Chaotic Lifestyles Research Articles

Nutritional status of people who inject drugs in Coastal Kenya: a cross-sectional study

IntroductionDespite documentation on injection drug use (IDU) in Kenya, the nutritional status of people who inject drugs (PWIDs) is under-explored. Elsewhere studies report under-nutrition among PWIDs which is attributed to food insecurity; competing priorities between drugs and food supply; chaotic lifestyle; reduced food intake; substance use induced malnutrition due to inflammation and comorbidities.MethodsThis was a cross-sectional study that sought to assess the nutritional status of PWIDs in Coastal Kenya. We recruited 752 participants of whom 371(49%) were on IDUs and 75 non-IDUs and 306 non-drug users using respondent driven sampling, traditional snowball, makeshift outreach and purposive sampling methods.ResultsMore than one half of the participants (56%) had BMI classified as normal while 35% had BMI < 18.5. The proportion with BMI < 18.5 was higher among IDUs (46%) compared to the non-IDUs (33%) and non-drug users (23%) at P < 0.001. Using the mid upper arm circumference (MUAC), 17% were classified as underweight and the proportion was lowest (11%) among non- drugs users compared to 22% among IDUs (P < 0.001). However, the IDUs had lower proportion of overweight (8.1%) compared to 55% among the non- drug users. The proportion with low waist-for-hip ratio was highest among the IDUs (74%) while high waist-for-hip ratio was lowest in the same group of IDUs (11%) at P < 0.001. One half (50%), of the participants had no signs of anaemia, (47%) had mild/moderate anaemia while 21 (2.8%) had severe anaemia. However, IDUs were more likely to be overweight based on waist circumference as a parameter. The IDUs had the highest proportion (54%) of mild to moderate anaemia compared to non-IDUs (37%) and 40% non- drug users (P < 0.001). In the multivariable models, IDUs (aRRR 2.83 (95%CI 1.84‒4.35)) and non-IDUs (aRRR 1.42 (95%CI 1.07‒1.88)) compared to non- drug users were positively associated with BMI < 18.5. Being an IDU was positively associated with mild or moderate anaemia (aRRR 1.65 (95%CI 1.13‒2.41)) while non-IDUs were positively associated with severe anaemia (aRRR 1.69 (95%CI 1.16‒2.48)).ConclusionA significant proportion of the participants were under-nourished with those injecting drugs bearing the heaviest brunt. Being an IDU was positively associated with the low BMI, MUAC, waist for hip ratio and mild or moderate anaemia but high waist circumference. People who inject drugs have high risk for under-nutrition and should be targeted with appropriate interventions.

The trials and tribulations of linking real-world data: When research doesn’t go quite as planned

ObjectiveDrawing upon learning from bringing youth justice data into SAIL Databank, this paper will focus some of the challenges associated with using real world data, and the implications that this for the research.&#x0D; MethodsAs part of a feasibility study model how the probability of further offending changes over time for children looked after relative to their peers, two local authorities agreed to share historic risk assessment data. This was then linked to linking education, social services, health and family court data. The temporal coverage of the data was such that records did not go back to birth in many instances, and the chaotic lifestyles of some of the data subjects meant that it was not possible for an ALF to be created.&#x0D; ResultsAn examination of the match rates highlights where there may well be issues for other researchers wishing to understand the vulnerabilities and circumstances of those in the criminal justice system through larger datasets. Whilst the quality of the data provided placed limitations on the study, the exercise also demonstrated the potential opportunities afforded by data linkage to identify how best to support those with complex lives as they navigate the justice system. As one of the first Welsh studies, this study highlights the richness of the social science datasets available to researchers who are concerned with interface between justice and devolved policy areas.&#x0D; ConclusionWhilst not all of the objectives of the study could be realised, the insights gained represent a methodological advancement, and contribute to understandings of the realities of working with real world data.

Oral health of people experiencing homelessness in London: a mixed methods study

BackgroundThose experiencing homelessness have significant health and oral health needs and are at the extreme of health inequalities. The aim of the study was to conduct an oral health needs assessment for those experiencing homeless in London and impacts on their oral health-related quality of life.MethodsThe oral health needs assessment consisted of quantitative and qualitative methods. This included a survey questionnaire to assess perceived oral health needs, and oral health related quality of life. In addition, a focus group was conducted with 13 peer advocates.ResultsFindings from the focus group revealed numerous challenges for homeless populations to maintain good oral health and access to dental care including mental ill-health, stigma, costs, and chaotic lifestyles. A response rate of 79% (n = 315) was achieved for the questionnaire survey. Results showed high levels of unmet dental needs and risky health behaviours including 60% reporting being smokers, 39% consuming high amounts of sugar and 52.4% brushing their teeth less than twice a day. More than a third (32.1%) had experienced toothache. The majority of respondents 80% (n = 224) were very or fairly concerned about their dental health. There were significant associations between perceived oral health status and oral health-related quality of life.ConclusionThose experiencing homelessness in London were found to have high levels of unmet oral health needs, which significantly impacted on their oral health-related quality of life. Focusing on changing behaviours alone is insufficient and therefore addressing the structural determinants of homelessness is vital in improving oral and health outcomes of this vulnerable population.

#6211 THE OPPORTUNITY COSTS EXPERIENCED BY PATIENTS WHO INJECT DRUGS UNDERGOING HAEMODIALYSIS: A CASE SERIES

Abstract Background and Aims Patients who inject drugs (PWIDs) represent a uniquely difficult population to manage with haemodialysis, often with reliance on tunneled venous access. This population is historically difficult to reach, and their care is usually associated with higher per capita healthcare costs [1], unsurprisingly poor outcomes are reported [2] with a multitude of likely causes. Here we show the time associated opportunity costs these patients experience including the significant complication of tunnelled dialysis line infection in a person who actively injects drugs. Method This study follows on from the work by Burns [3]. In this retrospective observational study, the electronic health records of patients who were known to be ongoing users of recreational drugs were reviewed from January 2015 – August 2021. Patients were reviewed from their first tunneled line placement until either their death or until the end of the study time period. Stata 14 was used to generate descriptive statistics. Results 6 Patients were identified, 5 had a primary diagnosis of AA Amyloidosis with the other being IgA. This cohort of patients did poorly, 5 out of 6 of the cohort had died with a mean survival of 27 months. Patients were followed for an average of 769 days (range 485 - 1052). The majority of this time alive was spent as an inpatient with the mean percentage of time as an inpatient being 55% (Range 35–81%) with a mean of 411 total inpatient days. The first confirmed bacteraemia occurred within the first 100 days in 4 out of 6 of the patients. Conclusion With this case series we demonstrate the opportunity cost PWIDs experience in the form of time spent as an inpatient. This cost is further added to by the burden of outpatient maintenance haemodialysis. Consideration should also be given to the excess burden their care places on over-stretched healthcare systems. Infections and dialysis compliance are key components in the care of PWIDs and while moving away from tunneled access should be sought whenever possible a multidisciplinary approach should also be considered; these patients commonly lead chaotic lifestyles and in-center dialysis is usually the only option. Including addiction, social and psychiatric services alongside dialysis may be a way to engage with this historically difficult to reach population. The hope is that this study provides the incentive for further studies focusing on the opportunity costs and the quality of life this population can expect when embarking on haemodialysis. This would provide patients with realistic expectations while also aiding clinicians in navigating this difficult ethical situation.

Analysis of Sleep apnea Considering Electrocardiogram Data Using Deep learning Algorithms

Sleep is a vital component of every human being. Adequate restful and restorative sleep reenergizes the body, enhances overall health and psychological well-being. Sleep hygiene, chaotic lifestyles, disorder breathing, stress, and anxiety contribute to poor sleep quality. Obstructive sleep apnea (OSA) sleep respiratory disorder causes temporary lapses of breathing results in gasping, choking, snoring sounds during sleep. The individual does not consciously wake up, but the brain has to start breathing again which disrupts the sleep quality. Polysomnography (PSG) sleep study is employed to diagnose sleep disorders by using either in-home or laboratory-based comprehensive tests. The untreated OSA leads to deterioration in health, performance consequences with severity including daytime sleepiness, motor vehicle accidents, workplace errors, cardiovascular morbidity, and mortality. The pre-processed, interpolated and segmented ECG signal is considered for the examination of OSA. This paper focuses on three types of deep learning classifiers-based prediction models for detection of apnea from the ECG signal. The accuracy value of Long Short Term Memory model (LSTM) is 85 percent and classifier’s ability to distinguish between normal and apnea events is 0.88.The Gated Recurrent Unit (GRU) classifier and Convolution Neural Network (CNN) model have an f1- score value of 0.80. The proposed LSTM model provides the optimal performance in comparison to other deep learning models used for classification with respect to area under the curve (AUC) and accuracy metrics.

Transportation as a barrier to colorectal cancer care

BackgroundTransportation barriers limit access to cancer care services and contribute to suboptimal clinical outcomes. Our objectives were to describe the frequency of Veterans reporting and the factors associated with transportation barriers to or from colorectal cancer (CRC) care visits.MethodsBetween November 2015 and September 2016, Veterans with incident stage I, II, or III CRC completed a mailed survey to assess perceived barriers to recommended care. Participants who reported difficulty with transportation to or from CRC care appointments were categorized as experiencing transportation barriers. We assessed pairwise correlations between transportation barriers, transportation-related factors (e.g., mode of travel), and chaotic lifestyle (e.g., predictability of schedules), and used logistic regression to examine the association between the reporting of transportation difficulties, distance traveled to the nearest Veterans Affairs (VA) facility, and life chaos.ResultsOf the 115 Veterans included in this analysis, 18% reported experiencing transportation barriers. Distance to the VA was not strongly correlated with the reporting of transportation barriers (Spearman’s ρ = 0.12, p = 0.19), but chaotic lifestyle was both positively and significantly correlated with experiencing transportation barriers (Spearman’s ρ = 0.22, p = 0.02). Results from the logistic regression model modestly supported the findings from the pairwise correlations, but were not statistically significant.ConclusionsTransportation is an important barrier to or from CRC care visits, especially among Veterans who experience greater life chaos. Identifying Veterans who experience chaotic lifestyles would allow for timely engagement in behavioral interventions (e.g., organizational skills training) and with support services (e.g., patient navigation).

Targeted HIV screening in the emergency department.

Despite considerable improvement in human immunodeficiency virus (HIV) knowledge and treatment in the last 3 decades, the overall number of people living with HIV (PLHIV) is still rising with up to one quarter being unaware of their HIV status. Early HIV diagnosis and treatment prolongs life, reduces transmission, improves quality of life, and is a cost-effective public health intervention. The emergency department (ED) sees a large number of patients from marginalized and traditionally underserved populations in whom HIV is known to be more prevalent and who may notattend traditional services because of either cultural reasons or because of a chaotic lifestyle. This article discusses the two main approaches to screening; 'Opt-out' screening offers testing routinely in all clinical settings, and 'Targeted' screening offers testing to individuals presenting with indicator conditions. There are many studies of 'Opt-out' ED HIV screening in urban areas of high-HIV prevalence. However, little is known about the effectiveness of 'targeted' HIV screening, especially in areas of low prevalence. This review discusses the background to HIV screening in the ED and reviews the evidence around 'targeted' HIV screening in adult EDs in different HIV prevalence settings, concluding that targeted HIV screening at the ED can be impactful, cost-effective, and well accepted in the ED population, but its long-term implementation requires extra funding and increased staffing resource limiting its application in low resource setting. Despite most evidence being from areas of high-HIV prevalence, targeted screening might also be appropriate in low-HIV prevalence areas.

People who use drugs in rehabilitation, from chaos to discipline: Advantages and pitfalls: A qualitative study.

Evidence-based models emphasizing on lifestyle behaviours for the treatment of drug use is still in its infancy. The development of multicomponent effective drug use intervention programs as part of health promotion is crucial to decrease risk of relapse. This study aims at exploring the lifestyle practices including dietary intake, physical activity and sleep of people who use drugs undergoing residential rehabilitation treatment in Lebanon with its perceived benefits and pitfalls. A purposive sample of 18 males and 9 females at different stages of recovery from drug use in rehabilitation centers participated in the qualitative discussions. The six phases thematic analysis revealed three themes: chaotic lifestyle, structuredlifestyle, benefits and pitfalls, and suggestions for making rehabilitation a better experience. Participants discussed their chaotic lifestyle during addiction with poor food intake, disrupted sleep and low physical activity moving to a more disciplined routine enforcing normality in lifestyle practices with social and professionlprofessional support. The early phases of treatment were marked with increased food intake and weight gain perceived as a health indicator and the sole divergent from drugs, moving towards more structured meals and efforts to lose weight in later stages. Lack of variety of Physical activity programs taking into consideration the motivational differences among the participants was also highlighted. Measures for improving rehabilitation services in terms of promoting healthy eating behaviours and environmental control were thoroughly addressed. These findings shed the light on the challenges faced in maintaining a healthy lifestyle in rehabilitation centers and the necessities of addressing them to improve the overall rehabilitation experience, prevent relapse and inform the development of future targeted intervention programs tackling all aspects of behavioural changes.

Applying a Social Exclusion Framework to Explore the Relationship Between Sudden Unexpected Deaths in Infancy (SUDI) and Social Vulnerability.

Background: Sudden Unexpected Death in Infancy (SUDI) is a leading cause of preventable infant mortality and strongly associated with social adversity. While this has been noted over many decades, most previous studies have used single economic markers in social disadvantage analyses. To date there have been no previous attempts to analyze the cumulative effect of multiple adversities in combination on SUDI risk.Methods: Based on sociological theories of social exclusion, a multidimensional framework capable of producing an overall measure of family-level social vulnerability was developed, accounting for both increasing disadvantage with increasing prevalence among family members and effect of family structures. This framework was applied retrospectively to all cases of SUDI that occurred in Queensland between 2010 and 2014. Additionally, an exploratory factor analysis was performed to investigate whether differing “types” of vulnerability could be identified.Results: Increased family vulnerability was associated with four major known risk factors for sudden infant death: smoking, surface sharing, not-breastfeeding and use of excess bedding. However, families with lower levels of social vulnerability were more likely to display two major risk factors: prone infant sleep position and not room-sharing. There was a significant positive relationship between family vulnerability and the cumulative total of risk factors. Exploratory factor analysis identified three distinct vulnerability types (chaotic lifestyle, socioeconomic and psychosocial); the first two were associated with presence of major SUDI risk factors. Indigenous infants had significantly higher family vulnerability scores than non-Indigenous families.Conclusion: A multidimensional measure that captures adversity across a range of indicators highlights the need for proportionate universalism to reduce the stalled rates of sudden infant death. In addition to information campaigns continuing to promote the importance of the back-sleeping position and close infant-caregiver proximity, socially vulnerable families should be a priority population for individually tailored or community based multi-model approaches.

Qualitative evaluation of asthma services for young people: a sequential simulation study

BackgroundAsthma is the most common chronic disease of childhood and an important preventable cause of mortality in children and young people (CYP). Few studies have brought together CYP and health...

Working with addicted patients - meaning, recognition and management

Introduction : Drug abuse is common and is on the rise. Addiction usually occurs among younger people. The risk of dealing with drug addicts is high. Aim : The purpose is to analyze the risks, importance and guidelines in management when dealing with drug addicted individuals, which determines the approach and specifics of their treatment. Material s and Methods: A critical analysis has been made on the available scientific literature over the past 10 years. The results of articles published in Pubmed, Google Scholar, PubMed Central, and ScienceDirect were analyzed and compared. Our own study was conducted among 47 patients on methadone treatment. Results: Opiate addiction, most commonly heroin, is one of the forms of drug abuse that is considered to be potentially harmful. Other commonly used drugs are the stimulants amphetamines, cocaine and methamphetamines. Dependent individuals lead a chaotic lifestyle, neglecting nutrition, health and personal hygiene, incl. oral hygiene. Very often, drug users are at great risk, such as overdose, infectious diseases and subsequent complications of non-treatment. Conclusion : A proper approach to drug addicts is needed to protect doctors and patients, and in order to achieve a better physical, mental and emotional, incl. oral health. Recognizing drug addicts and treating them properly are key points in good management.

Provider and patient perspectives on barriers to buprenorphine adherence and the acceptability of video directly observed therapy to enhance adherence

BackgroundBuprenorphine effectively reduces opioid craving and illicit opioid use. However, some patients may not take their medication as prescribed and thus experience suboptimal outcomes. The study aim was to qualitatively explore buprenorphine adherence and the acceptability of utilizing video directly observed therapy (VDOT) among patients and their providers in an office-based program.MethodsClinical providers (physicians and staff; n = 9) as well as patients (n = 11) were recruited from an office-based opioid treatment program at an urban academic medical center in the northwestern United States. Using a semi-structured guide, interviewers conducted individual interviews and focus group discussions. Interviews were digitally recorded and transcribed verbatim. Transcripts were independently coded to identify key themes related to non-adherence and then jointly reviewed in an iterative fashion to develop a set of content codes.ResultsAmong providers and patients, perceived reasons for buprenorphine non-adherence generally fell into several thematic categories: social and structural factors that prevented patients from consistently accessing medications or taking them reliably (e.g., homelessness, transportation difficulties, chaotic lifestyles, and mental illness); refraining from taking medication in order to use illicit drugs or divert; and forgetting to take medication, especially in the setting of taking split-doses. Some participants perceived non-adherence to be less of a problem for buprenorphine than for other medications. VDOT was viewed as potentially enhancing patient accountability, leading to more trust from providers who are concerned about diversion. On the other hand, some participants expressed concern that VDOT would place undue burden on patients, which could have the opposite effect of eroding patient-provider trust. Others questioned the clinical indication.ConclusionsFindings suggest potential arenas for enhancing buprenorphine adherence, although structural barriers will likely be most challenging to ameliorate. Providers as well as patients indicated mixed attitudes toward VDOT, suggesting it would need to be thoughtfully implemented.

Risk of cancer in patients with eating disorders: A population-based study

Objectives: Patients with eating disorder (ED) have been associated with some risk factors for cancer, including nutritional deficiency, chaotic life styles, alcohol or tobacco use, dysfunctional immune system, and impaired organ functions. In this study, we intended to study the risk of cancer in ED patients. Methods: During the period of January 1998 to December 2013, 13,755 ED patients were identified from Taiwan's National Health Insurance Research Database. We enrolled 13,276 patients as study cohort, and 53,104 patients that had never been diagnosed with ED as age- and sex-matched comparisons. Participants were monitored for diagnoses of cancer during the follow-up period. We used the Cox proportional hazards model to investigate the risk of cancer between patients with ED and those without ED. Results: Compared with the non-ED controls, the study cohort had significantly higher prevalence of comorbidities, alcohol abuse, tobacco use disorder, and chronic obstructive pulmonary disease. After adjusting demographic data and comorbidities, there was no significant risk for later occurrence of cancer in ED patients, irrespective of anorexia nervosa (AN) type (hazard ratio [HR] = 1.10, 95% confidence interval [CI], = 0.83 – 1.47, nonsignificant difference) or non-AN type (HR = 0.98, 95% CI = 0.79 – 1.23, nonsignificant difference). Conclusion: There is no established evidence to support the relationship between cancer incidence and ED.

Scheduled care-As a way of caring: A phenomenological study of being cared for when suffering from alcohol use disorders.

To elucidate the lived experience of how patients with alcohol use disorders experience being cared for when admitted to acute medical units. Alcohol use is health damaging and is identified as one of the major avoidable risk factors, and alcohol use disorder is classified among the most harmful, debilitating disease categories. Patients suffering from alcohol use disorders are characterised by complex problems and health pictures spawned by chaotic lifestyles. However, the experience of the hospitalisation from patients' perspective is poorly documented. The present study has a qualitative research design and is anchored in phenomenological and hermeneutical methodology, as described in reflective lifeworld research. The data set consists of 15 in-depth interviews with patients suffering from alcohol use disorders admitted to an acute medical unit. A purposive sampling strategy was used, and the interviews were conducted as open dialogues. The study was reported in accordance with the consolidated criteria for reporting qualitative research. Being cared for when hospitalised was experienced as a two-stage process that changed throughout the hospitalisation from an experience of scheduled care experienced as caring to an experience of scheduled care experienced as non-caring. Four constituents further described the variable experiences: being in a safe haven, sharing a tacit but mutual goal, being in a chaotic space and being on your own. The study showed that being met in an authentic presence by nurses was a powerful tool that helped ease the hospitalisation. Patients suffering from alcohol use disorders call for an intentional and distinctive attentiveness and authentic presence from the nurses throughout their hospitalisation. Our findings highlight that patients suffering from alcohol use disorders call for an intentional and distinct attentiveness from nurses throughout the hospitalisation, where a possible transfer of attention is noticed and responded to in the care provided.

Performances Analysis of Heart Disease Dataset using Different Data Mining Classifications

nowadays, heart disease is one of the major diseases that cause death. It is a matter for us to concern in today’s highly chaotic life style that leads to various diseases. Early prediction of identification to heart-related diseases has been investigated by many researchers. The death rate can be further brought down if we can predict or identify the heart disease earlier. There are many studies that explore the different classification algorithms for classification and prediction of heart disease. This research studied the prediction of heart disease by using five different techniques in WEKA tools by using the input attributes of the dataset. This research used 13 attributes, such as sex, blood pressure, cholesterol and other medical terms to detect the likelihood of a patient getting heart disease. The classification techniques, namely J48, Decision Stump, Random Forest, Sequential Minimal Optimization (SMO), and Multilayer Perceptron used to analyze the heart disease. Performance measurement for this study are the accuracy of correct classification, mean absolute error and kappa statistics of the classifier. The result shows that Multilayer Perceptron Neural Networks is the most suited for early prediction of heart diseases.

Factors Associated with Perceived Life Chaos among Post-Myocardial Infarction Survivors in a Malaysian Cardiac Care Facility.

Background and objectives: Survivors of chronic life-threatening conditions like myocardial infarction (MI) are often confronted with multiple physical and psychological stressors as a consequence of elevated demands of lifestyle adjustments and modifications. Such stressors, collectively known as “life chaos”, cause disruption to one’s lifestyle equilibrium of having organized, calm, and regular routines. The objective of the current study was to determine the level of life chaos and its associated correlates among post-myocardial infarction (post-MI) survivors in Malaysia. Materials and Methods: An analytical cross-sectional study was conducted among 242 post-MI survivors in a Malaysian cardiac health facility from July to September 2016. A self-administered questionnaire in Malay that consisted of items on socio-demographics, health attributes, validated OSLO-3 Social Support Scale (OSS-3), and the Modified Confusion, Hubbub, and Order Scale (CHAOS-6) was utilized in this study. Descriptive, bivariate, and multivariate analyses were conducted. Results: The sample constituted of 208 (86%) men and 34 (14%) women. The average age was 55 years (SD = 11), and the age ranged between 24 and 96 years. Overall, 128 (52.9%) of the total post-MI survivors had highly chaotic lives. In multivariate analysis, younger age, lower household income, perceived financial insecurity, poor health status, and multiple comorbidities were related to the high chaos score, and these associations were statistically significant (p < 0.05). Conclusions: Highly chaotic lifestyles were prevalent in post-MI survivors. Demographic, health attributes, and socio-economic factors were important correlates of life chaos.

The feasibility of following up prisoners, with mental health problems, after release: a pilot trial employing an innovative system, for engagement and retention in research, with a harder-to-engage population

BackgroundFollowing up released prisoners is demanding, particularly for those prisoners with mental health problems, for whom stigma and chaotic lifestyles are problematic. Measurement of mental health outcomes after release is challenging. To evaluate mental healthcare for offender populations, using high-quality randomised controlled trials, evidenced-based methods must be developed to engage them while in custody, to locate and re-interview them after release, and to collect potentially stigmatising mental health outcomes data.MethodsWe developed an initial theoretical model and operational procedures for collecting baseline and follow-up data informed by a literature search, focus groups, and case studies. Male prisoners from five prisons in two sites were invited to participate. The inclusion criteria included individuals who were above threshold on nine-item Patient Health Questionnaire, seven-item Generalized Anxiety Disorder, or post-traumatic stress disorder scales, or who had reported mental health problems in the past 2 years or had been assessed with a likely personality disorder. Potential participants were interviewed to generate baseline data and were re-contacted before their release. We then contacted them for a follow-up interview, which included repeating the earlier data collection measures 2–8 weeks after release. A qualitative formative process evaluation produced and refined a model procedure for the recruitment and retention of male prison leavers in trials, identified the mechanisms which promoted engagement and retention, and mapped these against a theoretical behaviour change model.ResultsWe developed a flexible procedure which was successful in recruiting male prison leavers to a pilot trial: 185/243 (76%, 95% confidence interval (CI) 70–81%) of those approached agreed to participate. We also retained 63% (95% CI 54–71%) of those eligible to participate in a follow-up interview 2–8 weeks after release. Mental health outcomes data was collected at both these time points.ConclusionsIt is possible to design acceptable procedures to achieve sustained engagement critical for delivering and evaluating interventions in prison and in the community and to collect mental health outcomes data. These procedures may reduce attrition bias in future randomised controlled trials of mental health interventions for prison leavers. This procedure has been replicated and successfully delivered in a subsequent pilot trial and a definitive randomised controlled trial.

Exploration of the influence of insecure attachment and parental maltreatment on the incidence and course of adult clinical depression.

Both childhood maltreatment and insecure attachment are known to be associated with depression in adulthood. The extent insecure attachment increases the risk of adult clinical depression over that of parental maltreatment among women in the general population is explored, using those at high risk because of their selection for parental maltreatment together with an unselected sample. Semi-structured interviews and investigator-based measures are employed. Insecure attachment is highly associated with parental maltreatment with both contributing to the risk of depression, with attachment making a substantial independent contribution. Risk of depression did not vary by type of insecure attachment, but the core pathways of the dismissive and enmeshed involved the whole life course in terms of greater experience of a mother's physical abuse and their own anger as an adult, with both related to adult depression being more often provoked by a severely threatening event involving humiliation rather than loss. By contrast, depression of the insecure fearful and withdrawn was more closely associated with both current low self-esteem and an inadequately supportive core relationship. In terms of depression taking a chronic course, insecure attachment was again a key risk factor, but with this now closely linked with the early experience of a chaotic life style but with this involving only a modest number of women. Both insecure attachment and parental maltreatment contribute to an increased risk of depression with complex effects involving types of insecure attachment.

Participants’ experiences of ketamine bladder syndrome: A qualitative study

The aim of this study is to explore recreational ketamine users’ experiences of ketamine bladder syndrome (KBS) and related health care provision issues. KBS is an emerging condition caused by chronic, recreational ketamine use, which can result in extensive, irreparable damage to the bladder and urinary tract. However, little is yet known about how patients are personally affected by the condition, their help seeking behaviour or experiences of related health care services. A qualitative study, informed by Heideggerian hermeneutics was undertaken. Twelve participants affected by KBS were purposively recruited into the study from an National Health Service (NHS) continence service and a drug support agency in South Wales, UK. Data were collected through recorded, semi‐structured interviews and analysed using a three‐step approach. Participants were predominantly younger, poly‐drug users and typically developed KBS following prolonged, habitual ketamine use. The effects of KBS were considerable and included incontinence, haematuria, profound abdominal pain and embarrassment and were exacerbated by delays in help seeking, disjointed medical care and on‐going ketamine use, which was integral to the self‐management of KBS pain. KBS has significant impact on those affected and can result in extensive, irreversible damage to the bladder and urinary tract. The condition, and its management, is further compounded by chronic poly‐drug use, chaotic lifestyles and a range of complex, related co‐morbidities, which require a collaborative, multi‐disciplinary approach. Anderson's behavioural model of health services use provides an appropriate framework for better understanding help seeking/avoidance behaviour in this cohort, which can help inform clinical practice.

The role of joint working between primary and secondary care in supporting people with type 1 diabetes

The role of joint working between primary and secondary care in supporting people with type 1 diabetes