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Competing Interests: Declaration of interests PM reports grants from National Institute for Health and Care Research (NIHR), the Medical Research Council (MRC), Bristol & Weston Hospitals Charity, and The Cassell Hospital Charitable Trust; and salary support from the NIHR Applied Research Collaboration Southwest, the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation, and Avon and Wiltshire Mental Health Partnership NHS Trust. NK reports grants from NIHR, Health Quality Improvement Partnership, and the Department of Health and Social Care; has received salary support from the Greater Manchester NIHR Patient Safety Research Collaboration, Mersey Care NHS Foundation Trust, and the University of Manchester; has chaired and contributed to committees for the National Institute for Health and Clinical Excellence (NICE) guidelines, including those on the management of self-harm; and is a member of the National Suicide Prevention Strategy Advisory Group (England). RCO is a trustee and science council member of MQ Mental Health Research, president of the International Association for Suicide Prevention, co-chair of the academic advisory group to the Scottish Government's National Suicide Prevention Leadership Group, and a board member of the International Academy of Suicide Research; was a member of the NICE guideline group for the management of self-harm; and reports grants from Medical Research Foundation, the Mindstep Foundation, Chief Scientist Office, MRC, Public Health Scotland, Scottish Government, NIHR, Shout 85258, Scottish Association for Mental Health, Zoetis Foundation, Jonathan's Voice, ADHD UK, and Barfil Charitable Trust. HC reports grants from the National Health and Medical Research Council (NHMRC), the Medical Research Future Fund, Paul Ramsay Foundation, and the Australian Government; is Scientia Professor at the University of New South Wales, supported by an NHMRC Elizabeth Blackburn Research Fellowship, and chief investigator on the NHMRC Centre for Research Excellence in Suicide Prevention; sits on the Million Minds Committee; and is a director of the Black Dog Institute Board and the Ramsay Health Care Research Foundation. MS declares salary support through academic scholar awards from Sunnybrook Health Sciences Centre and the University of Toronto. OJK is currently supported by a Research Foundation Flanders Senior Postdoctoral Fellowship; reports grants from Research Foundation Flanders and the King Baudouin Foundation; is co-chair of the International Association for Suicide Prevention Early Career Group, for which she receives complimentary student membership; is a former member of the Samaritans research ethics board; and has previously received travel grants and waived registration to present at conferences of the International Academy of Suicide Research. JP reports grants from NHMRC, the Medical Research Future Fund, Department of Health of the Australian Government, New South Wales Health, and the National Suicide Prevention Office. LFC is the vice president of the International Association for Suicide Prevention and is a permanent member of the Malaysian technical working group for suicide prevention; reports grants from the Centre of Pesticide Suicide Prevention at the University of Edinburgh; has received honorarium from Johnson & Johnson as a consultant and speaker; and, through her institution, has received access to the industry-sponsored medication sampling programme (compassionate patient programme) for clinical use for medication samples of esketamine (Johnson & Johnson), brexpiprazole (Lundbeck), Abilify Maintena (Lundbeck), and Trinza (Johnson & Johnson). DK is funded through the Elizabeth Blackwell Institute for Health Research at the University of Bristol, which is supported by the Wellcome Trust; has received grants from the Centre for Pesticide Suicide Prevention and the American Foundation for Suicide Prevention; and is a steering group member of the UK's National Suicide Prevention Alliance, and the Migration Health and Development Research Initiative. VP has consulted with Google and Modern Health (unrelated to the scope of this project). AC reports grants from Wellcome Trust, Leverhulme Trust, Economic and Social Research Council; has received funded consultancy from the Scottish Government and Alcohol Change UK; and is a member of the academic advisory group to the Scottish Government's National Suicide Prevention Leadership Group. SPe reports a 2021–2024 Vanier Canada Graduate Scholarship from the Canadian Institutes of Health Research. NS is a lived experience advisor to the Wellcome Trust, consumer academic at the University of Melbourne, lived experience lead at the Royal Children's Hospital, member of the Lived Experience Air Academy for University of Wollongong's Project Air, lived experience director for the Australian BPD Foundation, and associate at yLab (a division of the Foundation for Young Australians); reports previous employment with Orygen, and previous roles with the Youth Affairs Council of Victoria, Victorian Department of Families, Fairness, and Housing, Victorian Department of Premier and Cabinet, and Moonee Valley City Council; funded travel through Black Dog Institute and International Association of Suicide Prevention; and a current research tie to Orygen. FSt reports a grant from the Burdett Trust for Nursing and support from Abertay University. PSFY is a member of the advisory committee on mental health for the government of the Hong Kong Special Administrative Region. All other authors declare no competing interests.

Background: Although studies have suggested a high risk of suicide in people with eating disorders, most studies have focused on suicidal ideation and attempts. There is little research on the characteristics of people with eating disorders who died by suicide, nor investigation of trends over time. We aimed to compare the characteristics of patients with eating disorders who died by suicide versus patients with other mental health diagnoses who died by suicide in England and to examine the trends in rates., Methods: In this national retrospective cohort study, data on all people (aged ≥10 years) who died by suicide in England, UK, between Jan 1, 1997, and Dec 31, 2021, while under the care (within the previous 12 months) of mental health services were obtained from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), in which clinical information is collected via a questionnaire completed by the mental health professional responsible for the patient's care. Incidence of suicide in, and demographic, clinical, and treatment characteristics of, patients with a diagnosis of eating disorder (as recorded by the treating clinician) who died by suicide were compared with patients with other mental health diagnoses who died by suicide within the same timeframe using univariable logistic regression analysis. People with related lived experience were involved in the study design, implementation, interpretation, and writing of the manuscript., Findings: Of 119 446 people for whom NCISH were notified of dying by suicide in England, 30 795 were under the recent care of mental health services, of whom 30 246 had known diagnoses and were included in analyses. Of these individuals, 10 373 (34%) were female and 19 873 (66%) were male; 2236 (8%) were of minority ethnicity; 382 (1%) had a diagnosis of eating disorder and 29 864 (99%) had another mental health diagnosis. Compared with patients with other mental health diagnoses who died by suicide, patients with eating disorders were younger (median age 33 years [range 15-90] vs 45 years [10-100]), more often female (343 [90%] female and 39 [10%] male in the eating disorders group; 10 030 [34%] female and 19 834 [66%] male in the other diagnoses group), and less likely to have evidence of conventional risk factors for suicide such as living alone (odds ratio [OR] 0·68, 95% CI 0·55-0·84). 22 (6%) of 382 were from a minority ethnic group. Patients with an eating disorder were characterised by a greater clinical complexity (eg, self-harm [OR 2·31, 95% CI 1·78-3·00], comorbidity [9·79, 6·81-14·1], and longer duration of illness [1·95, 1·56-2·43]), and were more likely to have died following overdoses (2·00, 1·62-2·45) than patients with other diagnoses. Childhood abuse (52 [37%] of 140) and domestic violence (18 [20%] of 91) were common in patients with eating disorders. Similar to patients with other diagnoses, most (244 [75%] of 326) of those with eating disorders who died by suicide were rated as low risk by clinicians at last contact. The number of suicide deaths in patients with eating disorders rose between 1997 and 2021 (incidence rate ratio [IRR] 1·03, 95% CI 1·02-1·05; p<0·0001), but rates fell when accounting for the greater number of patients entering mental health services (IRR 0·97, 0·95-1·00; p=0·033)., Interpretation: This study was focused on people who sought help from mental health services. It did not consider subtypes of eating disorders or include a control group, but it does highlight possible areas for intervention. The comprehensive provision of evidence-based treatment for eating disorders and underlying conditions to address the clinical complexity in these patients might help to reduce suicide. Recognising limitations in clinical risk assessment, addressing early life experiences and current adversities, and appropriate prescribing might also be of benefit. Suicide prevention must remain a priority for eating disorder services and mental health care more widely., Funding: The Healthcare Quality Improvement Partnership., Competing Interests: Declaration of interests NK works with NHS England on national quality-improvement initiatives for suicide and self-harm; is on the Department of Health and Social Care (DHSC) National Suicide Prevention Strategy Advisory Group for England; chaired the guideline development group for the 2012 UK National Institute for Health and Clinical Excellence (NICE) guidelines on the longer-term management of self-harm; chaired the guideline development group for the 2022 NICE guideline on depression in adults; and was a topic advisor for the 2022 NICE guideline Self-Harm: Assessment, Management and Preventing Recurrence. LA is Chair of the DHSC National Suicide Prevention Strategy Advisory Group. NK, LA, and PT report grants from the Healthcare Quality Improvement Partnership, NHS England, the Department for Education, and the Medical Research Council. PT reports a grant from the Gambling Research Exchange Ontario. All other authors declare no competing interests., (Copyright Crown Copyright © 2024 Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.)

Background: Understanding of ethnic disparities in suicide in England and Wales is poor as ethnicity is not recorded on death certificates. Using linked data, we examined variations, by sex, in suicide rates in England and Wales by ethnicity and migrant and descendant status., Methods: Using the Office for National Statistics 2012-19 mortality data linked to the 2011 census from the Public Health Research Database, we calculated the age-standardised suicide rates by sex for each of the 18 self-identified ethnicity groups in England and Wales. We present rates by age, sex, and methods used for suicide by ethnic group. We estimated age-adjusted and sex-adjusted incidence rate ratios (IRRs) using Poisson regression models for each minority ethnic group compared with the majority population. We involved people with lived experience in the research., Findings: Overall, 31 644 suicide deaths occurred over the study period, including 3602 (11%) in people from minority ethnic backgrounds, with a mean age of death of 43·3 years (SD 17·0, range 13-96). Almost all minority ethnic groups had a lower rate of suicide than the White British majority, apart from individuals who identified as being from a Mixed heritage background or White Gypsy or Irish Travellers. In females who identified as Mixed White and Caribbean, the suicide IRR was 1·79 (95% CI 1·45-2·21) compared with the White British majority; in those who identified as White Gypsy or Irish Travellers, the IRR was 2·26 (1·42-3·58). Rates in males identifying as from these two groups and those identifying as White Irish were similar to the White British majority. Compared with the non-migrant population, migrants had a lower rate of suicide regardless of ethnicity, but in the descendant population, people from a Mixed ethnicity background had a higher risk of suicide than the White British majority., Interpretation: There are ethnic disparities in suicide mortality in England and Wales, but the reasons for this are unclear. The higher rate in previously overlooked minority ethnic groups warrants further attention., Funding: Wellcome Trust., Competing Interests: Declaration of interests DK reports grants and personal fees from the Wellcome Trust, the Centre for Pesticide Suicide Prevention, and the UK Department of Health and Social Care. DK is a steering group member of the Migration Health and Development Research Initiative and the UK National Suicide Prevention Alliance; she receives no fees for this work. NK reports grants and personal fees from the UK Department of Health and Social Care, the National Institute for Health and Care Research (NIHR), the National Institute for Health and Care Excellence (NICE), and the Healthcare Quality and Improvement Partnership, outside the submitted work; and work with NHS England on national quality improvement initiatives for suicide and self-harm. He sits on the Department of Health and Social Care's (England) National Suicide Prevention Strategy Advisory Group. He has chaired and been the Topic Advisor for NICE guideline committees for self-harm and depression. LR is an ONS employee. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Bronchiectasis, a previously neglected condition, now has renewed research interest. There are a few systematic reviews that have reported on the economic and societal burden of bronchiectasis in adults, but none have reported on children. We undertook this systematic review to estimate the economic burden of bronchiectasis in children and adults., Research Question: What is the health care resource utilization and economic burden of bronchiectasis in adults and children?, Study Design and Methods: We performed a systematic review identifying publications from Embase, PubMed, Web of Science, Cochrane (trials, reviews, and editorials), and EconLit about the economic burden and health care utilization in adults and children with bronchiectasis between January 1, 2001, and October 10, 2022. We used a narrative synthesis approach and estimated aggregate costs for several countries., Results: We identified 53 publications reporting on the economic burden and/or health care utilization of people with bronchiectasis. Total annual health care costs per adult patient ranged from 2021 $3,579 to $82,545 USD and were predominantly driven by hospitalization costs. Annual indirect costs including lost income because of illness (reported in only five studies) ranged from $1,311 to $2,898 USD. Total health care costs in children with bronchiectasis were $23,687 USD annually in the one study that estimated them. Additionally, one publication found that children with bronchiectasis missed 12 school days per year. We estimated aggregate annual health care costs for nine countries, ranging from $101.6 million per year in Singapore to $14.68 billion per year in the United States. We also estimated the aggregate cost of bronchiectasis in Australian children to be $17.77 million per year., Interpretation: This review highlights the substantial economic burden of bronchiectasis for patients and health systems. To our knowledge, it is the first systematic review to include the costs for children with bronchiectasis and their families. Future research to examine the economic impact of bronchiectasis in children and economically disadvantaged communities, and to further understand the indirect burden of bronchiectasis on individuals and the community, is needed., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: J. D. C. has received research grants from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Gilead Sciences, Grifols, Novartis, Insmed, and Trudell; and received consultancy or speaker fees from Antabio, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Insmed, Janssen, Novartis, Pfizer, Trudell, and Zambon. A. B. C. reports multiple grants from NHMRC and other fees to the institution from work relating to IDMC membership of an unlicensed vaccine (GlaxoSmithKline), unlicensed monoclonal antibody for RSV (AstraZeneca), and a COVID-19 vaccine (Moderna), outside the submitted work; and fees to the institution from work relating to unlicensed therapies for bronchiectasis (inhaled antibiotics from Zambon and a molecule from Boehringer Ingelheim). P. C. G. has received grants from Chiesi, speaker fees from Insmed and GSK, and an advisory board fee from GlaxoSmithKline. None declared (J. M. R., V. G., S. K., N. K., F. H., J. M. M., S. M. M.)., (Copyright © 2023 American College of Chest Physicians. All rights reserved.)

Suicide and self-harm are major health and societal issues worldwide, but the greatest burden of both behaviours occurs in low-income and middle-income countries. Although rates of suicide are higher in male than in female individuals, self-harm is more common in female individuals. Rather than having a single cause, suicide and self-harm are the result of a complex interplay of several factors that occur throughout the life course, and vary by gender, age, ethnicity, and geography. Several clinical and public health interventions show promise, although our understanding of their effectiveness has largely originated from high-income countries. Attempting to predict suicide is unlikely to be helpful. Intervention and prevention must include both a clinical and community focus, and every health professional has a crucial part to play., Competing Interests: Declaration of interests DK is funded through the Elizabeth Blackwell Institute for Health Research at the University of Bristol, which is supported by the Wellcome Trust. DK is also in receipt of a grant from the Centre for Pesticide Suicide Prevention. PP's PhD clinical fellowship is funded by the UK Medical Research Council Addiction Research Clinical Training programme, grant number MR/N00616X/1. PP is also in receipt of a grant from Bristol and Weston Hospitals Charity. LFC declares receiving funding from Johnson & Johnson. NK chaired the committees developing the UK National Institute for Health and Care Excellence (NICE) guidelines for self-harm (longer term management) 2012, and the NICE quality standards on self-harm 2013; NK is currently topic adviser for the new NICE guidelines on self-harm and chair of the guideline committee for the NICE depression guidelines. NK works with National Health Service (NHS) England on national quality improvement initiatives for suicide and self-harm, and sits on the Department of Health and Social Care's National Suicide Prevention Strategy Advisory Group for England. The views expressed in this article are the authors' own and not those of the Department of Health and Social Care, NHS England, or NICE., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

In ever more pressured health-care systems, technological solutions offering scalability of care and better resource targeting are appealing. Research on machine learning as a technique for identifying individuals at risk of suicidal ideation, suicide attempts, and death has grown rapidly. This research often places great emphasis on the promise of machine learning for preventing suicide, but overlooks the practical, clinical implementation issues that might preclude delivering on such a promise. In this Review, we synthesise the broad empirical and review literature on electronic health record-based machine learning in suicide research, and focus on matters of crucial importance for implementation of machine learning in clinical practice. The challenge of preventing statistically rare outcomes is well known; progress requires tackling data quality, transparency, and ethical issues. In the future, machine learning models might be explored as methods to enable targeting of interventions to specific individuals depending upon their level of need-ie, for precision medicine. Primarily, however, the promise of machine learning for suicide prevention is limited by the scarcity of high-quality scalable interventions available to individuals identified by machine learning as being at risk of suicide., Competing Interests: Declaration of interests OJK reports grants from UCB Community Health Fund, outside the submitted work. NK reports grants and personal fees from the UK Department of Health and Social Care, the UK National Institute of Health Research, the UK National Institute of Health and Care Excellence (NICE), and Healthcare Quality and Improvement Partnership, outside the submitted work; and has worked with the National Health Service England on national quality improvement initiatives for suicide and self-harm. NK sits on the Department of Health and Social Care's (England) National Suicide Prevention Strategy Advisory Group. NK has chaired and been the Topic Advisor for NICE guideline committees for self-harm and depression., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Recent evidence on suicide rates among psychiatric patients from minority ethnic backgrounds is scarce. We aimed to examine suicide rates among minority ethnic psychiatric patients and describe their social and clinical characteristics., Methods: We did a retrospective observational cohort study on a national case-series of patients in England and Wales who died by suicide within 12 months of contact with mental health services between 2007 and 2018. Data were collected as part of the National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide rates and standardised mortality ratios (SMRs) were estimated for South Asian (Indian, Pakistani, and Bangladeshi), Black African, Black Caribbean, Chinese, and White patients., Findings: A total of 698 patients in the four minority ethnic groups of South Asian, Black Caribbean, Black African, and Chinese were included (482 [69%] men; 216 [31%] women; mean age 41 years [SD 14·9, range 12-91] and compared with 13 567 White patients (9030 [66·6%] men; 4537 [33·4%] women; mean age 48 years [SD 15·8, range 10-100]). Rates and SMRs for suicide among minority ethnic patients were lower than for White patients (2·73 deaths, 95% CI 2·68-2·78) per 100 000 population. Differences were found between ethnic groups with higher suicide rates in Black Caribbean patients (1·89 deaths [95% CI 1·55-2·23] per 100 000 population) and lower rates in South Asian patients (1·49 deaths [1·33-1·64] per 100 000 population). There was an increase in rates among White patients in 2007-12 followed by a fall but no change among other ethnic groups. Schizophrenia was more common among Black African patients (54%) and Black Caribbean patients (44%), while affective disorder was more common among South Asian patients (41%). Minority ethnic patients overall showed markers of social adversity and received higher intensity care yet were viewed by clinicians as at lower risk than White patients., Interpretation: Effective approaches to prevention might differ between minority ethnic groups. Clinicians and the services in which they work should be aware of the common and distinct social and clinical needs of minority ethnic patients with mental illness., Funding: The Healthcare Quality Improvement Partnership., Competing Interests: Declaration of interests NK is supported by Greater Manchester Mental Health National Health Service Foundation Trust. NK chairs the National Institute for Health and Care Excellence (NICE) depression in adults guideline and was a topic expert member for the NICE suicide prevention guideline; he previously chaired the NICE self-harm guideline (longer term management) and is currently topic advisor for the new NICE self-harm guideline. LA chairs the National Suicide Prevention Strategy Advisory Group at the Department of Health and Social Care (of which NK is also a member) and is a non-executive Director for the Care Quality Commission. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: In adults with bronchiectasis, multicentre data advanced the field including disease characterisation and derivation of phenotypes such as 'frequent exacerbator (FE)' (≥3 exacerbations/year). However, paediatric cohorts are largely limited to single centres and no scientifically derived phenotypes of paediatric bronchiectasis yet exists. Using paediatric data from the Australian Bronchiectasis Registry (ABR), we aimed to: (a) describe the clinical characteristics and compare Indigenous with non-Indigenous children, and (b) determine if a FE phenotype can be identified and if so, its associated factors., Methods: We retrieved data of children (aged <18-years) with radiologically confirmed bronchiectasis, enrolled between March 2016-March 2020., Results: Across five sites, 540 children [288 Indigenous; median age = 8-years (IQR 6-11)] were included. Baseline characteristics revealed past infection/idiopathic was the commonest (70%) underlying aetiology, most had cylindrical bronchiectasis and normal spirometry. Indigenous children (vs. non-Indigenous) had significantly more environmental tobacco smoke exposure (84% vs 32%, p < 0.0001) and lower birth weight (2797 g vs 3260 g, p < 0.0001). FE phenotype present in 162 (30%) children, was associated with being younger (OR adjusted  = 0.85, 95%CI 0.81-0.90), more recent diagnosis of bronchiectasis (OR adjusted  = 0.67; 95%CI 0.60-0.75), recent hospitalization (OR adj  = 4.51; 95%CI 2.45-8.54) and Pseudomonas aeruginosa (PsA) infection (OR adjusted  = 2.43; 95%CI 1.01-5.78). The FE phenotype were less likely to be Indigenous (OR adjusted  = 0.14; 95%CI 0.03-0.65)., Conclusion: Even within a single country, the characteristics of children with bronchiectasis differ among cohorts. A paediatric FE phenotype exists and is characterised by being younger with a more recent diagnosis, PsA infection and previous hospitalization. Prospective data to consolidate our findings characterising childhood bronchiectasis phenotypes are required., (Copyright © 2021. Published by Elsevier Ltd.)

Background: The COVID-19 pandemic is having profound mental health consequences for many people. Concerns have been expressed that, at their most extreme, these consequences could manifest as increased suicide rates. We aimed to assess the early effect of the COVID-19 pandemic on suicide rates around the world., Methods: We sourced real-time suicide data from countries or areas within countries through a systematic internet search and recourse to our networks and the published literature. Between Sept 1 and Nov 1, 2020, we searched the official websites of these countries' ministries of health, police agencies, and government-run statistics agencies or equivalents, using the translated search terms "suicide" and "cause of death", before broadening the search in an attempt to identify data through other public sources. Data were included from a given country or area if they came from an official government source and were available at a monthly level from at least Jan 1, 2019, to July 31, 2020. Our internet searches were restricted to countries with more than 3 million residents for pragmatic reasons, but we relaxed this rule for countries identified through the literature and our networks. Areas within countries could also be included with populations of less than 3 million. We used an interrupted time-series analysis to model the trend in monthly suicides before COVID-19 (from at least Jan 1, 2019, to March 31, 2020) in each country or area within a country, comparing the expected number of suicides derived from the model with the observed number of suicides in the early months of the pandemic (from April 1 to July 31, 2020, in the primary analysis)., Findings: We sourced data from 21 countries (16 high-income and five upper-middle-income countries), including whole-country data in ten countries and data for various areas in 11 countries). Rate ratios (RRs) and 95% CIs based on the observed versus expected numbers of suicides showed no evidence of a significant increase in risk of suicide since the pandemic began in any country or area. There was statistical evidence of a decrease in suicide compared with the expected number in 12 countries or areas: New South Wales, Australia (RR 0·81 [95% CI 0·72-0·91]); Alberta, Canada (0·80 [0·68-0·93]); British Columbia, Canada (0·76 [0·66-0·87]); Chile (0·85 [0·78-0·94]); Leipzig, Germany (0·49 [0·32-0·74]); Japan (0·94 [0·91-0·96]); New Zealand (0·79 [0·68-0·91]); South Korea (0·94 [0·92-0·97]); California, USA (0·90 [0·85-0·95]); Illinois (Cook County), USA (0·79 [0·67-0·93]); Texas (four counties), USA (0·82 [0·68-0·98]); and Ecuador (0·74 [0·67-0·82])., Interpretation: This is the first study to examine suicides occurring in the context of the COVID-19 pandemic in multiple countries. In high-income and upper-middle-income countries, suicide numbers have remained largely unchanged or declined in the early months of the pandemic compared with the expected levels based on the pre-pandemic period. We need to remain vigilant and be poised to respond if the situation changes as the longer-term mental health and economic effects of the pandemic unfold., Funding: None., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Multiple studies have investigated the role of statins in prostate cancer (CaP), the leading cause of cancer related death in men. Retrospective cohort studies investigating the correlation between statin use and biochemical recurrence free (BCRF) survival in men with CaP have been inconclusive., Objectives: In the largest reported surgical cohort to date, we investigated the effect of statin therapy on BCRF and overall survival in patients with CaP who have undergone radical prostatectomy (RP)., Patients and Methods: We performed a retrospective analysis of men (n = 3,088) participating in the NCI funded Specialized Program of Research Excellence (SPORE) in CaP at Northwestern University (NM) in Chicago, Illinois. Patients were treated with RP between 2002 and 2015. Patients in the statin users group received treatment within 2 years prior to or subsequent to RP. Wilcoxon rank-sum and Fisher's exact tests were used to compare age, race, Gleason score, clinical staging, and pathological stage between statin users and nonstatin users., Results: The analysis identified 1,222 statin users and 1,865 nonusers (mean age 71 years, 92% Caucasian). After a median follow-up time of 49.0 months, the 5-year BCRF survival rate was 93.3% (95% confidence interval [CI]: 91.9-94.8%) among statin users and 88.6% (95% CI: 87.1%-90%) among nonusers (log-rank P< 0.001). After 10 years, the progression-free survival (PFS) was 91.7% (95% CI: 90.1%-93.3%) among statin users and 86.5% (95% CI: 84.4%-88.2%) among nonusers (log-rank P< 0.001)., Conclusions: Extended follow-up data in this large surgical cohort show statin use improves BCRF but not overall survival in RP patients., (Copyright © 2020. Published by Elsevier Inc.)

Background: Risk assessments are a central component of mental health care. Few national studies have been done in the UK on risk assessment tools used in mental health services. We aimed to examine which suicide risk assessment tools are in use in the UK; establish the views of clinicians, carers, and service users on the use of these tools; and identify how risk assessment tools have been used with mental health patients before suicide., Methods: We did a mixed-methods study involving three components: collection and content analysis of risk assessment tools used by UK mental health services; an online survey of clinicians, service-users, and carers; and qualitative telephone interviews with clinicians on their use of risk assessment tools before a suicide death and their views of these tools. The online survey was advertised through the National Confidential Inquiry into Suicide and Safety in Mental Health's (NCISH) website and social media, and it included both quantitative and open-ended qualitative questions, and respondents were recruited through convenience sampling. For the telephone interviews, we examined the NCISH database to identify clinicians who had been responsible for the care of a patient who died by suicide and who had been viewed as being at low or no immediate risk of suicide., Findings: We obtained 156 risk assessment tools from all 85 National Health Service mental health organisations in the UK, and 85 (one per each organisation) were included in the analysis. We found little consistency in use of these instruments, with 33 (39%) of 85 organisations using locally developed tools. Most tools aimed to predict self-harm or suicidal behaviour (84 [99%] of 85), and scores were used to determine management decisions (80 [94%]). Clinicians described positive aspects of risk tools (facilitating communication and enhancing therapeutic relationships) but also expressed negative views (inadequate training in the use of tools and their time-consuming nature). Both patients and carers reported some positive views, but also emphasised little involvement during risk assessment, and a lack of clarity on what to do in a crisis., Interpretation: Assessment processes need to be consistent across mental health services and include adequate training on how to assess, formulate, and manage suicide risk. An emphasis on patient and carer involvement is needed. In line with national guidance, risk assessment should not be seen as a way to predict future behaviour and should not be used as a means of allocating treatment. Management plans should be personalised and collaboratively developed with patients and their families and carers., Funding: The Healthcare Quality Improvement Partnership., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Suicide has emerged as a major cause of death from non-communicable disease worldwide, leading to a burgeoning interest in its prevention. Naturally, in this context one of the focuses of research and clinical interest is the presence of suicidal thinking-a potentially identifiable and reversible precursor of suicide-with much interest lately being in the relation between suicidal thinking and suicidal behaviour. In this Personal View we argue that, notwithstanding important and nuanced research into the nature of these phenomena, the field currently suffers from approaches to the terminology and reporting of suicidal thinking that pay insufficient regard to key features of its definition, and that these have clinical and research implications., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Current trends in regenerative medicine treatments for bone repair applications focus on cell-based therapies. These aim to deliver the treatment via a minimally invasive injection to reduce patient trauma and to improve efficacy. This paper describes the injectability of porous calcium phosphate glass microspheres to be used for bone repair based on their formulation, rheology and flow behavior. The use of excipients (xanthan gum, methyl cellulose and carboxyl methyl cellulose) were investigated to improve flow performance. Based on our results, the flow characteristics of the glass microsphere pastes vary according to particle size, surface area, and solid to liquid ratio, as well as the concentration of viscosity modifiers used. The optimal flow characteristics of calcium phosphate glass microsphere pastes was found to contain 40 mg/mL of xanthan gum which increased viscosity whilst providing elastic properties (∼29,000 Pa) at shear rates that mirror the injection process and the resting period post injection, preventing the glass microspheres from both damage and dispersion. It was established that a base formulation must contain 1 g of glass microspheres (60-125 μm in size) per 1 mL of cell culture media, or 0.48 g of glass microspheres of sizes between 125 and 200 μm. Furthermore, the glass microsphere formulations with xanthan gum were readily injectable via a syringe-needle system (3-20 mL, 18G and 14G needles), and have the potential to be utilized as a cell (or other biologics) delivery vehicle for bone regeneration applications., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Background: Self-harm is the strongest risk factor for subsequent suicide, but risk may vary. We compared the risk of suicide following hospital presentation for self-harm according to patient characteristics, method of self-harm, and variations in area-level socioeconomic deprivation, and estimated the incidence of suicide by time after hospital attendance., Methods: In this ongoing Multicentre Study of Self-harm in England, the study population consists of individuals aged at least 15 years who had attended the emergency department of five general hospitals in Oxford, Manchester, and Derby after non-fatal self-harm between Jan 1, 2000, and Dec 31, 2013. Information on method of self-harm was obtained through systematic monitoring in hospitals. Level of socioeconomic deprivation was based on the Index of Multiple Deprivation (IMD) characterising the area where patients lived, grouping them according to IMD quintiles. Mortality follow-up was up to Dec 31, 2015, resulting in up to 16 years of follow-up. We calculated incidence of suicide since first hospital presentation by follow-up period and estimated the association between individual factors (age, gender, method of self-harm, IMD, and number of non-fatal self-harm presentations to hospital) and suicide using mixed-effect models., Findings: Between Jan 1, 2000, and Dec 31, 2013, there were 92 177 presentations to the study hospitals by 51 108 individuals. 1325 patients involved in 1563 self-harm episodes were excluded from the study because they had missing information on gender, age, or mortality. The resulting study sample consisted of 90 614 hospital presentations by 49 783 individuals. By the end of follow-up on Dec 31, 2015, 703 patients had died by suicide. The overall incidence of suicide was 163·1 (95% CI 151·5-175·6) per 100 000 person-years, and 260·0 (237·4-284·8) per 100 000 person-years in men and 94·6 (83·3-107·4) per 100 000 person-years in women. The incidence of suicide was highest in the year following discharge from hospital (511·1 [451·7-578·2] per 100 000 person-years), particularly in the first month (1787·1 [1423·0-2244·4] per 100 000 person-years). Based on all presentations to hospital, men were three times more likely than women to die by suicide after self-harm (OR 3·36 [95% CI 2·77-4·08], p<0·0001). Age was positively related to suicide risk in both genders, with a 3% increase in risk for every one-year increase in age at hospital presentation (OR 1·03 [1·03-1·04], p<0·0001). Relative to hospital presentations after self-poisoning alone, presentations involving both self-injury and self-poisoning were associated with higher suicide risk (adjusted OR 2·06 [95% CI 1·42-2·99], p<0·0001], as were presentations after self-injury alone (adjusted OR 1·36 [1·09-1·70], p=0·007). Similarly, relative to self-harm by self-poisoning alone, attempted hanging or asphyxiation (adjusted OR 2·70 [1·53-4·78], p=0·001) and traffic-related acts of self-injury (adjusted OR 2·99 [1·17-7·65], p=0·022) were associated with greater risk of suicide. Self-cutting combined with self-poisoning was also associated with increased suicide risk (adjusted OR 1·36, [1·08-1·71], p=0·01). Compared with those patients living in the most deprived areas, those who lived in the least deprived areas (first national IMD quintile) had a greater risk of dying by suicide (adjusted OR 1·76 [1·32-2·34], p<0·0001) after adjusting for gender, age, previous self-harm, and psychiatric treatment, as did those living in the second least deprived areas (adjusted OR 1·64 [1·20-2·25], p=0·002)., Interpretation: Patients attending hospital for self-harm are at high risk of suicide, especially immediately after hospital attendance. Certain patient characteristics and methods of self-harm, together with living in areas of low socioeconomic deprivation, can increase patients' subsequent suicide risk. However, while specific risk factors can be usefully integrated into the assessment process, individual factors have poor utility in predicting suicide, so the needs and risks of all patients should be assessed to develop appropriate aftercare plan, including early follow-up., Funding: UK Department of Health and Social Care., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Self-harm is a major risk factor for suicide, with older adults (older than 65 years) having reportedly greater suicidal intent than any other age group. With the aging population rising and paucity of research focus in this age group, the extent of the problem of self-harm needs to be established. In a primary care cohort of older adults we aimed to investigate the incidence of self-harm, subsequent clinical management, prevalence of mental and physical diagnoses, and unnatural-cause mortality risk, including suicide., Methods: The UK Clinical Practice Research Datalink contains anonymised patient records from general practice that routinely capture clinical information pertaining to both primary and secondary care services. We identified 4124 adults aged 65 years and older with a self-harm episode ascertained from Read codes recorded during 2001-14. We calculated standardised incidence and in 2854 adults with at least 12 months follow-up examined the frequency of psychiatric referrals and prescription of psychotropic medication after self-harm. We estimated prevalence of mental and physical illness diagnoses before and after self-harm and, using Cox regression in a matched cohort, we examined cause-specific mortality risks., Findings: Overall incidence of self-harm in older adults aged 65 years and older was 4·1 per 10 000 person-years with stable gender-specific rates observed over the 13-year period. After self-harm, 335 (11·7%) of 2854 adults were referred to mental health services, 1692 (59·3%) were prescribed an antidepressant, and 336 (11·8%) were prescribed a tricyclic antidepressant (TCA). Having a diagnosed previous mental illness was twice as prevalent in the self-harm cohort as in the comparison cohort (prevalence ratio 2·10 [95% CI 2·03-2·17]) and with a previous physical health condition prevalence was 20% higher in the self-harm cohort compared to the comparison cohort (1·20 [1·17-1·23]). Adults from the self-harm cohort (n=2454) died from unnatural causes an estimated 20 times more frequently than the comparison cohort (n=48 921) during the first year. A markedly elevated risk of suicide (hazard ratio 145·4 [95% CI 53·9-392·3]) was observed in the self-harm cohort., Interpretation: Within primary care, we have identified a group of older adults at high risk from unnatural death, particularly within the first year of self-harm. We have highlighted a high frequency of prescription of TCAs, known to be potentially fatally toxic in overdose. We emphasise the need for early intervention, careful alternative prescribing, and increased support when older adults consult after an episode of self-harm and with other health conditions., Funding: National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY NC 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Photodynamic Therapy (PDT) is an attractive modality for treating solid cancers. This study evaluates the efficacy of Hypericin-PDT as a cytotoxic therapy in colorectal cancer (CRC), using 2D cell cultures and 3D multicellular tumour spheroids., Methods: Spheroids were generated through forced-floating and agitation-based techniques. 2D and spheroid models of HT29 and HCT116 CRC cells were incubated with Hypericin (0-200 nM) for 16 h. Cultures were irradiated with light (1 J/cm 2 ) and cytotoxicity assessed using Propidium Iodide fluorescence. Expression of ABCG2 protein was assessed by immunoassays in 2D and spheroid cultures. The effect of ABCG2 inhibition, using 10 μM Ko143, on cytotoxicity following Hypericin-PDT was evaluated., Results: Hypericin-PDT produced a significant reduction in HT29 (p < 0.0001) and HCT116 (p < 0.0001) cell viability in 2D cultures, with negligible non-phototoxicity. Spheroids were more resistant than 2D cultures to Hypericin-PDT (HT29: p = 0.003, HCT116: p = 0.006) and had a greater expression of ABCG2. Inhibition of ABCG2 in spheroids with Ko143 resulted in an enhanced Hypericin-PDT effect compared to Hypericin-PDT alone (HT29: p = 0.04, HCT116: p = 0.01)., Conclusions: Hypericin-PDT has reduced efficacy in CRC spheroids as compared to 2D cultures, which may be attributable through upregulation in ABCG2. The clinical efficacy of Hypericin-PDT may be enhanced by ABCG2 inhibition., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Little is known about the relative incidence of fatal and non-fatal self-harm in young people. We estimated the incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England., Methods: We used national mortality statistics (Jan 1, 2011, to Dec 31, 2013), hospital monitoring data for five hospitals derived from the Multicentre Study of Self-Harm in England (Jan 1, 2011, to Dec 31, 2013), and data from a schools survey (2015) to estimate the incidence of fatal and non-fatal self-harm per 100 000 person-years in adolescents aged 12-17 years in England. We described these incidences in terms of an iceberg model of self-harm., Findings: During 2011-13, 171 adolescents aged 12-17 years died by suicide in England (119 [70%] male and 133 [78%] aged 15-17 years) and 1320 adolescents presented to the study hospitals following non-fatal self-harm (1028 [78%] female and 977 [74%] aged 15-17 years). In 2015, 322 (6%) of 5506 adolescents surveyed reported self-harm in the past year in the community (250 [78%] female and 164 [51%] aged 15-17 years). In 12-14 year olds, for every boy who died by suicide, 109 attended hospital following self-harm and 3067 reported self-harm in the community, whereas for every girl who died by suicide, 1255 attended hospital for self-harm and 21 995 reported self-harm in the community. In 15-17 year olds, for every male suicide, 120 males presented to hospital with self-harm and 838 self-harmed in the community; whereas for every female suicide, 919 females presented to hospital for self-harm and 6406 self-harmed in the community. Hanging or asphyxiation was the most common method of suicide (125 [73%] of 171), self-poisoning was the main reason for presenting to hospital after self-harm (849 [71%] of 1195), and self-cutting was the main method of self-harm used in the community (286 [89%] of 322)., Interpretation: Ratios of fatal to non-fatal rates of self-harm differed between males and females and between adolescents aged 12-14 years and 15-17 years, with a particularly large number of females reporting self-harm in the community. Our findings emphasise the need for well resourced community and hospital-based mental health services for adolescents, with greater investment in school-based prevention., Funding: UK Department of Health., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: There is concern about the mental health of children and young people and a possible rise in suicidal behaviour in this group. We have done a comprehensive national multi-agency study of suicide in under 20s in England. We aimed to establish how frequently suicide is preceded by child-specific and young person-specific suicide risk factors, as well as all-age factors, and to identify contact with health-care and social-care services and justice agencies., Methods: This study is a descriptive examination of suicide in a national consecutive sample of children and young people younger than 20 years who died by suicide in England between Jan 1, 2014, and April 30, 2015. We obtained general population mortality data from the Office for National Statistics (ONS). We collected information about antecedents considered to be relevant to suicide (eg, abuse, bullying, bereavement, academic pressures, self-harm, and physical health) from a range of investigations and inquiries, including coroner inquest hearings, child death investigations, criminal justice system reports, and the National Health Service, including data on people in contact with mental health services in the 12 months before their death., Findings: 145 suicides in people younger than 20 years were notified to us during the study period, of which we were able to obtain report data about antecedents for 130 (90%). The number of suicides rose sharply during the late teens with 79 deaths by suicide in people aged 18-19 years compared with 66 in people younger than 18 years. 102 (70%) deaths were in males. 92 (63%) deaths were by hanging. Various antecedents were reported among the individuals for whom we had report data, including academic (especially exam) pressures (35 [27%] individuals), bullying (28 [22%]), bereavement (36 [28%]), suicide in family or friends (17 [13%]), physical health conditions (47 [36%]), family problems (44 [34%]), social isolation or withdrawal (33 [25%]), child abuse or neglect (20 [15%]), excessive drinking (34 [26%]), and illicit drug use (38 [29%]). Suicide-related internet use was recorded in 30 (23%) cases. In the week before death 13 (10%) individuals had self-harmed and 35 (27%) had expressed suicidal ideas. 56 (43%) individuals had no known contact with health-care and social-care services or justice agencies., Interpretation: Improved services for self-harm and mental health are crucial to suicide prevention, but the wide range of antecedents emphasises the roles of schools, primary care, social services, and the youth justice system., Funding: The Healthcare Quality Improvement Partnership., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Research into which aspects of service provision in mental health are most effective in preventing suicide is sparse. We examined the association between service changes, organisational factors, and suicide rates in a national sample., Methods: We did a before-and-after analysis of service delivery data and an ecological analysis of organisational characteristics, in relation to suicide rates, in providers of mental health care in England. We also investigated whether the effect of service changes varied according to markers of organisational functioning., Findings: Overall, 19 248 individuals who died by suicide within 12 months of contact with mental health services were included (1997-2012). Various service changes related to ward safety, improved community services, staff training, and implementation of policy and guidance were associated with a lower suicide rate after the introduction of these changes (incidence rate ratios ranged from 0·71 to 0·79, p<0·0001). Some wider organisational factors, such as non-medical staff turnover (Spearman's r=0·34, p=0·01) and incident reporting (0·46, 0·0004), were also related to suicide rates but others, such as staff sickness (-0·12, 0·37) and patient satisfaction (-0·06, 0·64), were not. Service changes had more effect in organisations that had low rates of staff turnover but high rates of overall event reporting., Interpretation: Aspects of mental health service provision might have an effect on suicide rates in clinical populations but the wider organisational context in which service changes are made are likely to be important too. System-wide change implemented across the patient care pathway could be a key strategy for improving patient safety in mental health care., Funding: The Healthcare Quality Improvement Partnership commissions the Mental Health Clinical Outcome Review Programme, National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, on behalf of NHS England, NHS Wales, the Scottish Government Health and Social Care Directorate, the Northern Ireland Department of Health, Social Services and Public Safety, and the States of Jersey and Guernsey., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Self-poisoning and self-injury are associated with a high risk of suicide or death from any cause but the effect of routine aspects of hospital management on mortality risk is unknown., Methods: We did a prospective cohort study using data for adults who had self-harmed presenting to five emergency departments in the UK between 2000 and 2010. We assessed the relation between four aspects of management (psychosocial assessment, medical admission, psychiatric admission, referral for mental health follow-up) and death by suicide or any cause within 12 months of presentation., Findings: Of 38 415 individuals presenting with self-harm, 261 (0·7%) died by suicide and 832 (2·2%) died from any cause within 12 months. Most aspects of management were associated with a higher mortality risk in unadjusted analyses. Psychiatric admission was associated with the highest risks for both suicide (hazard ratio 2·35, 95% CI 1·59-3·45) and all-cause mortality (2·35, 2·04-2·72). After adjustment for baseline variables, the hazard ratios were generally smaller, particularly for psychiatric admission. There were significant interactions by sex, age, and history of self-harm., Interpretation: This was an observational study and so we cannot infer causation. However, our finding that clinical services seem to reserve the most intensive levels of treatment for patients at highest risk is reassuring. Aspects of routine management might be associated with a lower mortality risk but these effects vary by clinical subgroup., Funding: UK Department of Health., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Understanding the cement flow behaviour and accurately predicting the cement placement within the vertebral body is extremely challenging. Vertebral cancellous bone displays highly complex geometrical structures and architectural inhomogeneities over a range of length scales, thus making the scientific understanding of the cement injection behaviour difficult in clinical or cadaveric studies. Previous experimental studies on cement flow have used open-porous aluminum foam to represent osteoporotic bone. Although the porosity was well controlled, the geometrical structure of each of the foams was inherently unique. This paper presents novel methodology using customized, reproducible and pathologically representative three-dimensional bone surrogates to help study biomaterial--biofluid interaction. The aim was to provide a robust tool for comprehensive assessment of biomaterial injection behaviour through controlling the bone surrogate morphology and the injection parameters (i.e. needle gauge, needle placement, flow rate and injected volume), measuring the injection pressure, and allowing the visualization and quantitative analysis of the spreading distribution. This methodology provides a clinically relevant representation of cement flow patterns and a tool for validating computational simulations., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Community care provided by crisis resolution home treatment teams is used increasingly as an alternative to admission to psychiatric wards. No systematic analysis has been done of the safety of these teams in terms of rates of suicide. We aimed to compare the rate and number of suicides among patients under the care of crisis resolution home treatment teams with those of psychiatric inpatients. We also assessed the clinical features of individuals who died by suicide in both home and hospital settings., Methods: We did a retrospective longitudinal analysis between 2003 and 2011 of all adults (aged 18 years or older) treated by the National Health Service in England who died by suicide while under the care of crisis resolution home treatment services or as a psychiatric inpatient. We obtained data from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness and from the Mental Health Minimum Dataset., Findings: 1256 deaths by suicide (12% of all patient suicides) were recorded among patients cared for under crisis resolution home treatment teams, an average of 140 deaths per year. Different denominators meant that direct comparison between groups was difficult, but the average rate of suicide under crisis resolution home treatment services (14·6 per 10 000 episodes under crisis care) seemed higher than the average rate of suicide among psychiatric inpatients (8·8 per 10 000 admissions). The number of suicides in patients under the care of crisis resolution home treatment teams increased from an average of 80 per year (in 2003 and 2004) to 163 per year (in 2010 and 2011) and were twice as frequent as inpatient suicides in the last few years of the study. However, because of the growing number of patients under the care of crisis resolution home treatment teams, the average rate of suicide fell by 18% between the first and last 2 years of the study. 548 (44%) patients who died by suicide under the care of crisis resolution home treatment teams lived alone and 594 (49%) had had a recent adverse life event. In a third of patients (n=428) under the care of crisis resolution home treatment teams, suicide happened within 3 months of discharge from psychiatric inpatient care., Interpretation: Although the number of suicides under the care of crisis resolution home treatment teams has risen since 2003, the rate has fallen. However, suicide rates remain high compared with the inpatient setting, and safety of individuals cared for by crisis resolution home treatment teams should be a priority for mental health services. For some vulnerable people who live alone or have adverse life circumstances, crisis resolution home treatment might not be the most appropriate care setting. Use of crisis resolution home treatment teams to facilitate early discharge could present a risk to some patients, which should be investigated further., Funding: Healthcare Quality Improvement Partnership., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: The media attention received by homicides committed by patients with mental illness is thought to increase stigma. However, people with mental illness can also be victims of violence. We aimed to assess how often victims of homicide are current mental health patients and their relationship to the perpetrators., Methods: In a national consecutive case-series study, we obtained data for victims and perpetrators of all confirmed homicides between Jan 1, 2003, and Dec 31, 2005, in England and Wales. We requested information about contact with mental health services in the 12 months before the homicide for all victims and perpetrators. For victims and perpetrators who had contact with mental health services in the 12 months before homicide, we sent questionnaires to the clinician responsible for the patient's care., Findings: 1496 victims of confirmed homicide died between Jan 1, 2003, and Dec 31, 2005, in England and Wales. Patients with mental illness were more likely to die by homicide than were people in the general population (incidence rate ratio 2·6, 95% CI 1·9-3·4). 90 homicide victims (6%) had contact with mental health services in the 12 months before their death. 213 patients with mental illness were convicted of homicide in the same 3 year period. 29 of 90 patient victims were killed by another patient with mental illness. In 23 of these 29 cases, the victim and perpetrator were known to each other, and in 21 of these cases, the victims and perpetrators were undergoing treatment at the same National Health Service Trust. In these 29 cases in which patient victims were killed by another patient with mental illness, alcohol and drug misuse (19 victims [66%], 27 perpetrators [93%]) and previous violence (7 victims [24%], 7 perpetrators [24%]) were common in both victims and, particularly, perpetrators. In seven of the 29 cases in which the victim was killed by another patient with mental illness, both victim and perpetrator were diagnosed with schizophrenia., Interpretation: The high risk of patients with mental illness being victims of homicide is an important antistigma message, although this risk partly comes from other patients with mental illness; overall, the risk of patients committing homicide is greater than the risk of being a victim of homicide. Identification and safeguarding of patients at risk of violence should be prominent in clinical risk assessment., Funding: Healthcare Quality Improvement Partnership., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: People who self-harm have an increased risk of premature death. The aim of this study was to investigate cause-specific premature death in individuals who self-harm, including associations with socioeconomic deprivation., Methods: We undertook a cohort study of patients of all ages presenting to emergency departments in Oxford, Manchester, and Derby, UK, after self-poisoning or self-injury between Jan 1, 2000, and Dec 31, 2007. Postcodes of individuals' place of residence were linked to the Index of Multiple Deprivation 2007 in England. Mortality information was supplied by the Medical Research Information Service of the National Health Service. Patients were followed up to the end of 2009. We calculated age-standardised mortality ratios (SMRs) and years of life lost (YLL), and we tested for associations with socioeconomic deprivation., Findings: 30 950 individuals presented with self-harm and were followed up for a median of 6·0 years (IQR 3·9-7·9). 1832 (6·1%) patients died before the end of follow-up. Death was more likely in patients than in the general population (SMR 3·6, 95% CI 3·5-3·8), and occurred more in males (4·1, 3·8-4·3) than females (3·2, 2·9-3·4). Deaths due to natural causes were 2-7·5 times more frequent than was expected. For individuals who died of any cause, mean YLL was 31·4 years (95% CI 30·5-32·2) for male patients and 30·7 years (29·5-31·9) for female patients. Mean YLL for natural-cause deaths was 25·9 years (25·7-26·0) for male patients and 25·5 years (25·2-25·8) for female patients, and for external-cause deaths was 40·2 years (40·0-40·3) and 40·0 years (39·7-40·5), respectively. Disease of the circulatory (13·1% in males; 13·0% in females) and digestive (11·7% in males; 17·8% in females) systems were major contributors to YLL from natural causes. All-cause mortality increased with each quartile of socioeconomic deprivation in male patients (χ(2) trend 39·6; p<0·0001), female patients (13·9; p=0·0002), and both sexes combined (55·4; p<0·0001). Socioeconomic deprivation was related to mortality in both sexes combined from natural causes (51·0; p<0·0001) but not from external causes (0·30; p=0·58). Alcohol problems were associated with death from digestive-system disease, drug misuse with mental and behavioural disorders, and physical health problems with circulatory-system disease., Interpretation: Physical health and life expectancy are severely compromised in individuals who self-harm compared with the general population. In the management of self-harm, clinicians assessing patients' psychosocial problems should also consider their physical needs., Funding: Department of Health Policy Research Programme., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: The burden of disease in children with non-cystic fibrosis (non-CF) bronchiectasis is unknown. Our study aimed to identify the determinants of quality of life (QOL) and parental mental health in this group of patients and their parents and to evaluate the effect of exacerbations on these parameters., Methods: Parents of 69 children (median age 7 years) with non-CF bronchiectasis prospectively completed two questionnaires (parent-proxy cough-specific quality of life [PC-QOL] and the Depression, Anxiety, and Stress Scale [DASS]) at stable and exacerbation states. Data on clinical, investigational, and lung function parameters were also collected., Results: During the stable state, the median interquartile range (IQR) PC-QOL score was 6.5 (5.3-6.9) and the DASS 21-item questionnaire score was 6 (0-20). Being of a young age correlated with a worse QOL (r(5) = 0.242, P = .04) but radiologic extent, lung function, underlying cause, environmental tobacco smoke exposure, and chronic upper-airway disease did not influence these scores. Exacerbations caused significant worsening in the PC-QOL scores (median [IQR], 4.6 [3.8-5.4]; P = .001) and DASS scores (median [IQR], 22 [9-42]; P < .001; 38% with elevated anxiety, 54% with abnormal depression/stress scores during exacerbation). The presence of viral infection, hypoxia, and hospitalization did not influence the exacerbation PC-QOL and DASS scores., Conclusions: There is a significant burden of disease, especially during exacerbation, on parents of children with bronchiectasis. Prevention, early detection, and appropriate treatment of exacerbations are likely to reduce psychologic morbidity in this group.

Background: Research investigating which aspects of mental health service provision are most effective in prevention of suicide is scarce. We aimed to examine the uptake of key mental health service recommendations over time and to investigate the association between their implementation and suicide rates., Methods: We did a descriptive, cross-sectional, and before-and-after analysis of national suicide data in England and Wales. We collected data for individuals who died by suicide between 1997 and 2006 who were in contact with mental health services in the 12 months before death. Data were obtained as part of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. When denominator data were missing, we used information from the Mental Health Minimum Data Set. We compared suicide rates for services implementing most of the recommendations with those implementing fewer recommendations and examined rates before and after implementation. We stratified results for level of socioeconomic deprivation and size of service provider., Findings: The average number of recommendations implemented increased from 0·3 per service in 1998 to 7·2 in 2006. Implementation of recommendations was associated with lower suicide rates in both cross-sectional and before-and-after analyses. The provision of 24 h crisis care was associated with the biggest fall in suicide rates: from 11·44 per 10 000 patient contacts per year (95% CI 11·12-11·77) before to 9·32 (8·99-9·67) after (p<0·0001). Local policies on patients with dual diagnosis (10·55; 10·23-10·89 before vs 9·61; 9·18-10·05 after, p=0·0007) and multidisciplinary review after suicide (11·59; 11·31-11·88 before vs 10·48; 10·13-10·84 after, p<0·0001) were also associated with falling rates. Services that did not implement recommendations had little reduction in suicide. The biggest falls in suicide seemed to be in services with the most deprived catchment areas (incidence rate ratio 0·90; 95% CI 0·88-0·92) and the most patients (0·86; 0·84-0·88)., Interpretation: Our findings suggest that aspects of provision of mental health services can affect suicide rates in clinical populations. Investigation of the relation between new initiatives and suicide could help to inform future suicide prevention efforts and improve safety for patients receiving mental health care., Funding: National Patient Safety Agency, UK., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: The radiologic definition of airway dilatation and bronchiectasis in children has substantial limitations. Bronchoarterial (BA) ratio is a commonly used criterion to define airway dilatation despite the lack of normative pediatric data. The objective of our study was to determine the range of normal bronchial to accompanying arterial diameter ratio on high-resolution CT scan of the chest in children and compare it with the available adult data., Methods: Children undergoing multidetector CT scan of the chest for nonpulmonary conditions at a single center were prospectively identified. High-resolution reconstruction was performed on those included and both airway lumen and vessel diameters were measured in the upper and lower lobes of both lungs. Mean BA ratio was calculated for each included child, and its correlation with age was assessed., Results: Forty-one children were included; the mean (SD) BA ratio was 0.626 (0.068) (range, 0.437-0.739). This ratio was lower than comparable adult data (combined mean [SD], 0.676 [0.12]; P = .01). No correlation was found with age in our cohort (r = -0.21, P = .19). There was no difference in the ratio based on laterality or lobe., Conclusions: In the pediatric age group, the airway is significantly smaller than the adjoining vessel. Using the radiologic criteria of BA ratio > 1 to define bronchial dilatation would underestimate the presence and extent of bronchiectasis, leading to delayed and missed diagnosis. This highlights the need to redefine the criteria for bronchial dilatation in children.

Background: Longitudinal FEV(1) data in children with non-cystic fibrosis (non-CF) bronchiectasis (BE) are contradictory, and there are no multifactor data on the evolution of lung function and growth in this group. We longitudinally reviewed lung function and growth in children with non-CF BE and explored biologically plausible factors associated with changes in these parameters over time., Methods: Fifty-two children with > or = 3 years of lung function data were retrospectively reviewed. Changes in annual anthropometry and spirometry at year 3 and year 5 from baseline were analyzed. The impact of sex, age, cause, baseline FEV(1), exacerbation frequency, radiologic extent, socioeconomic status, environmental tobacco smoke exposure, and period of diagnosis was evaluated., Results: Over 3 years, the group mean forced expiratory flow midexpiratory phase percent predicted and BMI z-score improved by 3.01 (P = .04; 95% CI, 0.14-5.86) and 0.089 (P = .01; 95% CI, 0.02-0.15) per annum, respectively. FEV(1)% predicted, FVC% predicted, and height z-score all showed nonsignificant improvement. Over 5 years, there was improvement in FVC% predicted (slope 1.74; P = .001) annually, but only minor improvement in other parameters. Children with immunodeficiency and those with low baseline FEV(1) had significantly lower BMI at diagnosis. Frequency of hospitalized exacerbation and low baseline FEV(1) were the only significant predictors of change in FEV(1) over 3 years. Decline in FEV(1)% predicted was large (but nonsignificant) for each additional year in age of diagnosis., Conclusions: Spirometric and anthropometric parameters in children with non-CF BE remain stable over a 3- to 5-year follow-up period once appropriate therapy is instituted. Severe exacerbations result in accelerated lung function decline. Increased medical cognizance of children with chronic moist cough is needed for early diagnosis, better management, and improving overall outcome in BE.