Background The mental health of medical students is a national and international problem increasing in both demand and acuity. Medical students face barriers to accessing mental health support that ...is clinically effective, timely and appropriate for their needs. This mixed methods study aimed to explore experiences of these barriers and the challenges to health service delivery aligned to the Candidacy Framework. Methods One hundred three medical students studying at The University of Sheffield completed an online survey comprising the CCAPS-34 and follow-up questions about service access and use. Semi-structured interviews with a nested sample of 20 medical students and 10 healthcare professionals explored barriers to service access and provision. A stakeholder panel of medical students and professionals met quarterly to co-produce research materials, interpret research data and identify touchpoints by pinpointing specific areas and moments of interaction between a medical student as a service user and a mental health service. Results Medical students who experienced barriers to help-seeking and accessing support scored significantly higher for psychological symptoms on the CCAPS-34. Uncertainty and fear of fitness to practice processes were important barriers present across all seven stages of candidacy. The fragmented structure of local services, along with individual factors such as perceived stigma and confidentiality concerns, limited the progression of medical students through the Candidacy Framework (a framework for understanding the different stages of a person's journey to healthcare). Conclusion This study outlines important areas of consideration for mental health service provision and policy development to improve access to and the quality of care for medical students. Keywords: Medical student, Mental health, Candidacy Framework, Access to health care, Mixed Methods Research
Background Persistent Physical Symptoms (PPS) include symptoms such as chronic pain, and syndromes such as chronic fatigue. They are common, but are often inadequately managed, causing distress and ...higher costs for health care systems. A lack of teaching about PPS has been recognised as a contributing factor to poor management. Methods The authors conducted a scoping review of the literature, including all studies published before 31 March 2023. Systematic methods were used to determine what teaching on PPS was taking place for medical undergraduates. Studies were restricted to publications in English and needed to include undergraduate medical students. Teaching about cancer pain was excluded. After descriptive data was extracted, a narrative synthesis was undertaken to analyse qualitative findings. Results A total of 1116 studies were found, after exclusion, from 3 databases. A further 28 studies were found by searching the grey literature and by citation analysis. After screening for relevance, a total of 57 studies were included in the review. The most commonly taught condition was chronic non-cancer pain, but overall, there was a widespread lack of teaching and learning on PPS. Several factors contributed to this lack including: educators and learners viewing the topic as awkward, learners feeling that there was no science behind the symptoms, and the topic being overlooked in the taught curriculum. The gap between the taught curriculum and learners' experiences in practice was addressed through informal sources and this risked stigmatising attitudes towards sufferers of PPS. Conclusion Faculties need to find ways to integrate more teaching on PPS and address the barriers outlined above. Teaching on chronic non-cancer pain, which is built on a science of symptoms, can be used as an exemplar for teaching on PPS more widely. Any future teaching interventions should be robustly evaluated to ensure improvements for learners and patients. Keywords: Scoping review, Narrative synthesis, Undergraduate, Persistent physical symptoms, Medically unexplained symptoms, Chronic pain
Predicting health outcomes from longitudinal health histories is of central importance to healthcare. Observational healthcare databases such as patient diary databases provide a rich resource for ...patient-level predictive modeling. In this paper, we propose a Bayesian hierarchical vector autoregressive (VAR) model to predict medical and psychological conditions using multivariate time series data. Compared to the existing patient-specific predictive VAR models, our model demonstrated higher accuracy in predicting future observations in terms of both point and interval estimates due to the pooling effect of the hierarchical model specification. In addition, by adopting an elastic-net prior, our model offers greater interpretability about the associations between variables of interest on both the population level and the patient level, as well as between-patient heterogeneity. We apply the model to two examples: 1) predicting substance use craving, negative affect and tobacco use among college students, and 2) predicting functional somatic symptoms and psychological discomforts.
Variation in GP referral practice may be a factor contributing to the lower uptake of cardiology specialist services for people living in socioeconomic deprivation. Cardiology referrals were chosen ...for this study due to higher rates of premature death and emergency admissions resulting from coronary heart disease for patients living in more deprived areas.
To find out how socioeconomic deprivation influences GP referral practice.
A qualitative study of GPs working in affluent and deprived areas of one large city in the UK.
The authors used purposive and snowball sampling to recruit 17 GP participants to interviews and a focus group. Participants were asked to reflect on their own experience of making referrals. The authors used a framework approach to the analysis, with differences in themes for GPs working in least and most deprived areas being highlighted.
The authors identified four main themes by which socioeconomic deprivation influenced GP referral practice: identifying problems; making decisions about referral; navigating the healthcare system; and external pressures. Using a published framework of consultation complexity, the authors then examined the data in relation to a fifth theme of complexity. Referrals from areas of high socioeconomic deprivation involved greater complexity in the majority of the domains of this framework.
Socioeconomic deprivation influences GP referral decisions and navigation of the healthcare system in multiple ways. Referral practice for GPs working in deprived areas is more complex than for their peers working in more affluent areas.
Self-monitoring (self-testing and self-management) could be a valid option for oral anticoagulation therapy monitoring in the NHS, but current evidence on its clinical effectiveness or ...cost-effectiveness is limited.
We investigated the clinical effectiveness and cost-effectiveness of point-of-care coagulometers for the self-monitoring of coagulation status in people receiving long-term vitamin K antagonist therapy, compared with standard clinic monitoring.
We searched major electronic databases (e.g. MEDLINE, MEDLINE In Process & Other Non-Indexed Citations, EMBASE, Bioscience Information Service, Science Citation Index and Cochrane Central Register of Controlled Trials) from 2007 to May 2013. Reports published before 2007 were identified from the existing Cochrane review (major databases searched from inception to 2007). The economic model parameters were derived from the clinical effectiveness review, other relevant reviews, routine sources of cost data and clinical experts' advice.
We assessed randomised controlled trials (RCTs) evaluating self-monitoring in people with atrial fibrillation or heart valve disease requiring long-term anticoagulation therapy. CoaguChek(®) XS and S models (Roche Diagnostics, Basel, Switzerland), INRatio2(®) PT/INR monitor (Alere Inc., San Diego, CA USA), and ProTime Microcoagulation system(®) (International Technidyne Corporation, Nexus Dx, Edison, NJ, USA) coagulometers were compared with standard monitoring. Where possible, we combined data from included trials using standard inverse variance methods. Risk of bias assessment was performed using the Cochrane risk of bias tool. A de novo economic model was developed to assess the cost-effectiveness over a 10-year period.
We identified 26 RCTs (published in 45 papers) with a total of 8763 participants. CoaguChek was used in 85% of the trials. Primary analyses were based on data from 21 out of 26 trials. Only four trials were at low risk of bias. Major clinical events: self-monitoring was significantly better than standard monitoring in preventing thromboembolic events relative risk (RR) 0.58, 95% confidence interval (CI) 0.40 to 0.84; p = 0.004. In people with artificial heart valves (AHVs), self-monitoring almost halved the risk of thromboembolic events (RR 0.56, 95% CI 0.38 to 0.82; p = 0.003) and all-cause mortality (RR 0.54, 95% CI 0.32 to 0.92; p = 0.02). There was greater reduction in thromboembolic events and all-cause mortality through self-management but not through self-testing. Intermediate outcomes: self-testing, but not self-management, showed a modest but significantly higher percentage of time in therapeutic range, compared with standard care (weighted mean difference 4.44, 95% CI 1.71 to 7.18; p = 0.02). Patient-reported outcomes: improvements in patients' quality of life related to self-monitoring were observed in six out of nine trials. High preference rates were reported for self-monitoring (77% to 98% in four trials). Net health and social care costs over 10 years were £7295 (self-monitoring with INRatio2); £7324 (standard care monitoring); £7333 (self-monitoring with CoaguChek XS) and £8609 (self-monitoring with ProTime). The estimated quality-adjusted life-year (QALY) gain associated with self-monitoring was 0.03. Self-monitoring with INRatio2 or CoaguChek XS was found to have ≈ 80% chance of being cost-effective, compared with standard monitoring at a willingness-to-pay threshold of £20,000 per QALY gained.
Compared with standard monitoring, self-monitoring appears to be safe and effective, especially for people with AHVs. Self-monitoring, and in particular self-management, of anticoagulation status appeared cost-effective when pooled estimates of clinical effectiveness were applied. However, if self-monitoring does not result in significant reductions in thromboembolic events, it is unlikely to be cost-effective, based on a comparison of annual monitoring costs alone. Trials investigating the longer-term outcomes of self-management are needed, as well as direct comparisons of the various point-of-care coagulometers.
This study is registered as PROSPERO CRD42013004944.
The National Institute for Health Research Health Technology Assessment programme.
Aims Functional somatic symptoms (FSS) is an umbrella term for symptoms inadequately explained by structural disease or damage. FSS show complex causality, and fall between the gaps in mainstream ...medical epistemology and/or mind-body dualism. Lack of explanations for FSS exacerbates uncertainty, anxiety and stigma for patients, and contributes to fragmented care and inappropriate management. We aimed to develop an open access health-educational resource that provides an acceptable, relevant, and usable explanatory model of FSS to internet users. Methods We carried out a participatory design study to develop the website bodysymptoms.org. Explanatory concepts were developed through iterative stages of dialogue between individuals with lived experience of multi-system FSS (n = 7), researchers, healthcare professionals and designers/developers. Initial explanatory components were collected from currently existing patient education about FSS, a review of the literature, and participants’ illness narratives. Principles were developed to filter, and organize these explanatory components into a coherent model. The model was translated into 5 European languages and through iterative rounds of feedback incorporated a diverse range of perspectives. Results We describe the explanatory model that developed through the bodysymptoms project, and considerations that arose through the dialogic process. The model is based on the body as a complex adaptive system with causal interactions operating across bio-psycho-socio-ecological levels. Mechanistic processes that can maintain persistent symptoms were chosen as the main nodes (or topics) of the model, and minor topics were structured to demonstrate interactions between mechanisms. Considerations that arose during the process included coherence across philosophic, scientific and clinical levels of explanation; a therapeutic model of agency, within which explanations empowered without blame; the need to introduce notions of biological time, like body rhythms and body memory; and the role of multi-media, embodied metaphors and lived experience narratives in communication of the explanatory model. Personalisation of the model was achieved through embedding the structure of the model into the graphical and navigational structure of the website, which allows website visitors to explore the model in a non-linear manner, tailored by relevance, acceptability, and prefered level of information. Conclusion We present results from a research in action study to develop a novel resource for understanding functional somatic symptoms. bodysymptoms.org is based on the model of the body as a complex system that adapts in personal ways. To explain FSS there is a need for new ways to understand the body and how we become unwell. Bringing diverse perspectives into dialogue generated new forms of knowledge and allowed the power of scholarship to be harnessed for immediate shared value.
Dementia and diabetes mellitus are common long-term conditions that coexist in a large number of older people. People living with dementia and diabetes may be at increased risk of complications such ...as hypoglycaemic episodes because they are less able to manage their diabetes.
To identify the key features or mechanisms of programmes that aim to improve the management of diabetes in people with dementia and to identify areas needing further research.
Realist review, using an iterative, stakeholder-driven, four-stage approach. This involved scoping the literature and conducting stakeholder interviews to develop initial programme theories, systematic searches of the evidence to test and develop the theories, and the validation of programme theories with a purposive sample of stakeholders.
Twenty-six stakeholders (user/patient representatives, dementia care providers, clinicians specialising in dementia or diabetes and researchers) took part in interviews and 24 participated in a consensus conference.
The following databases were searched from 1990 to March 2016: MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, Scopus, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Database of Abstracts of Reviews of Effects, the Health Technology Assessment (HTA) database, NHS Economic Evaluation Database, AgeInfo (Centre for Policy on Ageing - UK), Social Care Online, the National Institute for Health Research (NIHR) portfolio database, NHS Evidence, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (Google Inc., Mountain View, CA, USA).
We included 89 papers. Ten papers focused directly on people living with dementia and diabetes, and the rest related to people with dementia or diabetes or other long-term conditions. We identified six context-mechanism-outcome (CMO) configurations that provide an explanatory account of how interventions might work to improve the management of diabetes in people living with dementia. This includes embedding positive attitudes towards people living with dementia, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. A general metamechanism that emerges concerns the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement. A flexible service model for people with dementia and diabetes would enable this synergy in a way that would lead to the improved management of diabetes in people living with dementia.
There is little evidence relating to the management of diabetes in people living with dementia, although including a wider literature provided opportunities for transferable learning. The outcomes in our CMOs are largely experiential rather than clinical. This reflects the evidence available. Outcomes such as increased engagement in self-management are potential surrogates for better clinical management of diabetes, but this is not proven.
This review suggests that there is a need to prioritise quality of life, independence and patient and carer priorities over a more biomedical, target-driven approach. Much current research, particularly that specific to people living with dementia and diabetes, identifies deficiencies in, and problems with, current systems. Although we have highlighted the need for personalised care, continuity and family-centred approaches, there is much evidence to suggest that this is not currently happening. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to the needs of people living with dementia and diabetes.
This study is registered as PROSPERO CRD42015020625.
The NIHR HTA programme.
Sources and selection criteria We conducted a PubMed search of evidence for diagnosis of functional neurological disorder (FND) until June 2020, especially systematic reviews.143031 We also relied on ...author research paper archives, and a recent international comprehensive textbook on FND (JS and AC were co-editors).32 The article was reviewed and improved by representatives from five patient organisations: FND Hope, FND Hope UK, FND Action, FND Dimensions, and FND Friends. Patients may also have other functional disorders such as irritable bowel syndrome, fibromyalgia, or chronic pelvic pain. Growing evidence supports the notion that in FND the early pre-conscious phases of motor planning are corrupted by a combination of abnormal involuntary brain-generated predictions about bodily states and interference from more emotionally orientated brain networks such as the limbic system and amygdala.678 For example, signs such as tubular visual field loss (see infographic) can be explained by considering the brain as a largely “predictive” organ which makes and tests predictions about the body rather than constructing perceptions from scratch. A systematic review and meta-analysis of 34 case-control studies of functional neurological disorder (FND) found that adverse events are more common in FND than in the general population (with an odds ratio of 2-4), but are certainly not always present, and their presence is not useful diagnostically.10 Exploring past traumatic life events may help with individual formulation of aetiology and future treatment, but doing so may also cause distress.
The occupational therapy (OT) in care homes study (OTCH) aims to investigate the effect of a targeted course of individual OT (with task training, provision of adaptive equipment, minor environmental ...adaptations and staff education) for stroke survivors living in care homes, compared to usual care.
A cluster randomised controlled trial of United Kingdom (UK) care homes (n = 90) with residents (n = 900) who have suffered a stroke or transient ischaemic attack (TIA), and who are not receiving end-of-life care. Homes will be stratified by centre and by type of care provided and randomised (50:50) using computer generated blocked randomisation within strata to receive either the OT intervention (3 months intervention from an occupational therapist) or control (usual care). Staff training on facilitating independence and mobility and the use of adaptive equipment, will be delivered to every home, with control homes receiving this after the 12 month follow-up.Allocation will be concealed from the independent assessors, but the treating therapists, and residents will not be masked to the intervention. Measurements are taken at baseline prior to randomisation and at 3, 6 and 12 months post randomisation. The primary outcome measure is independence in self-care activities of daily living (Barthel Activities of Daily Living Index). Secondary outcome measures are mobility (Rivermead Mobility Index), mood (Geriatric Depression Scale), preference based quality of life measured from EQ-5D and costs associated with each intervention group. Quality adjusted life years (QALYs) will be derived based on the EQ-5D scores. Cost effectiveness analysis will be estimated and measured by incremental cost effectiveness ratio. Adverse events will be recorded.
This study will be the largest cluster randomised controlled trial of OT in care homes to date and will clarify the currently inconclusive literature on the efficacy of OT for stroke and TIA survivors residing in care homes.
ISRCTN00757750.
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