Intervention

Major depressive disorder is a common global disease that causes a significant societal burden. Most interventional studies of depression provide a limited assessment of the interventions on mortality and suicide risks. This study utilizes data from an observational registry of patients with major depressive disorder to determine the impact of intervention (vagus nerve stimulation or standard pharmacological/non-pharmacological therapy) and a latent factor, patient trajectory toward response, on mortality, suicide and suicidal ideation. A total of 636 patients were available for an intent-to-treat analysis of all-cause mortality, suicide and suicidal ideation. Patients treated with vagus nerve stimulation in addition to standard therapies experienced lower, but not statistically significant, all-cause mortality (vagus nerve stimulation 4.93 per 1,000 person-years vs. 10.02 per 1,000 patient years for treatment as usual) and suicide rates (vagus nerve stimulation 0.88 per 1,000 person-years vs. 1.61 per 1,000 patient years for treatment as usual). Treatment with vagus nerve stimulation produced a statistically lower relative risk of suicidal ideation 0.80, 95% confidence interval (0.68,0.95). Further, patients that responded to either treatment saw a 51% reduction in relative risk of suicidal behavior; relative risk and 95% confidence interval of 0.49 (0.41,0.58). In summary, we find that treatment with adjunctive vagus nerve stimulation can potentially lower the risk of all-cause mortality, suicide and suicide attempts.     

The future of aging therapies

Advances in understanding aging processes and their consequences are leading to the development of therapies to slow or reverse adverse changes formerly considered to be "normal" aging and processes that underlie multiple age-related conditions. Estimating the effectiveness of candidate aging therapies, whose effects on human aging may require many years to determine, is a particular challenge. Strategies for identifying candidate interventions can be developed through multiple approaches, including the screening of molecular targets and pathways in vitro and in animal models, informed as well by evidence from human genetic and epidemiologic data. A number of recently established programs and networks can serve as resources for such research. For all these research approaches, from in vitro molecular studies to clinical trials, contributions of cell and molecular biology are crucial and offer the prospect of therapeutic advances that address fundamental biological processes as well as the clinically important challenges of aging.     

Suicidality in Body Dysmorphic Disorder

Suicidal ideation, suicide attempts, and completed suicide appear common in individuals with body dysmorphic disorder (BDD). Available evidence indicates that approximately 80% of individuals with BDD experience lifetime suicidal ideation and 24% to 28% have attempted suicide. Although data on completed suicide are limited and preliminary, the suicide rate appears markedly high. These findings underscore the importance of recognizing and effectively treating BDD. However, BDD is underrecognized in clinical settings even though it is relatively common and often presents to psychiatrists and other mental health practitioners, dermatologists, surgeons, and other physicians. This article reviews available evidence on suicidality in BDD and discusses how to recognize and diagnose this often secret disorder. Efficacious treatments for BDD, ie, serotonin reuptake inhibitors (SRIs) and cognitive-behavioral therapy, are also discussed. Although data are limited, it appears that SRIs often diminish suicidality in these patients. Additional research is greatly needed on suicidality rates, characteristics, correlates, risk factors, treatment, and prevention of suicidality in BDD.     

Environment--a new key area for Health of the Nation?

Later this month the government will be consulting on whether the environment should be adopted as a new key area for their Health of the Nation strategy. It is proposing to have five topic areas and to adopt 10-15 environmental targets. This would reaffirm its commitment to linking environmental policy and health policy following publication earlier this year of its environmental health action plan. Critics may respond to the consultation document with suggestions for more far reaching targets--based, for example, on the "Health for All" targets from the World Health Organisation, or those arising out of Agenda 21 from the earth summit in Rio De Janeiro. Whatever the criticism, this move will be a chance to link environmental and health agendas at both national and local level.     

Improving Diabetes Care in Rural Areas: A Systematic Review and Meta-Analysis of Quality Improvement Interventions in OECD Countries

Background and Aims

Despite well documented disparities in health and healthcare in rural communities, evidence in relation to quality improvement (QI) interventions in those settings is still lacking. The main goals of this work were to assess the effectiveness of QI strategies designed to improve diabetes care in rural areas, and identify characteristics associated with greater success.

Methods

We conducted a systematic review and meta-analysis. Systematic electronic searches were conducted in MEDLINE, EMBASE, CINAHL, and 12 additional bibliographic sources. Experimental studies carried out in the OECD member countries assessing the effectiveness of QI interventions aiming to improve diabetes care in rural areas were included. The effect of the interventions and their impact on glycated hemoglobin was pooled using a random-effects meta-analysis.

Results

Twenty-six studies assessing the effectiveness of twenty QI interventions were included. Interventions targeted patients (45%), clinicians (5%), the health system (15%), or several targets (35%), and consisted of the implementation of one or multiple QI strategies. Most of the interventions produced a positive impact on processes of care or diabetes self-management, but a lower effect on health outcomes was observed. Interventions with multiple strategies and targeting the health system and/or clinicians were more likely to be effective. Six QI interventions were included in the meta-analysis (1,496 patients), which showed a significant reduction in overall glycated hemoglobin of 0.41 points from baseline in those patients receiving the interventions (95% CI -0.75% to -0.07%).

Conclusions

This work identified several characteristics associated with successful interventions to improve the quality of diabetes care in rural areas. Efforts to improve diabetes care in rural communities should focus on interventions with multiple strategies targeted at clinicians and/or the health system, rather than on traditional patient-oriented interventions.     

Clustering of Vector Control Interventions Has Important Consequences for Their Effectiveness: A Modelling Study

Vector control interventions have resulted in considerable reductions in malaria morbidity and mortality. When universal coverage cannot be achieved for financial or logistical reasons, the spatial arrangement of vector control is potentially important for optimizing benefits. This study investigated the effect of spatial clustering of vector control interventions on reducing the population of biting mosquitoes. A discrete-space continuous-time mathematical model of mosquito population dynamics and dispersal was extended to incorporate vector control interventions of insecticide treated bednets (ITNs), Indoor residual Spraying (IRS), and larviciding. Simulations were run at varying levels of coverage and degree of spatial clustering. At medium to high coverage levels of each of the interventions or in combination was more effective to spatially spread these interventions than to cluster them. Suggesting that when financial resources are limited, unclustered distribution of these interventions is more effective. Although it is often stated that locally high coverage is needed to achieve a community effect of ITNs or IRS, our results suggest that if the coverage of ITNs or IRS are insufficient to achieve universal coverage, and there is no targeting of high risk areas, the overall effects on mosquito densities are much greater if they are distributed in an unclustered way, rather than clustered in specific localities. Also, given that interventions are often delivered preferentially to accessible areas, and are therefore clustered, our model results show this may be inefficient. This study provides evidence that the effectiveness of an intervention can be highly dependent on its spatial distribution. Vector control plans should consider the spatial arrangement of any intervention package to ensure effectiveness is maximized.     

Community‐based social interventions for people with severe mental illness: a systematic review and narrative synthesis of recent evidence

People living with severe mental illness (SMI) are one of the most marginalized groups in society. Interventions which aim to improve their social and economic participation are of crucial importance to clinicians, policy‐makers and people with SMI themselves. We conducted a systematic review of the literature on social interventions for people with SMI published since 2016 and collated our findings through narrative synthesis. We found an encouragingly large amount of research in this field, and 72 papers met our inclusion criteria. Over half reported on the effectiveness of interventions delivered at the service level (supported accommodation, education or employment), while the remainder targeted individuals directly (community participation, family interventions, peer‐led/supported interventions, social skills training). We identified good evidence for the Housing First model of supported accommodation, for the Individual Placement and Support model of supported employment, and for family psychoeducation, with the caveat that a range of models are nonetheless required to meet the varied housing, employment and family‐related needs of individuals. Our findings also highlighted the importance of contextual factors and the need to make local adaptations when “importing” interventions from elsewhere. We found that augmentation strategies to enhance the effectiveness of social interventions (particularly supported employment and social skills training) by addressing cognitive impairments did not lead to transferable “real life” skills despite improvements in cognitive function. We also identified an emerging evidence base for peer‐led/supported interventions, recovery colleges and other interventions to support community participation. We concluded that social interventions have considerable benefits but are arguably the most complex in the mental health field, and require multi‐level stakeholder commitment and investment for successful implementation.     

The Cost Effectiveness of Psychological and Pharmacological Interventions for Social Anxiety Disorder: A Model-Based Economic Analysis

Background

Social anxiety disorder is one of the most persistent and common anxiety disorders. Individually delivered psychological therapies are the most effective treatment options for adults with social anxiety disorder, but they are associated with high intervention costs. Therefore, the objective of this study was to assess the relative cost effectiveness of a variety of psychological and pharmacological interventions for adults with social anxiety disorder.

Methods

A decision-analytic model was constructed to compare costs and quality adjusted life years (QALYs) of 28 interventions for social anxiety disorder from the perspective of the British National Health Service and personal social services. Efficacy data were derived from a systematic review and network meta-analysis. Other model input parameters were based on published literature and national sources, supplemented by expert opinion.

Results

Individual cognitive therapy was the most cost-effective intervention for adults with social anxiety disorder, followed by generic individual cognitive behavioural therapy (CBT), phenelzine and book-based self-help without support. Other drugs, group-based psychological interventions and other individually delivered psychological interventions were less cost-effective. Results were influenced by limited evidence suggesting superiority of psychological interventions over drugs in retaining long-term effects. The analysis did not take into account side effects of drugs.

Conclusion

Various forms of individually delivered CBT appear to be the most cost-effective options for the treatment of adults with social anxiety disorder. Consideration of side effects of drugs would only strengthen this conclusion, as it would improve even further the cost effectiveness of individually delivered CBT relative to phenelzine, which was the next most cost-effective option, due to the serious side effects associated with phenelzine. Further research needs to determine more accurately the long-term comparative benefits and harms of psychological and pharmacological interventions for social anxiety disorder and establish their relative cost effectiveness with greater certainty.     

Risk scoring in the assessment of cardiovascular risk

PURPOSE OF REVIEW: Cardiovascular risk scoring is incorporated in guidelines and recommended for targeting preventive treatment. Evidence is required on the most appropriate method, its accuracy in a given population, and its effectiveness in favourably influencing clinical behaviour and health outcomes. RECENT FINDINGS: Recent risk scores address inaccuracies that arise when methods are transferred between populations, and specific methods and recalibrations are described for use in low-risk populations. Ethnic and social differences in risk are also recognized in the context of cardiovascular risk scoring.More sensitive measures of known risk factors and numerous emerging risk factors are reported and new statistical methods and sources of data suggested. Little emphasis has been placed on evaluation of the clinical effectiveness of cardiovascular risk scores. Education in cardiovascular risk assessment may help improve uptake of methods by healthcare professionals. SUMMARY: Numerous risk scoring methods are available to the healthcare professional but use is patchy. Accuracy varies between populations and methods have been developed to compensate for some of this variability. If risk scoring methods are to be widely used in general practice, evidence is required on both the accuracy of methods in appropriate populations and their effectiveness in improving health outcomes.     

Multifactorial day hospital intervention to reduce falls in high risk older people in primary care: a multi-centre randomised controlled trial [ISRCTN46584556]

Background

There are many barriers to patient participation in randomised controlled trials of cancer treatments. To increase participation in trials, strategies need to be identified to overcome these barriers. Our aim was to assess the effectiveness of interventions to overcome barriers to patient participation in randomised controlled trials (RCTs) of cancer treatments.

Methods

A systematic review was conducted. Published and unpublished studies in any language were searched for in fifteen electronic databases, including MEDLINE, EMBASE, CINAHL and PsycINFO, from inception to the end of 2004. Studies of any interventions to improve cancer patient participation in RCTs, which reported the change in recruitment rates, were eligible for inclusion. RCTs and non-randomised controlled trials as well as before and after studies reporting baseline rates specific to the population being investigated were included. Data were extracted by one reviewer into structured summary tables and checked for accuracy by a second reviewer. Each included study was assessed against a checklist for methodological quality by one reviewer and checked by a second reviewer. A narrative synthesis was conducted.

Results

Eight studies were identified that met the inclusion criteria: three RCTs, two non-randomised controlled trials and three observational studies. Six of the studies had an intervention that had some relevance to the UK. There was no robust evidence that any of the interventions investigated led to an increase in cancer patient participation in RCTs, though one good quality RCT found that urologists and nurses were equally effective at recruiting participants to a treatment trial for prostate cancer. Although there was no evidence of an effect in any of the studies, the evidence was not of sufficient quality to be able to conclude that these interventions therefore do not work.

Conclusion

There is not a strong evidence-base for interventions that increase cancer patient participation in randomised trials. Further research is required to evaluate the effectiveness of strategies to increase participation in cancer treatment trials.     

The Civic Engagement of Immigrant Youth: New Evidence From the 2006 Civic and Political Health of the Nation Survey

We present new evidence on the civic engagement of immigrants and the children of immigrant parents (ages 15 to 25). Utilizing the 2006 Civic and Political Health of the Nation Survey conducted by CIRCLE, we find that young immigrants report lower levels of civic engagement on most measures compared to natives. However, once observable demographic factors are controlled, many of these differences are eliminated. In contrast, the children of immigrant parents report levels of civic engagement that match or exceed those of natives.     

Disseminating the best available evidence: New challenges in public reporting of health care

As a direct benefit of the Health Care Reform Act (2010), concerted effort has been deployed to define and characterize the process by which the best available evidence for diagnosis or treatment intervention prognosis can be obtained. The science of research synthesis in health care has established the systematic research protocol by which randomized clinical trials and other clinical studies must be reviewed and compared for the level and quality of the evidence presented, as well as the consensus of the best available evidence synthesized and shared. This process of systematic review yields a reliable and valid approach in comparing different interventions and strategies to prevent, diagnose, treat and monitor health conditions in terms of efficacy, and or of effectiveness. The resulting bioinformation outcome of comparative effectiveness and efficacy research review of the available clinical data is expressed as a consensus of the best available evidence, which finds its way in evidence-based clinical practice guidelines, standards of care and eventually, in policies: hence, the acronym CEERAP (comparative effectiveness and efficacy review and policy). The methodological and the procedural criteria that determine and regulate the public reporting dissemination of this sort of bioinformation, and the extent of benefit to the patient's health literacy, which have remained a bit more elusive to this date, are investigated and discussed in this paper.