Emotional disorder and absence from school: Findings from the 2004 British Child and Adolescent Mental Health Survey

This is the final version. Available on open access from Springer via the DOI in this recordBackground Emotional disorder may be associated with absence from school, but the existing evidence is methodologically weak. We studied the relationships between anxiety, depression and emotional difficulties, and school absence (total, authorised and unauthorised) using data from the 2004 British Child and Adolescent Mental Health Survey (BCAMHS). Method The BCAMHS was a cross-sectional, community survey of 7977 five to 16 year olds. Emotional disorder was assessed using the Development and Wellbeing Assessment (DAWBA), and emotional difficulties using the Strengths and Difficulties Questionnaire (SDQ) completed by teachers and parents. Teachers reported days absent in the previous school term. Multivariable negative binomial regression was used to examine the impact of emotional disorder and difficulties on absence. Age, gender and general health were explored as moderators. Results Anxiety, depression and emotional difficulties were associated with higher rates of all types of absence (rate ratios for total absence: anxiety 1.69 (1.39 to 2.06) p<0.001; depression 3.40 (2.46 to 4.69) p<0.001; parent-reported emotional difficulties 1.07 (1.05 to 1.10) p<0.001; teacher-reported emotional difficulties 1.10 (1.08 to 1.13) p<0.001). The strongest association was observed for depression and unauthorised absence. Relationships were stronger for secondary compared to primary school children. Conclusions Health and educational professionals should be aware that children with poor attendance may be experiencing emotional ill health, regardless of absence type. Absence may provide a useful tool to identify those who require additional mental health support. Findings highlight the widespread burden of emotional disorder and the need to support those with emotional ill health in continuing to access education.University of ExeterWellcome TrustNational Institute for Health Research (NIHR

Prescribing for young people with Attention Deficit Hyperactivity Disorder in UK primary care: analysis of data from the Clinical Practice Research Datalink

This is the author accepted manuscript. The final version is available from Springer via the DOI in this record.Background Guidance on management of Attention Deficit Hyperactivity Disorder [ADHD] in the UK was issued by the National Institute for Clinical Excellence [NICE] in 2008. No UK study has examined all psychotropic prescribing in young people with ADHD since the introduction of the guidance; this is especially relevant due to the high prevalence of psychiatric comorbidity in this population. Aim To describe primary care prescribing of ADHD and other psychotropic medication for young people with ADHD. Design and setting Analysis of records of patients with an ADHD diagnosis in the UK Clinical Practice Research Datalink from 2005 to 2013. Methods Estimation of the prevalence of prescribing of ADHD and other psychotropic medication over 8 years follow-up for cases aged 10 to 20 years in 2005. Results Of 9,390 ADHD cases, 61.6% (95% confidence interval (CI) = 60.6% to 62.5%) had a prescription at some point for ADHD medication. Prescribing of other psychotropic medication was higher in girls than boys (36.4% versus 22.7%; p<0.001). ADHD prescribing prevalence declined steeply between the ages of 16 and 18 from 37.8% (95% CI 36.6 to 38.9) to 23.7% (95% CI: 22.7 to 24.6%). There was a parallel increase in prescribing of other psychotropics from 3.8% (95% CI: 3.4% to 4.3%) to 6.6% (95% CI 6.0 to 7.3%). Conclusion There is scope to optimise the management of ADHD and psychiatric comorbidities in young people, and a need for sustainable models of ADHD care for young adults, supported by appropriate training and specialist services.National Institute for Health Research (NIHR

Resumption of Attention Deficit Hyperactivity Disorder medication in early adulthood: findings from a UK primary care prescribing study

This is the author accepted manuscript. The final version is available from Springer via the DOI in this record.This study aimed to examine resumption of Attention Deficit Hyperactivity Disorder (ADHD) prescriptions in early adulthood in young people whose ADHD prescriptions stopped in adolescence. Whilst prescribing studies indicate that the proportion of those with ADHD stopping treatment in late adolescence remains in excess of the proportion expected to be symptom free, very few studies have examined patterns of resumption amongst young adults previously prescribed medication. Primary care records from the UK Clinical Practice Research Datalink from 2008 to 2013 were used to examine the outcome of resumption of ADHD prescriptions from age 20 years in a sample of cases with ADHD whose prescriptions stopped aged 14-18. A Cox regression model was fitted to explore variables that could theoretically be associated with resumption of prescriptions. Of 1,440 cases, 109 (7.6%) had their ADHD prescriptions resumed. Characteristics associated with an increased probability of resumption included female gender, learning disability, referral to adult mental health services, and prescription of antipsychotic medication. In this study, only a small proportion of adolescents who stopped ADHD medication subsequently resumed their prescriptions in primary care. Those that did resume were a more complex group. As many vulnerable individuals with ongoing ADHD symptoms may not have the resources required to surmount the barriers to re-enter services, the implication is that not all those who could benefit from resuming medication are able to do so. The findings raise questions around whether current care models are flexible enough and whether primary care are adequately supported in managing this group

The outcomes of revision surgery for a failed ankle arthroplasty

Aims Revision rates for ankle arthroplasties are higher than hip or knee arthroplasties. When a total ankle arthroplasty (TAA) fails, it can either undergo revision to another ankle replacement, revision of the TAA to ankle arthrodesis (fusion), or amputation. Currently there is a paucity of literature on the outcomes of these revisions. The aim of this meta-analysis is to assess the outcomes of revision TAA with respect to surgery type, functional outcomes, and reoperations. Methods A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Medline, Embase, Cinahl, and Cochrane reviews were searched for relevant papers. Papers analyzing surgical treatment for failed ankle arthroplasties were included. All papers were reviewed by two authors. Overall, 34 papers met the inclusion criteria. A meta-analysis of proportions was performed. Results Six papers analyzed all-cause reoperations of revision ankle arthroplasties, and 14 papers analyzed failures of conversion of a TAA to fusion. It was found that 26.9% (95% confidence interval (CI) 15.4% to 40.1%) of revision ankle arthroplasties required further surgical intervention and 13.0% (95% CI 4.9% to 23.4%) of conversion to fusions; 14.4% (95% CI 8.4% to 21.4%) of revision ankle arthroplasties failed and 8% (95% CI 4% to 13%) of conversion to fusions failed. Conclusion Revision of primary TAA can be an effective procedure with improved functional outcomes, but has considerable risks of failure and reoperation, especially in those with periprosthetic joint infection. In those who undergo conversion of TAA to fusion, there are high rates of nonunion. Further comparative studies are required to compare both operative technique

Dementia-PersonAlised Care Team (D-PACT) intervention

Statistical Analysis Pla

The implementation of NICE guidance on venous thromboembolism risk assessment and prophylaxis: A before- after observational study to assess the impact on patient safety across four hospitals in England.

Exact publication date to be confirmed.Introduction: Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. VTE prevention has been identified as a major health need internationally to improve patient safety. A National Institute for Health and Clinical Excellence (NICE) guideline was issued in February 2010. Its key priorities were to assess patients for risk of VTE on admission to hospital, assess patients for bleeding risk and evaluate the risks and benefits of prescribing VTE prophylaxis. Objectives: To evaluate the implementation of NICE guidance and its impact on patient safety. Design: Before and after observational study design was used to investigate changes in VTE risk assessment documentation and inappropriate prescribing of prophylaxis between the year prior to (2009) and the year following (2010) the implementation of NICE guidance. A total of 816 patients were sampled in each year in four hospitals in the NHS South region. Results: The percentage of patients for whom a VTE risk assessment was documented increased from 51.5% (210/408) in 2009 to 79.2% (323/408) in 2010; difference 27.7% (95% CI: 21.4% to 33.9%; p<0.001). There was little evidence of change in the percentage who were prescribed prophylaxis amongst patients without a risk assessment (71.7% (142/198) in 2009 and 68.2% (58/85) in 2010; difference -3.5%% (95% CI: -15.2% to 8.2%; p =0.56) nor the percentage who were prescribed low molecular weight heparin amongst patients with a contraindication (14% (4/28) in 2009 and 15% (6/41) in 2010; RD = 0.3% (95% CI: -16.5% to 17.2%; p =0.97). Conclusions: The documentation of risk assessment improved following the implementation of NICE guidance but this did not lead to improved patient safety when prescribing prophylaxis

Plasma and Cerebrospinal fluid (CSF) Abeta42 for the differential diagnosis of Alzheimer's disease dementia in participants diagnosed with any dementia subtype in a specialist care setting

© 2014 The Cochrane Collaboration. This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the diagnostic accuracy of the plasma and CSF Abeta42 index tests for distinguishing Alzheimer's disease dementia from each of the other forms of dementia in people who meet the general criteria for a dementia syndrome. To investigate the heterogeneity of test accuracy in the included studies. We expect that heterogeneity will be likely and that it will be an important component of the review. The potential sources of heterogeneity, which will be used as a framework for the investigation of heterogeneity, include target population, index test, target disorder and study quality and are detailed in the analysis section

Does a simple web-based intervention facilitate the articulation of patients' unvoiced agenda for a consultation with their diabetologists? A qualitative study

OBJECTIVE: To explore whether a preconsultation web-based intervention enables patients with diabetes to articulate their agenda in a consultation in the hospital outpatient clinic with their diabetologist. METHODS AND DESIGN: A qualitative study embedded in a pragmatic pilot randomised controlled trial. SETTING: Two city outpatient departments in England. PARTICIPANTS: 25 patients attending a follow-up consultation and 6 diabetologists. INTERVENTION: The PACE-D, a web-based tool adapted for patients with diabetes to use before their consultation to generate an agenda of topics to discuss with their diabetologist. DATA COLLECTION: 25 participants had their consultation with their diabetologist audio-recorded: 12 in the control arm and 13 in the intervention arm; 12 of the latter also had their PACE-D intervention session and a consultation recorded. Semi-structured interviews with 6 diabetologists, and 12 patients (6 in the intervention group and 6 in the control group). ANALYSIS: Thematic discourse analysis undertaken with patient representatives trained in qualitative data analysis techniques. RESULTS: We identified four consultation types: diabetologist facilitated; patient identified; consultant facilitated and patient initiated and patient ignored. We also identified three critical aspects that explained the production and utilisation of the agenda form: existing consultative style; orientation to the use of the intervention and impact on the consultation. Where patients and diabetologists have a shared preference for a consultant-led or patient-led consultation, the intervention augments effective communication and shared decision making. However, where preferences diverge (eg, there is a mismatch in patients' and diabetologists' preferences and orientations), the intervention does not improve the potential for shared decision making. CONCLUSION: A simple web-based intervention facilitates the articulation of patients' unvoiced agenda for a consultation with their diabetologist, but only when pre-existing consultation styles and orientations already favour shared decision making. More needs to be done to translate patient empowerment in the consultation setting into genuine self-efficacy. TRIAL REGISTRATION NUMBER: ISRCTN75070242.This article is freely available via Open Access. Click on the Publisher URL to access the full-text from the publisher's site

Planning a cluster randomized trial with unequal cluster sizes: practical issues involving continuous outcomes

BACKGROUND: Cluster randomization design is increasingly used for the evaluation of health-care, screeening or educational interventions. At the planning stage, sample size calculations usually consider an average cluster size without taking into account any potential imbalance in cluster size. However, there may exist high discrepancies in cluster sizes. METHODS: We performed simulations to study the impact of an imbalance in cluster size on power. We determined by simulations to which extent four methods proposed to adapt the sample size calculations to a pre-specified imbalance in cluster size could lead to adequately powered trials. RESULTS: We showed that an imbalance in cluster size can be of high influence on the power in the case of severe imbalance, particularly if the number of clusters is low and/or the intraclass correlation coefficient is high. In the case of a severe imbalance, our simulations confirmed that the minimum variance weights correction of the variation inflaction factor (VIF) used in the sample size calculations has the best properties. CONCLUSION: Publication of cluster sizes is important to assess the real power of the trial which was conducted and to help designing future trials. We derived an adaptation of the VIF from the minimum variance weights correction to be used in case the imbalance can be a priori formulated such as "a proportion (γ) of clusters actually recruit a proportion (τ) of subjects to be included (γ ≤ τ)"