NHS Setting Research Articles

Support workers knowledge, skills and education relating to dementia – a national survey

Background Dementia affects over 55 million people globally, projected to double by 2050. In the UK, non-registered staff, including healthcare assistants (HCAs) and clinical support workers, provide a significant portion of dementia care, yet receive limited training. This study explores the knowledge, training, and attitudes of support workers towards dementia. Methods A cross-sectional web-based survey was conducted from February 1 to April 1, 2024, targeting support workers in England. The survey included demographic information, dementia knowledge (using the Dementia Knowledge Assessment Scale, DKAS), and attitudes (using the Dementia Attitudes Scale, DAS). Data were analysed using descriptive statistics, ANOVA, t-tests, and Pearson’s correlation. Results One hundred and nine support workers responded, predominantly female (90%) and white British (76.4%), from various NHS settings and occupational groups. The majority (79.8%) had received dementia training, primarily from their organisations. Challenges included managing behavioural and psychological symptoms and communication difficulties. There was no significant correlation between years of experience and dementia knowledge (r = -0.019) or attitudes (r = -0.057). However, higher occupational grades were associated with greater dementia knowledge (p = <0.01). A moderate positive correlation was found between dementia knowledge and attitudes (r = 0.35, p = <0.01). Despite high levels of knowledge, support workers often feel inadequately prepared to provide optimal dementia care, indicating a need for more comprehensive training. Challenges in communication and managing symptoms highlight areas for improvement. The study suggests that better training can improve both knowledge and attitudes, enhancing care quality for people living with dementia. Conclusion Support workers play a crucial role in dementia care but require more robust training programs to meet the growing demands. Enhanced training can improve their knowledge and attitudes, leading to better care outcomes for people with dementia.

Experiences, acceptability and feasibility of an isometric exercise intervention for stage 1 hypertension: embedded qualitative study in a randomised controlled feasibility trial

BackgroundHealthy lifestyle changes for patients with stage 1 hypertension are recommended before antihypertensive medication. Exercise has antihypertensive benefits; however, low adoption and high attrition are common. Patients need easily adoptable, effective and manageable exercise interventions that can be sustained for life. We present participant and stakeholder perceptions of an isometric exercise intervention for stage 1 hypertension delivered in the National Health Service (NHS, UK).MethodsAn embedded qualitative study within a randomised-controlled feasibility study included intervention arm participants (n = 10), healthcare professionals from participating NHS sites (n = 3) and non-participating NHS sites (n = 5) taking part in semi-structured interviews to explore feasibility of delivering an isometric exercise intervention within the study design and an NHS context. Data was analysed using reflective thematic analysis.ResultsThree themes were identified: study deliverability; motivators and barriers; support for study participation. Findings indicated that the study was well designed. Health benefits, unwillingness to take medication, altruism and interest in the study helped motivation and adherence. Study support received was good, but healthcare professionals were insecure in intervention delivery with regular training/supervision needed. Perception of health improvement was mixed, but, in some, uptake of wider lifestyle changes resulted from participation. Stakeholders felt that current service challenges/demand would make implementation challenging.ConclusionsDespite participant positivity, delivery of an isometric intervention in an NHS setting was considered challenging given the current service demand, although possible with robust effectiveness evidence. Findings support further effectiveness data and implementation development of the isometric exercise intervention.Trial registrationISRCTN, ISRCTN13472393. Registered 18 September 2020.

CSP2023: 433 - Characteristics of patients attending for MSK corticosteroid injections in an NHS setting

CSP2023: 433 - Characteristics of patients attending for MSK corticosteroid injections in an NHS setting

E041 Feasibility and acceptability of electronic patient reported outcome measures in the routine care of people with inflammatory arthritis: Haywood Arthritis Portal study

Abstract Background/Aims Electronic patient-reported outcome measures (ePROMs) assessing disease activity, function, pain, and quality of life can facilitate innovative inflammatory arthritis (IA) care, such as automating patient-initiated follow-up. This mixed-methods study evaluated whether their use is feasible and acceptable in routine care of people with inflammatory arthritis in an NHS setting. Methods The Haywood Arthritis Portal (HAP) is an NHS co-designed online patient platform, enabling people with IA under the Midlands Partnership University NHS Foundation Trust (MPFT) to enter ePROMs using any internet-enabled device. People with IA attending recruiting clinics from January-October 2023 received text message/letter invitations to complete HAP pre-appointment. Non-completers could complete HAP on tablets at the clinic. Consenters also completed a survey assessing ePROMs acceptability and HAP usability. Responses were summarised as proportions, stratified by age, gender, IA type, and home/clinic-completion status. Purposively sampled survey-completers participated in semi-structured interviews, providing deeper understanding of ePROMs/HAP feasibility/acceptability. This abstract presents data from an interim analysis of consenting patients with available survey and case report form data. Results Survey Population: 210 patients were included: 107 (51%) home-completers; 98 (47%) clinic-completers; 5 (2%) HAP non-completers; 70% female; mean age 60 years. Most had RA (70%), followed by Axial SpA (15%), undifferentiated IA (8%), and PsA/other SpA (7%). ePROMs Acceptability: 86% rated ePROMs acceptable/completely acceptable; 82% felt their completion required little/no effort; 87% agreed/strongly agreed their answers were likely to help their care. Fewer people aged >70 years rated ePROMs acceptable/completely acceptable (70%) compared with younger age groups (ranging 82%-100%); the same was the case for clinic-completers (79%) vs. home-completers (93%). Perceived ePROMs Use by Clinicians: 58% agreed/strongly agreed their healthcare professional had looked at their ePROMs. This was proportionally more in people aged 18-40 (79%) than older age groups (ranging 48%-58%), in axial SpA (70%) than other IA types (ranging 50%-54%), and in males (67%) vs. females (53%). HAP Usability: 78% agreed/strongly agreed HAP was easy to use. This was higher in those aged 18-40 years (93%) than those aged >70 years (70%), and in home-completers (89%) than clinic-completers (67%), Interviews: involved 11 participants and findings supported quantitative results, in that participants generally considered ePROMs acceptable, HAP easy to use, yet they were uncertain if their entries were used by their healthcare professional. In addition, participants were reassured that HAP was NHS-developed and secure, and expressed interest in completing ePROMs more regularly. Conclusion Using ePROMs in routine NHS care is acceptable to most people with IA, particularly younger people and those able to enter them on their own devices. The next step in this study is to consider healthcare professionals’ perspectives on ePROMs, including how they can be best integrated into consultations to ensure patients feel their entries are considered. Disclosure N. Cox: None. C. Kettle: None. H. Wang: None. S. Dutta: None. J. Packham: None. J. Galloway: None. J. Hill: None. S. Muller: None. S. Hider: None. Z. Paskins: None. L. Bullock: None. I.C. Scott: None.

Distribution of case volumes in surgery: an analysis of the British Spine Registry

ObjectivesTo characterize the distribution of case volumes within a surgical field.DesignAn analysis of British Spine Registry.Setting295 centers in England that conducted at least one spinal operation either within the NHS...

Doing dementia differently: A range of co-produced resources from the IDEAL programme

This article introduces different free resources for people with dementia, carers and professionals working within dementia care. All were produced as part of the IDEAL research programme, drawing on the wealth of evidence created as part of this large cohort longitudinal study. Explaining the background, the creation process and where to find each resource, the article directs readers towards resources readily available for use, as well as information about forthcoming resources.Four ready-to-use resources are described in detail. The Living with Dementia Toolkit is a comprehensive suite of resources for people with dementia and carers. It also features lots of different people with dementia and carers sharing their stories in their own words. The Toolkit is being widely used in NHS and third-sector settings, as well as by community groups. My Life Questionnaire is a new measure of living well which was co-produced with people living with mild-to-moderate dementia and scientifically validated with the IDEAL cohort. ‘The World Turned Upside Down’ began as a play and became a documentary film which can be used to raise awareness, promote discussion and within educational or continuing professional development settings. ‘The Bridge’ is an opera about the experience of living with dementia through the diagnostic process and how a husband and wife manage following diagnosis. Both artistic productions involved people with lived experience advising the performers on how to portray dementia authentically.

Healthcare professional and commissioners' perspectives on the factors facilitating and hindering the implementation of digital tools for self-management of long-term conditions within UK healthcare pathways.

Physical activity is important in the self-management of long-term conditions (LTCs). However, implementing physical activity into clinical practice is challenging, due to complex barriers including access to programmes, time pressures, and transport costs, for people with comorbidities, managing multiple responsibilities. Various digital tools exist to overcome these barriers and support wide-scale implementation to help people stay physically active. We explored the experiences, needs and preferences of healthcare professionals and commissioners, regarding the use of digital tools to support people with LTCs to self-manage using physical activity. This included barriers and facilitators to implementing digital tools to support people with LTCs in NHS settings. Semi-structured interviews were conducted (April 2021 to January 2022) in Wessex, southern England, UK. Purposive sampling was used to recruit general practitioners and healthcare professionals, and convenience sampling to recruit commissioners (n = 15). Transcripts were coded to develop conceptual themes allowing comparisons between and among perspectives, with the Normalisation Process Theory (NPT)'s four constructs used to aid interpretation. Results showed that most digital tools supporting physical activity for LTCs, are not well implemented clinically. Current digital tools were seen to lack condition-specificity, usability/acceptability evidence-base, and voluntary sector involvement (i.e., NPT: coherence or 'making sense'). Healthcare professionals and commissioners were unlikely to engage with use of digital tools unless they were integrated into health service IT systems and professional networks (i.e., NPT: cognitive participation), or adaptable to the digital literacy levels of service users and staff (i.e., NPT: collective action-needs for implementation). In practice, this meant being technically, easy to use and culturally accessible (i.e., NPT: collective action-promoting healthcare work). COVID-19 changed professional attitudes towards digital tools, in that they saw them being viable, feasible and critical options in a way they had not done before the pandemic. Implementation was also influenced by endorsement and trustworthiness enhancing the perception of them as secure and evidence-based (i.e., NPT: reflective monitoring). Our findings highlight that consideration must be given to ensuring that digital tools are accessible to both healthcare professionals and patients, have usability/acceptability, and are adaptable to specific LTCs. To promote clinical engagement, digital tools must be evidence-based, endorsed by professional networks, and integrated into existing health systems. Digital literacy of patients and professionals is also crucial for cross-service implementation.

A Modular Cataract Surgery Training Model Incorporating Human Factors and a Pedagogical Theory.

High volume cataract lists arecost-effective, reduce waiting times, and facilitate surgical teaching.We propose a stepwise training modelthat incorporates human factor principles and a reflective pedagogical approach, which has not been documented previously. Surgical training in ophthalmology is effective when a modular approach is utilised. High volume lists further enhance training by increasing exposure to a newer way of learning and working. We evaluated the efficiency and safety of trainee-assisted cataract surgery across a single NHS eye unit and an independent sector (IS) provider. We examined results from audits of surgical efficiency and safety in trainee-assisted high-volume lists, including a single-centre comparative evaluation of consultant-only and trainee lists. The quantitative and qualitative information gained from these projects helped us to implement a modular, structured training programme that utilises a reflective cycle of pedagogy, suitable for any grade of trainee. Our projects included an audit following cataract surgery performed by a surgical trainee over a 5-month period, which showed excellent post-op refractive results and no cases of intra-operative and post-operative complications. A single-centre observational study demonstrated comparable surgical throughput and safety results for trainee and solo consultant high volume lists. Systemic and ocular complication rates were reported to be similar for low and medium risk cataract surgery among trainee supervised IS and NHS lists. Cataract surgery outcomes and patient feedback support the effectiveness of the surgical training model. Combining Gibbs' reflective cycle of critical reflection with the International Council of Ophthalmology's principles helped us to develop the QM Model of modular teaching for cataract surgery, which we believe is suitable for utilisation in all surgical centres in the NHS and IS settings, for both low volume and high-volume surgical lists regardless of trainee experience.

Health and social care professionals' views and experiences of supporting parents with serious mental illness.

A significant number of individuals with a serious mental illness (SMI) such as schizophrenia or bipolar disorder are also parents of dependent children. Despite the risk of adverse psychological, behavioral, and social outcomes their needs often go unmet. To better understand the needs of parents with SMI and their children it is necessary to gain insight into the perspectives and experiences of the professionals in adult mental health and children's services who work with them, and who, ultimately, are best placed to meet those needs. To explore the views and experiences of health and social care professionals working with parents with SMI to understand the needs of, and their role supporting, parents with SMI and their children. Semi-structured interviews were conducted with seventeen professionals from six NHS and Local Authority settings in England, UK. Participants were included if they were employed in adult mental health or local authority children's services and had experience of working with parents with SMI. Sampling was purposive, including a wide range of professions in these settings. Interview data were analyzed using template analysis taking a critical realist perspective. Three top-level themes were generated: (1) Impact of parental SMI on the child, (2) Accessing support from services, (3) Role of professionals working with parents with SMI. Themes highlight diverse, wide-ranging effects of SMI on the child and a reluctance from parents to seek help due to stigma and fear. Available services are reported to be inaccessible and unacceptable to parents with SMI and practitioners experience conflict when balancing the needs of the parent and child. A whole-family approach facilitated by improved communication between services is advocated. Participants believed that parents with SMI experience complex parenting challenges over and above other parents, describing a largely detrimental impact on the child. Support services were deemed inadequate, and participants stressed the need to develop specialist services tailored toward the needs of parents with SMI and their children. Although participants endorsed joined up working across health and social care settings to facilitate a whole family approach, they required greater service knowledge and training in parental SMI.

Peritoneal malignancy in the global COVID-19 pandemic: experience of recovery and restoration in a high-volume centre through NHS and independent sector collaboration.

Treatment of peritoneal malignancy with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) requires substantial critical care, theatre and nursing resources. The COVID-19 pandemic caused challenges in providing a high volume, tertiary referral service. We reviewed data on referrals and operations performed in a tertiary referral centre in both NHS and independent sector settings. The impact of COVID-19 on activity was assessed using 2019 as a benchmark. New patient referrals were similar, with 891 in 2019 compared with 833 in 2020. Delivery of CRS and HIPEC operations were initially impacted by COVID-19. NHS and independent sector collaboration facilitated recovery, with 284 patients treated in 2020 compared with 280 in 2019. Close collaboration and structural organisation between the clinical and management teams in the NHS and independent sectors facilitated recovery and restoration of a complex tertiary referral service for peritoneal malignancy during the COVID pandemic.

EGS P11 Super-charged colonic interposition after Upper Gastrointestinal tract resections: technical considerations from both benign and malignant cases and review of literature

Abstract Background Oesophageal reconstruction is performed after an oesophagectomy, for either malignant or benign pathology. During reconstruction, variables include choice of conduit, route of reconstruction, and site of anastomosis. The stomach is preferred for neo-oesophageal reconstruction. However, when the stomach is not viable, alternatives including colon, jejunum, skin, or anterolateral thigh (ALT) musculocutaneous flaps are considered. Of these, colon is preferred for its ability to provide long-length grafts and reliable vascular supply. However, complications remain significant problems, including ischaemia at the anastomosis. To address this, 'supercharging’ and ‘super drainage' techniques are used to enhance arterial flow and venous drainage via microvascular anastomosis. Methods Case 1 involves a 61-year-old male who underwent an oesophagectomy for GOJ adenocarcinoma. A year later he developed a strangulated diaphragmatic hernia with an ischaemic gastric conduit, which was replaced with an isoperistaltic colonic interposition using transverse and left colon with super-drainage. 3 years later, the patient presented with pancreatitis, perforated gallbladder, and duodenum. Diffuse ischaemic changes of the interposed colon were recognised. A re-do colonic interposition using right colon with an arterial graft between the right transverse cervical artery and branch of ileal artery and super-drainage via a branch of the ileal and right external jugular veins was created. Results Case 2 involves a 68-year-old female who underwent an elective hiatus hernia repair with Nissen’s fundoplication. She deteriorated shortly post-operatively where re-look surgery found early hernia recurrence causing strangulation of the distal oesophagus and proximal stomach leading to ischaemia, necrosis, and perforation. She underwent a laparotomy and resection of the ischaemic distal oesophagus and proximal stomach, oesophagostomy and feeding jejunostomy. 16 months later, she underwent interposition of the right colon between the proximal oesophagus and remaining stomach. Arterial flow was adequate and supercharging was performed between the left external jugular vein and a branch of the middle colic vein. Conclusions There is limited literature on methods of both supercharging and super-drainage, as well as the optimal choice of organ for neo-oesophageal reconstruction. Currently, no established treatment protocols exist. There is evidence that supercharging and super-drainage are associated with longer operative times. However, benefits include lower leak incidence, shorter duration to oral intake, and reduced length of stay in relation to interposition without supercharge. Associated venous congestion may contribute to anastomotic leak, and may be prevented by super-drainage. Whilst supercharging has been reported worldwide, our case series adds to the UK practice showing it improves patient outcomes in an NHS setting.

A cognitive-behavioural therapy programme for managing depression and anxiety in long-term physical health conditions: mixed-methods real-world evaluation of the COMPASS programme.

Mental health comorbidities are common in physical long-term health conditions. We evaluate the effectiveness of COMPASS, a therapist-supported, digital cognitive-behavioural therapy programme specifically designed to treat anxiety/depression in the context of long-term conditions. We also investigate patient experiences of the programme. We utilised a mixed-methods, non-randomised design. We analysed pre-post data from 76 patients with long-term conditions who were receiving psychological treatment (COMPASS) via local NHS services, using paired sample t-tests and Cohen's d, with depression, anxiety, distress and functional impairment self-report scales. Qualitative interviews explored patients' experiences of using COMPASS. Twenty-one semi-structured interviews were completed and underwent inductive thematic analysis. Patients who received COMPASS had significantly reduced depression (-2.47, 95% CI -3.7 to -1.3, P < 0.001; Cohen's d = -0.376), anxiety (-2.30, 95% CI -3.6 to -1.2, P < 0.001; Cohen's d = -0.420) and psychological distress (-4.87, 95% CI -7.0 to -2.7, P < 0.001; Cohen's d = -0.422) and significantly improved functional impairment (-3.00, 95% CI -4.8 to -1.2, P ≤ 0.001; Cohen's d = -0.282). Effect sizes were larger when analyses included only patients with clinically significant baseline symptoms: depression (-4.02, 95% CI -5.6 to -2.5, P < 0.001; Cohen's d = -0.701), anxiety (-3.60, 95% CI -5.3 to -1.9, P < 0.001; Cohen's d = -0.739), psychological distress (-5.58, 95% CI -7.9 to -3.2, P < 0.001; Cohen's d = -0.523), functional impairment (-3.28, 95% CI -5.4 to -1.1, P ≤ 0.001; Cohen's d = -0.355). Qualitative analysis yielded two meta-themes: engagement and integration of mental and physical health. Results suggest that COMPASS is effective in NHS settings, and is acceptable to patients. Content tailored to long-term conditions, therapist support and clear delivery strategies should be prioritised to aid intervention implementation.

Appraisals and performance reviews: measuring progress

The aim of the annual appraisal meeting is to provide an opportunity for you and your manager to review your performance over the previous 12 months and to agree key goals, objectives and personal development needs for the year ahead. This article gives readers information concerning appraisals and performance reviews and how to prepare for them within an NHS setting. The primary focus is on being prepared and ready for the appraisal, to gain as much from the activity as possible. Issues surrounding appraisals and performance reviews are discussed, for example, the relevance of the NHS Constitution and the importance of wellbeing conversations. The article provides readers with information that is necessary for them to prepare effectively for such reviews. Tips that may help with the appraisal process are provided at the end of the discussion.

459 Clinical Utility of Pharmacogenetic Tests When Prescribing Antidepressant Therapy for Depression, A Systematic Review and Meta-analysis of Randomised Controlled Trials

Abstract Introduction Pharmacogenetic testing when prescribing medicines has the potential to reduce harmful side effects, optimise treatment, and improve clinical outcomes. Depression is a major global disease burden with high economic costs and it’s becoming more prevalent (1). There is a growing number of clinical trials and reviews that support the use of pharmacogenetic testing for depression and more results are available from randomised controlled trials (RCTs) that were completed recently to warrant a new systematic review (2). Aim The aim was to evaluate the clinical utility of pharmacogenetic tests when prescribing antidepressant therapy for depression (including mild, moderate, and major depression) by comparing the remission rate, antidepressant response and adverse events from RCTs for the pharmacogenetic guided therapy group and the treatment as usual group (TAU) through a systematic review and meta-analysis. Methods The PICO inclusion criteria are adults with depression requiring antidepressant therapy for depression. The intervention is a pharmacogenetic gene test(s) and the comparator is usual treatment. The outcomes are depression remission, antidepressant response and adverse events. This research was undertaken between April and September 2022 by the main author (SJ). The second author (HA) peer reviewed the title/abstract screening, full text review, and the third author (PD) provided supervisory support. A systematic literature search was completed using Embase, Medline, Cochrane, and PubMed databases according to a published PROSPERO protocol. Articles published between 2000 - 2022 were eligible. Only RCTs that had TAU as the comparator were included. Bias and quality assessments were carried out using the RoB 2 tool. Studies with a high risk of bias were excluded. Heterogeneity was calculated using I2. A random effects model meta-analysis was conducted using RevMan. Results In total, 520 articles were retrieved at first search (excluding duplicates) and seven double-blinded (rater and patient blinded) RCTs were identified that met the full inclusion and exclusion criteria. The RCTs were based in North America (5), Australia (1) and Europe (1). The meta-analysis revealed the remission rate was greater for pharmacogenetic guided groups compared to the TAU groups, pooled risk ratio (RR) = 1.54 (95% CI 1.07-2.21, p = 0.02). For the response rate, results from 6 double blinded RCTs which measured this had a pooled RR= 1.23 (95% CI 0.95-1.59, p = 0.11) which indicates a greater (but not statistically significant) response rate in the pharmacogenetic guided group. Conclusion A limitation of this study is that it showed improvement in remission but not response rate, which is potentially due to response data missing from one of the seven pooled studies. Pharmacogenetic tests might have the potential to improve remission and response rates for antidepressant therapy compared to treatment as usual. However, further studies in the UK are warranted to help determine whether pharmacogenetic tests should be used in an NHS setting.

Emergency scrotal exploration in children: Following a change in mindset in the UK

A survey of 200 emergency scrotal explorations done over four paediatric surgical centres in the UK revealed that the incidence of finding testicular torsion (TT) was 24% and the preoperative utilisation of Doppler ultrasound (DUS) was 10% [1]. We changed our practice to include better preoperative utilisation of a clinical risk score (TWIST) and DUS. This led to a significant increase in the incidence of finding TT from 18% to 53%. Obtaining a DUS did not lead to an increase in our orchidectomy rate. Adopting this change is possible in an NHS setting and it has significant clinical and economic benefits.

Group antenatal care: findings from a pilot randomised controlled trial of REACH Pregnancy Circles

BackgroundAntenatal care has the potential to impact positively on maternal and child outcomes, but traditional models of care in the UK have been shown to have limitations and particularly for those from deprived populations. Group antenatal care is an alternative model to traditional individual care. It combines conventional aspects of antenatal assessment with group discussion and support. Delivery of group antenatal care has been shown to be successful in various countries; there is now a need for a formal trial in the UK.MethodAn individual randomised controlled trial (RCT) of a model of group care (Pregnancy Circles) delivered in NHS settings serving populations with high levels of deprivation and diversity was conducted in an inner London NHS trust. This was an external pilot study for a potential fully powered RCT with integral economic evaluation. The pilot aimed to explore the feasibility of methods for the full trial. Inclusion criteria included pregnant with a due date in a certain range, 16 + years and living within specified geographic areas. Data were analysed for completeness and usability in a full trial; no hypothesis testing for between-group differences in outcome measures was undertaken. Pre-specified progression criteria corresponding to five feasibility measures were set. Additional aims were to assess the utility of our proposed outcome measures and different data collection routes. A process evaluation utilising interviews and observations was conducted.ResultsSeventy-four participants were randomised, two more than the a priori target. Three Pregnancy Circles of eight sessions each were run. Interviews were undertaken with ten pregnant participants, seven midwives and four other stakeholders; two observations of intervention sessions were conducted. Progression criteria were met at sufficient levels for all five measures: available recruitment numbers, recruitment rate, intervention uptake and retention and questionnaire completion rates. Outcome measure assessments showed feasibility and sufficient completion rates; the development of an economic evaluation composite measure of a ‘positive healthy birth’ was initiated.ConclusionOur pilot findings indicate that a full RCT would be feasible to conduct with a few adjustments related to recruitment processes, language support, accessibility of intervention premises and outcome assessment.Trial registrationISRCTN ISRCTN66925258. Retrospectively registered, 03 April 2017.

The treatment of PTSD in refugees and asylum seekers using imagery rescripting within an NHS setting.

Refugees and asylum seekers present with high levels of post-traumatic stress disorder (PTSD), whilst little research has been conducted to assess the effectiveness or acceptability of psychological interventions for this group. Imagery rescripting is effective in reducing distressing intrusive memories within a range of conditions. The current study evaluates this approach for the treatment of PTSD in refugees and asylum seekers within a UK NHS service. To evaluate the clinical outcomes of using imagery rescripting for the treatment of PTSD in UK-based refugees and asylum seekers. Ten adult service-users from an NHS specialist service with a primary diagnosis of PTSD were recruited as part of routine service delivery. A multiple baseline design was used with participants randomly allocated to a baseline varying from 5 to 9 weeks. A baseline wait-period was followed by up to five sessions of psychoeducation and treatment preparation, in turn followed by up to 10 sessions of imagery rescripting. The Post-traumatic Symptom Scale (PSS) and Physical Health Questionnaire-9 (PHQ-9) were collected every week during baseline, at end of treatment and weekly for 5 weeks after treatment, and again at 12-week follow-up. Data were analysed with mixed regression. Results indicate a significant improvement both in PTSD symptoms and mood, and that this was attributable to the imagery rescripting phase of the intervention, and not the passage of time or non-specific therapy factors. Evidence indicates imagery rescripting to be a safe and effective treatment choice for PTSD in refugees and asylum seekers.

Gay Men and Suicidality: The Development and Nature of the Critical Superego

National research studies report elevated suicide rates amongst gay men, particularly those under the age of 26. Much of the current health and psychiatric literature on suicide tends to focus on the external world impacting on the suicidal individual. Although valuable, it is not enough to understand the specific circumstances that could contribute to gay men's suicidality. This paper focuses on the relationship between the external and internal dynamics at play in the suicidality of gay men, with particular emphasis on the development, influences, and nature of a cruel and punishing superego. The author provides some contemporary psychoanalytic theories on same‐sex desire as a useful framework to understand minority sexuality. Some influential classic and contemporary psychoanalytic theories regarding suicidality and the development and character of a cruel and punishing superego are presented. The concept of internalized homophobia and the impact of heteronormative masculinity on the gay man's psyche are explored as drivers for suicidality. A composite case study from clinical experience with suicidal gay men in an NHS setting is presented to illuminate the discussion. This paper could add new perspectives and important dialogue for psychoanalytic psychotherapists working with this patient population.

Working with Trauma and Dissociation in the NHS

Using a composite clinical case, this paper describes working with complex trauma, non‐recent child sexual abuse and dissociative identity disorder within an NHS setting. The clinical work of an NHS trauma service is described in both historical and current terms. The case history elucidates the use of specialist group work for non‐recent child sexual abuse and then individual work within a trauma team setting as the diagnosis of dissociative identity disorder comes to light. The recognition of the role of shame in both non‐recent sexual abuse and dissociative identity disorder presentations serves to highlight the countertransference experiences of disbelief or inauthenticity. This is linked to the history in psychoanalysis of the shift away from external realities of abuse and to its exploration of the concept of dissociation. The question of acknowledging and attending to the reality of abuse continues to be an issue within many aspects of British psychotherapy and psychoanalysis and has perhaps added to the disbelief that the diagnosis of dissociative identity disorder often seems to engender. The consideration of setting in relation to the NHS and limitations on lengths of treatment is also addressed for these complex patients.

Follitropin Alpha for assisted reproduction: an analysis based on a non-interventional study in Greece

Objective To conduct an economic evaluation estimating the cost per live birth after controlled ovarian stimulation (COS) using Follitropin Alpha (Gonal-F), in the Greek National Health System setting. A secondary objective was to predict the live birth rateof the In Vitro Fertilization (IVF) procedure. Methods A single arm, multi-center, prospective, non-interventional study was conducted on which economic, efficacy and safety data were collected by six of the largest IVF centers. The participants were 350 female patients. Three statistical methods were employed for the analysis of the study outcomes, namely (a) Generalized Linear Modeling for the estimation of the costs of IVF treatment, (b) multivariable logistic regression and (c) an Artificial Neural Network (ANN) model for live birth prediction. Results The mean total cost of IVF therapy per patient was estimated at €3728 (95% CI: €3679–€3780), while the total cost per live birth was €14,872 (95% CI: €12,441–€17,951). The live birth rate after 3 complete IVF cycles was estimated at 22.9%, while the percentage of those suffering from OHSS was limited at 0.57%. In logistic regression, the Ovarian Sensitivity Index (OSI) was a factor found to be positively associated with live birth (OR 7.39, 95% CI: 1.84–29.71). For the ANN, important predictors included number of gestational sacs and the duration of infertility. Conclusion The present study constitutes the largest single-arm study based on real data in Greece to date. The cost of IVF treatment and the cost per live birth are not insignificant in this NHS setting. The live birth rate, cost per oocyte, and the cost per live birth are in line with literature. OSI was a main contributing factor to the accurate prediction of the live birth rate, while age and BMI were found to be negatively correlated.