Clinical Reference Group Research Articles

Impairments of executive function in young children referred to child psychiatric outpatient clinic.

Few studies have reported on the quantity and quality of executive function (EF) deficits in young children referred to child psychiatric outpatient clinic with multiple psychiatric symptoms. We evaluated the EF deficits with the Attention and Executive Function Rating Inventory-Preschool (ATTEX-P) filled out by day care teachers for 4- to 7-year-old clinical group ( n = 171) and reference group ( n = 709). Family background information was collected from all families by parent questionnaire. Diagnoses of the referred children were collected from medical records. Clinical group exhibited higher mean ranks across the ATTEX-P Total score and all nine subscales than reference group ( p < .001). Most of the children in the clinical group (58.5%) showed a significant amount of EF deficits (ATTEX-P Total score over clinical cut-off) including distractibility (55.6%) and impulsivity (53.8%) regardless of their diagnoses. In a multiple logistic regression model (controlling for age, gender and parental education), children in the clinical group had increased risk (odds ratio (OR)) = 10.6, 95% confidence interval (CI) = [6.88, 16.2], p < .001) for scoring over the clinical cut-off point on the ATTEX-P Total score. Assessment of EFs should be a routine part of the treatment plan in young children referred to child psychiatric outpatient clinic as it may guide the treatment choices.

Fear of Being Laughed at in Borderline Personality Disorder.

Building on the assumption of a possible link between biases in social information processing frequently associated with borderline personality disorder (BPD) and the occurrence of gelotophobia (i.e., a fear of being laughed at), the present study aimed at evaluating the prevalence rate of gelotophobia among BPD patients. Using the Geloph<15> , a questionnaire that allows a standardized assessment of the presence and severity of gelotophobia symptoms, rates of gelotophobia were assessed in a group of 30 female BPD patients and compared to data gathered in clinical and non-clinical reference groups. Results indicate a high prevalence of gelotophobia among BPD patients with 87% of BPD patients meeting the Geloph<15> criterion for being classified as gelotophobic. Compared to other clinical and non-clinical reference groups, the rate of gelotophobia among BPD patients appears to be remarkably high, far exceeding the numbers reported for other groups in the literature to date, with 30% of BPD patients reaching extreme levels, 37% pronounced levels, and 20% slight levels of gelotophobia.

Multiparametric MRI for early detection of diffuse liver disease: an interview with David Breen.

David J Breen is Associate Professor of Radiology and previous Clinical Director of Radiology at University Hospital Southampton. His interests are in abdominal imaging and intervention, particularly of hepato-pancreato-biliary (HPB)and renal disease. He has a major interest in image-guided tumor ablation and improving outcomes from these procedures. He has previously served as Vice Chair of the NHS England Clinical Reference Group in Interventional Radiology and for the NIHR/NCRN Upper GI Clinical Studies Group.

Why was a judicial review required to allow the English National Health Service to commission pre-exposure prophylaxis for HIV?

BackgroundFollowing research trial evidence, pre-exposure prophylaxis (PrEP), consisting of the drug combination tenofovir disoproxil and emtricitabine taken daily or episodically, was licensed to prevent HIV in high-risk individuals. In 2014, an NHS England (NHSE) HIV Clinical Reference Group outlined the position for commissioning PrEP. Despite stakeholders' belief that NHSE would adopt PrEP as a prevention strategy, NHSE announced in March 2016, that it did not have the legal authority to do so owing to the 2012 Health and Social Care Act, which devolved sexual health services to local authorities. This decision was met with criticism, and a judicial review was brought against NHSE by activists, which NHSE lost. This interview study explored the reasons for NHSE's original decision not to commission PrEP and the implications this has for commissioning prevention strategies. The transparency of NHSE's decision-making process, and the effect of recent health-care reforms were also explored. MethodsPurposive and snowball sampling methods were used to invite individuals to take part in semi-structured interviews. 15 interviewees (commissioners, activists, and individuals from national health bodies) were recruited. The interviews were anonymised and transcribed verbatim. Data saturation was reached, and two coders analysed the data using content analysis. FindingsParticipants cited the cost of PrEP as the reason behind NHSE's decision, especially in the context of austerity. Although NHSE's decision-making process was viewed positively, the final decision lacked transparency, highlighting a disconnect between the decision process and decision outcome. The Health and Social Care Act was viewed negatively with respect to deprioritisation of public health. InterpretationThe commissioning of prevention strategies is unclear while local authorities face budgetary cuts. This could mean future tensions leading to judicial reviews. However, NHSE losing the judicial review and the level of criticism may act as a deterrent to prevent future cases. Improved communication about roles and responsibilities, not least on the part of policy makers, are needed to help overcome tensions arising from the Health and Social Care Act. FundingKing's College London provided funds for expenses. PL and KK are supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London at King's College Hospital NHS Foundation Trust. The views expressed are not necessarily those of the NHS, the NIHR or the Department of Health.

The evolution of national care pathways in spinal cord injury management

Spinal cord injury service delivery in the UK has improved over the years. The modern concept of Spinal Cord Injury care commenced after the Second World War. Patients started to live longer after the improvement in the medical and nursing care which was delivered in Spinal Cord Injury Centres across the country. In the last five years, spinal cord injury care has seen major advances. The Spinal Cord Injury Strategy Board was established in 2010 which led to the development of the Spinal Injury Pathway, the Spinal Injury National database and the creation of the clinical reference group for Spinal Cord Injury. This led to improvement in the care of evidence-based management.

The Epidemiology of urological cancer 2001–2013

Background: The purpose of the NCRAS Urological Cancer Site-Specific Clinical Reference Group (SSCRG) is to link the knowledge of clinicians with the large amount of routine data collected by cancer registration. This study considers the latest available data and trends in incidence, mortality and survival and offers interpretation of findings in a clinical context. Methods: New diagnoses of urological cancer in England for 2001 to 2013 were extracted from the National Cancer Registration and Analysis Service (NCRAS). Deaths were counted from Office for National Statistics (ONS) data for the same years. Directly age-standardised rates (ASRs) and net survival were calculated. Results: Prostate cancer incidence has increased to 40,000 cases per year. Mortality rates are falling and hence the improvement seen in five-year survival is likely to be due to changes in treatment rather than artefact. Bladder cancer (including CIS and pTa disease) shows a stable incidence and decreasing mortality rates. Survival from T1–T4 bladder cancer is stable. There has been a marked rise in kidney cancer incidence in both sexes with a stable mortality. The stable mortality suggests that improved five-year survival may be an artefact due to increased detection as a result of more widespread use of diagnostic imaging. Incidence of upper-urinary-tract cancer has risen both for invasive and non-invasive disease, and mortality in men has risen for invasive disease. This may be down to better recognition and attribution of disease. Testicular cancer has shown little change. Deaths are now rare, and survival is the highest for any cancer. There have been no significant changes in penis cancer, which remains the rarest urological cancer. Conclusion: The epidemiological data suggest a generally improving picture for urological cancer. However, there are some areas which require further consideration. Population-based studies can show variation in rare cancers and highlight previously unrecognised inequalities.

Guidelines on transfusion for fetuses, neonates and older children.

Guidelines on transfusion for fetuses, neonates and older children.

Frontal Gamma Asymmetry Research in a Neurophenomenological Context

Neuroimaging studies examining the neurobiological basis of gambling disorder (GD) have increased over the past decade. Functional magnetic resonance imaging studies during appetitive cue and reward processing tasks demonstrate altered functioning in frontostriatal brain areas, including the ventral striatum and the ventromedial prefrontal cortex. Findings suggest differences in how the anticipation and outcome of rewards are processed in individuals with GD. Future research requires larger sample sizes and should include appropriate clinical reference groups. Overall, studies to date highlight a common pathophysiology between substance-based addictions and GD, the latter offering a unique condition in which to examine nonchemical factors in addiction.

Auditory verbal hallucinations (AVHs) and related psychotic phenomena in mood disorders: analysis of the 2010 Survey of High Impact Psychosis (SHIP) data

BackgroundAuditory verbal hallucinations (AVHs) are known to occur in mood disorders, but there has been scant research in the area. This paper aimed to explore the presence of hallucinations, and AVHs in particular, across affective disorders (with non-affective disorders serving as clinical reference groups). Specific attention was given to i) running commentary, ii) voices conversing, and iii) negative voices. A secondary aim was to examine patterns of associated delusional themes. MethodParticipants were 1550 Australians, aged 18–64 years, assigned to one of four groups on the basis of diagnosis: i) bipolar disorder (BD), ii) depressive psychosis (DP), iii) schizophrenia (SCZ), and iv) schizoaffective disorder (SAD). Relevant data collected from the 2010 Australian Survey of High Impact Psychosis (SHIP) was analysed. ResultsCurrent prevalence of hallucinations was such that BD<DP; severity of hallucinations, and AVHs in particular, was in the order BD=DP<SAD=SCZ. These results were statistically significant. Negative voices, and concomitantly, persecutory delusions, were prominent across all clinical groups. DiscussionFuture research should examine age of AVH onset as well as other forms of AVHs, whilst taking into account participants’ specific mood states.

Behind the scenes in neurology

British Journal of Neuroscience NursingVol. 12, No. 3 PolicyBehind the scenes in neurologySue ThomasSue ThomasSearch for more papers by this authorSue ThomasPublished Online:27 Jun 2016https://doi.org/10.12968/bjnn.2016.12.3.146AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References NHS England (2016a) Revisions to Clinical Reference Groups in Specialised Commissioning: Engagement Period Outcome Report. http://tinyurl.com/jdy5gqj (accessed 14 June 2016) Google ScholarNHS England (2016b) National programmes of care and clinical reference groups. http://tinyurl.com/jnexbdj (accessed 14 June 2016) Google ScholarNHS Right Care (2016) Right Care programme. http://tinyurl.com/z32n894 (accessed 14 June 2016) Google ScholarPublic Accounts Committee (2016) Services to people with neurological conditions: progress review. Conclusions and recommendations. Point 5. http://tinyurl.com/z2h928b (accessed 14 June 2016) Google ScholarPublic Health England/Right Care/NHS England (2015) Commissioning for Value: Integrated Care Pathways. NHS South Cheshire CCG http://tinyurl.com/z6nkhrk (accessed 14 June 2016) Google ScholarPublic Health England/Right Care/NHS England (2016a) Commissioning for Value: Comprehensive data packs to support CCGs and NHS England in the regions. http://tinyurl.com/jjbgj9w (accessed 14 June 2016) Google ScholarPublic Health England/RightCare/NHS England (2016b) Commissioning for Value: Where to Look. http://tinyurl.com/gt2lp9t (accessed 14 June 2016) Google ScholarWilliams A (2016) The future neuroscience national structures and expert advisory groups. Presentation to the West Midlands Neurology Commissioning Network. http://tinyurl.com/z2agm6p (accessed 14 June 2016) Google Scholar FiguresReferencesRelatedDetails 2 June 2016Volume 12Issue 3ISSN (print): 1747-0307ISSN (online): 2052-2800 Metrics History Published online 27 June 2016 Published in print 2 June 2016 Information© MA Healthcare LimitedPDF download

Guidelines for the follow-up of patients undergoing bariatric surgery.

Bariatric surgery can facilitate weight loss and improvement in medical comorbidities. It has a profound impact on nutrition, and patients need access to follow-up and aftercare. NICE CG189 Obesity emphasized the importance of a minimum of 2 years follow-up in the bariatric surgical service and recommended that following discharge from the surgical service, there should be annual monitoring as part of a shared care model of chronic disease management. NHS England Obesity Clinical Reference Group commissioned a multi-professional subgroup, which included patient representatives, to develop bariatric surgery follow-up guidelines. Terms of reference and scope were agreed upon. The group members took responsibility for different sections of the guidelines depending on their areas of expertise and experience. The quality of the evidence was rated and strength graded. Four different shared care models were proposed, taking into account the variation in access to bariatric surgical services and specialist teams across the country. The common features include annual review, ability for a GP to refer back to specialist centre, submission of follow-up data to the national data base to NBSR. Clinical commissioning groups need to ensure that a shared care model is implemented as patient safety and long-term follow-up are important.

Imaging the Gambling Brain.

Neuroimaging studies examining the neurobiological basis of gambling disorder (GD) have increased over the past decade. Functional magnetic resonance imaging studies during appetitive cue and reward processing tasks demonstrate altered functioning in frontostriatal brain areas, including the ventral striatum and the ventromedial prefrontal cortex. Findings suggest differences in how the anticipation and outcome of rewards are processed in individuals with GD. Future research requires larger sample sizes and should include appropriate clinical reference groups. Overall, studies to date highlight a common pathophysiology between substance-based addictions and GD, the latter offering a unique condition in which to examine nonchemical factors in addiction.

PTU-296 Evaluation of a regional teaching hospital’s 2 week wait gastrointestinal referral system from primary care against updated national figures:

<h3>Introduction</h3> The 2 week wait (2WW) system implemented in 2000 sought to stratify patients exhibiting high-risk symptoms for cancer, thereby establishing a dedicated pathway for urgent referrals. We audited the quality of GI 2WW referrals and their cancer conversion rate against the published literature. <h3>Method</h3> 1) All 2WW primary care referrals to BSUH gastroenterology over 3 weeks were prospectively analysed and followed up to diagnosis. 2) A 2009 systematic review¹was updated with more recent literature reports. <b>Inclusion Criteria</b>: All patients referred to our Digestive Disease Department as “2WW”. <h3>Results</h3> <b>Reasons for non-adherence:</b> No PR performed (37, 34%) No duration of symptoms (38, 35%) GI history unanswered (52, 48%) Family history unanswered (56, 52%) Additionally 5 (5%) were referred in an innapropriate age bracket. For UGI: 29 (43%) were referred with &gt;55 and dysphagia, 1 had cancer (3.4% risk from the symptom) 15 (22%) with dyspepsia, 0 had cancer 13 (19%) with unexplained weight loss, 0 had cancer For LGI: 46 (43%) were referred with &gt;60+BHC (bowel habit change), 2 had cancer (4.3% risk from the symptom) 26 (24%) with &gt;40 PR bleed + BHC, 1 had cancer (3.8% risk) 4 (4%) with palp PR mass and 1 had cancer (25% risk) <h3>Conclusion</h3> A published 2009 review¹indicated average cancer detection from 2WW referrals was 9.5% for LGI and 5.5% for UGI. A pubmed search for relevant GI 2WW articles combined with relevant GUT extracts found 26 later references. By combining total 2WW referrals and conversion rates from all studies, we found similar updated rates of 9.1% from 30237 referrals (LGI) and 6.7% from 10634 referrals (UGI). Our study adds weight to the growing evidence that, despite 2WW guidance stems from level 5 evidence, cancer conversion rates from 2WW referral is poor. In both our data and the literature, no criteria accurately predict cancer.² Additionally there is good evidence that lower quality referrals, lead to lower cancer detection rates^{3,4 and}a less effective service. The poor adherence to the referral criteria shown in our study may partly explain our particularly poor cancer conversion. We also suspect that historical underinvestment in the service, which led to long waiting times, may have tempted GPs to overstate the urgency of referrals, even though the endoscopy waits are now entirely within target. In an attempt to improve things, we have presented this data to our local clinical reference groups, and are exploring the difficulties encountered with the 2WW process from both sides, alongside ways in which we could improve the service. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Thorne 2009 Padwick 2013 Amin 2009 Jani 2012

I68. The Role of the NHS England Clinical Reference Group in Promoting Rheumatology and the Needs of Our Patients

I68. The Role of the NHS England Clinical Reference Group in Promoting Rheumatology and the Needs of Our Patients

NHS reforms in England: the implications for chemotherapy commissioning.

For oncology, one of the biggest effects of the reforms to the National Health Service (NHS) in England has been the designation of systemic anticancer treatments (other than hormonal agents) as a specialised service. This means that all decisions regarding the commissioning of chemotherapy are made at the national level via NHS England (NHSE), under expert guidance from the Chemotherapy Clinical Reference Group (CRG). Commissioning decisions will be based on several factors, not only clinical efficacy and cost/affordability, but also the ‘added value’ that a new treatment may offer in terms of patient outcomes, resource utilisation, and/or wider benefits to society. Oncology health-care professionals (HCPs) are in a position to affect cancer commissioning decisions in the reformed NHS, not only the small number who are members of the Chemotherapy CRG, but also as advisors to the Chemotherapy CRG via disease-specific consensus work, and through participation in the collection and reporting of real-life data on patient outcomes. With the emerging emphasis on both consensus work and outcomes data, a step change can also be expected in the relationship between HCPs and the pharmaceutical industry, including a strengthened role for non-promotional education, support for forums and consensus groups, and facilitation of the development, collection, and dissemination of findings from real-life practice. In addition, there will be an onus on the pharmaceutical industry to provide information on the implications that new products may have for service delivery and capacity and for meeting patients’ and society’s expectations. This information will need to be developed and delivered in a timely way, well in advance of the launch of a new product.

Complex symptomatology among young women who present with stress-related problems.

In Scandinavia and globally, mental health and stress-related problems among adolescent girls and young women are public health concerns that need attention. The aim of this study was to investigate mental health and somatic symptoms with a special focus on internalised problems, self-image and body-mind aspects of body perception in a group of adolescent girls and young women presenting with stress-related problems at a youth-friendly Swedish health centre, and to compare them with normative and clinical reference groups. The participants were 47 adolescent girls and young women, aged 17-25 years. The adult self-report (ASR), social analysis of social behaviour (SASB) and body perception questionnaire (BPQ) were used to measure multiple symptom areas. Compared to reference groups, adolescent girls and young women report complex symptomatology with high levels of internalised problems such as anxiousness, depression and somatic complaints. This manifested in attention problems, negative self-image and perceived bodily discomfort and distrust. Adolescent girls and young women emerging into adulthood present complex symptomatology of stress-related problems. This study gathered valuable information about their symptoms when they were seeking help. These young women showed higher symptom frequency than normative groups, and similar or higher symptom frequency than other clinical groups. Our findings of internalised and cognitive problems, including impaired self-image and body perceptions, point to the need for preventive strategies and tailored multidisciplinary interventions involving body-based methods to meet this complexity. Using tenets of stress theory, the complex symptomatology may be understood as logical responses to overwhelming stimuli and demands that exceed their ability to cope and disturb their 'equilibrium'. However, the complex gendered interplays between various external/internal stressors and a broad range of stress responses and health outcomes need further study in a long-term perspective.

Designing a safe and sustainable pediatric neurosurgical practice: the English experience.

The 2001 Report of the Public Inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995 stated that there must be standards for hospitals as a whole and that hospitals, which do not meet these standards, should not be able to offer services within the National Health Service (NHS). In 2013, agreed standards for pediatric neurosurgery were produced. Between 2001 and 2013 several key documents were published, which formed the background to the review that produced these standards:, the 'Safe and Sustainable' review. The process had the mission statement, 'Safe, sustainable and world class. Not ordinary, OK or just good enough.' In April 2013, the new commissioning structure of NHS England came into being. Clinical Reference Groups (reporting directly into the new structure) and pediatric neurosurgical operational delivery networks are taking the Safe and Sustainable pediatric neurosurgery standards and models of care into practice in England. Effective outcome data collection will allow us to assess whether these networks will improve equity of access for English children to world-class pediatric neurosurgical care and reduce the variation in outcomes seen at the present time.

Interventional radiology – current practice and future developments

Duncan Ettles is a consultant cardiovascular and interventional radiologist and honorary clinical professor in radiology based in Hull, UK. He graduated in Medicine with Honours from Edinburgh University Medical School (UK) and is a Fellow of the Royal College of Physicians and the Royal College of Radiologists. Professor Ettles is currently President of the British Society of Interventional Radiology and chairman of the Interventional Radiology Clinical Reference Group for NHS England. Throughout his career he has maintained an active role in teaching and training. He has published and lectured widely, both in the UK and overseas.

Funnel plots and spine surgery: unit level and surgeon level outcome data

Funnel plots and spine surgery: unit level and surgeon level outcome data

How much of socioeconomic differences in survival in patients with breast cancer can be explained by differences in stage of diagnosis and treatment? Application of causal mediation analysis to routine data

BackgroundSubstantial socioeconomic inequalities in breast cancer survival exist in England. Late presentation at more advanced stages and differential access to treatment are two main factors that might contribute to the survival differences. We aimed to adapt methods from the causal inference setting to examine what proportions of the differences in survival can be explained by these factors. MethodsInformation for 36 793 women diagnosed with breast cancer between 2000 and 2007 was gathered by the population-based Northern and Yorkshire Cancer Registry. Vital status was ascertained until the end of 2007, at which point 29 009 women were still alive. Information on surgical treatment was retrieved from the Hospital Episode Statistics (HES) dataset. Hierarchical matching was done using a unique identification number, date of birth, postcode, and sex. The OPCS-4 (Office of Population Censuses and Surveys Classification of Interventions and Procedures) codes from HES within 1 month before and 6 months after cancer diagnosis were dichotomised into major versus minor or no procedures using recommendations from a clinical reference group. Deprivation category, based on the indices of multiple deprivation (income domain), was allocated to each patient according to their area of residence at the time of diagnosis. G-computation procedures were used to estimate the proportion of the effect of deprivation on treatment mediated by stage, survival mediated by stage, and survival mediated by treatment. Single stochastic imputation was incorporated in the g-computation procedures to handle missing stage (8%). FindingsNet survival differed between the most affluent and the most deprived patients by 3·6% at 1 year (97·2% vs 93·6%) and 10·0% at 5 years (85·9% vs 75·9%) after diagnosis. Adverse stage distribution was associated with more deprived patients (localised stage 43% [2622 of 6045] in most affluent, 38% [2861 of 7489] in most deprived; distant metastasis 4% [224 of 6045] in most affluent, 6% [484 of 7489] in most deprived; p<0·0001). The more advanced the stage at diagnosis, the less likely the patient received major surgical treatment (p<0·0001). The most deprived patients were 9% (95% CI 1–18) more likely to receive major surgery than the most affluent patients. However, if most deprived patients had the stage distribution of the most affluent, they would be 8% (95% CI 5–13) more likely to receive such treatment. This effect was not noted for the other deprivation categories. The most deprived patients were almost three times more likely to die within 6 months after diagnosis than the most affluent patients (odds ratio 2·77, 95% CI 2·17–3·53); a third of this was mediated by adverse stage distribution (proportion mediated 0·35, 95% CI 0·23–0·48) whereas none was mediated through differential surgical treatment (p>0·5). InterpretationPreliminary results elucidate how much effect different contributory factors have on the differential short-term cancer survival between deprivation groups in patients with breast cancer. Efforts to advance diagnoses are important, but would reduce the socioeconomic inequalities in cancer survival by only a third. These results are based on population-based data—ie, they include virtually all patients diagnosed with a breast cancer in Yorkshire and the northeast of England, including those who were diagnosed with advanced stage and those who did not receive optimum treatment. Our study is nevertheless observational. We used a causal approach in which age, year of diagnosis, and regions of England were adjusted. We did not have reliable information on comorbidity, another potential mediator on the causal pathway. Quantifying the proportions of the deprivation gap mediated via comorbidity, stage, and treatment separately informs us about the parts they played and, ultimately, what could be done to most effectively reduce the deprivation gap in cancer survival. FundingNone.