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Purpose: There is great interest in whether type 2 diabetes and its treatments alter breast cancer risk and prognosis, but previous studies are inconclusive. We conducted a cohort study within the UK General Practice Research Database to investigate associations of type 2 diabetes and patterns of diabetes treatment with breast cancer risk and all-cause mortality. Methods: We identified 52,657 women with type 2 diabetes, diagnosed between 1987 and 2007, and 30,210 randomly selected women without diabetes. We performed a time-dependent analysis using Cox proportional hazards models. Results: Diabetes was associated with a 29 % increased overall breast cancer risk (95 % CI: 1.16-1.44), but the association markedly attenuated when adjusted for age, period of cohort entry, region, and body mass index (BMI) (HR: 1.12; 95 % CI: 0.98-1.29). Women with breast cancer and pre-existing diabetes had a 49 % (95 % CI: 1.17-1.88) increased all-cause mortality risk compared with women with breast cancer but without diabetes, after controlling for age, period, region, BMI, smoking, alcohol, and deprivation. Compared with sulfonylurea, we found weak evidence that metformin monotherapy (HR: 1.04; 95 % CI: 0.79-1.37) and insulin (HR: 1.33; 95 % CI: 0.63-2.83) modified breast cancer risk among women with diabetes. Conclusions: We found weak evidence that diabetes is associated with a small increased risk of breast cancer. Among treated women, there is no evidence that anti-diabetes treatments modify the risk of developing breast cancer, with wide confidence intervals indicating imprecise effect estimates. Women with breast cancer and diabetes, however, had an increased all-cause mortality risk highlighting the potential importance of maintaining adequate glycemic control alongside anti-cancer treatments and subsequent follow-up. [ABSTRACT FROM AUTHOR]

Background: In contrast to most other forms of cancer, data from some developing and developed countries show surprisingly similar survival rates for ovarian cancer. We aimed to compare ovarian cancer survival in Philippine residents, Filipino-Americans and Caucasians living in the US, using a high resolution approach, taking potential differences in prognostic factors into account.Methods: Using databases from the SEER 13 and from the Manila and Rizal Cancer Registries, age-adjusted five-year absolute and relative survival estimates were computed using the period analysis method and compared between Filipino-American ovarian cancer patients with cancer patients from the Philippines and Caucasians in the US. Cox proportional hazards modelling was used to determine factors affecting survival differences.Results: Despite more favorable distribution of age and cancer morphology and similar stage distribution, 5-year absolute and relative survival were lower in Philippine residents (Absolute survival, AS, 44%, Standard Error, SE, 2.9 and Relative survival, RS, 49.7%, SE, 3.7) than in Filipino-Americans (AS, 51.3%, SE, 3.1 and RS, 54.1%, SE, 3.4). After adjustment for these and additional covariates, strong excess risk of death for Philippine residents was found (Relative Risk, RR, 2.45, 95% confidence interval, 95% CI, 1.99-3.01). In contrast, no significant differences were found between Filipino-Americans and Caucasians living in the US.Conclusion: Multivariate analyses disclosed strong survival disadvantages of Philippine residents compared to Filipino-American patients, for which differences in access to health care might have played an important role. Survival is no worse among Filipino-Americans than among Caucasians living in the US. [ABSTRACT FROM AUTHOR]

Background: Human papillomavirus (HPV) vaccination has been offered in over a hundred countries worldwide (including the United Kingdom, since September 2008). Controversy around adverse effects persists, with inconsistent evidence from follow-up of randomized controlled trials and confounding by indication limiting the conclusions drawn from larger-scale observational studies. This study aims to estimate the association between receiving a quadrivalent HPV vaccine and the reporting of short-term adverse effects and to demonstrate the utility of regression discontinuity design for examining side effects in routine data., Methods: We applied a novel regression discontinuity approach to a retrospective population-based cohort using primary care data from the UK Clinical Practice Research Datalink linked to hospital and social deprivation data. We examined the new onset of gastrointestinal, neuromuscular, pain, and headache/migraine symptoms using READ and International Classification of Diseases, tenth revision diagnostic codes. For each year between 2012 and 2017, we compared girls in school year 8 (born July/August) who were eligible to receive the vaccine with girls in year 7 (born September/October) who were not eligible., Results: Of the 21,853 adolescent girls in the cohort, 10,881 (50%) were eligible for HPV vaccination. There was no evidence of increased new gastrointestinal symptoms (adjusted odds ratio [OR]: 0.99; 95% confidence interval [CI]: 0.85, 1.15), headache/migraine symptoms (OR: 0.84; 95% CI: 0.70, 1.01), or pain symptoms (OR: 1.05; 95% CI: 0.95, 1.16) when comparing those eligible and ineligible for HPV vaccination., Conclusion: This study found no evidence that HPV vaccination eligibility is associated with reporting short-term adverse effects among adolescent girls., Competing Interests: Disclosure: The authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: Our aim was to identify which patients are likely to stay in hospital longer following total hip replacement surgery., Design: Longitudinal, observational study used routinely collected data., Setting: Data were collected from an NHS Trust in South-West England between 2016 and 2019., Participants: 2352 hip replacement patients had complete data and were included in analysis., Primary and Secondary Outcome Measures: Three measures of length of stay were used: a count measure of number of days spent in hospital, a binary measure of ≤7 days/>7 days in hospital and a binary measure of remaining in hospital when medically fit for discharge., Results: The mean length of stay was 5.4 days following surgery, with 18% in hospital for more than 7 days, and 11% staying in hospital when medically fit for discharge. Longer hospital stay was associated with older age (OR=1.06, 95% CI 1.05 to 1.08), being female (OR=1.42, 95% CI 1.12 to 1.81) and more comorbidities (OR=3.52, 95% CI 1.45 to 8.55) and shorter length of stay with not having had a recent hospital admission (OR=0.44, 95% CI 0.32 to 0.60). Results were similar for remaining in hospital when medically fit for discharge, with the addition of an association with highest socioeconomic deprivation (OR=2.08, 95% CI 1.37 to 3.16)., Conclusions: Older, female patients with more comorbidities and from more socioeconomically deprived areas are likely to remain in hospital for longer following surgery. This study produced regression models demonstrating consistent results across three measures of prolonged hospital stay following hip replacement surgery. These findings could be used to inform surgery planning and when supporting patient discharge following surgery., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Outreach clinics were part of efforts to maximise uptake in COVID-19 vaccination., Methods: We used controlled interrupted time series, matching on age, sex, deprivation and vaccination eligibility date, to determine the effect of outreach clinics on time to first COVID-19 vaccine, using a population-based electronic health record database of 914,478 people, from December 2020 to December 2021; people living within 1 mile of each outreach clinics were exposed., Results: 50% of 288,473 exposed citizens were white British, and 71% were aged 0-49 years. There was no evidence for an overall statistically significant increase in cumulative percentage vaccinated due to the outreach clinic at 6 weeks, with an overall pooled effect estimate of -0.07% (95% CI: -1.15%, 1.02%). The pooled estimate for increased cumulative vaccine uptake varied slightly depending on how the analysis was stratified; by ethnic group it was - 0.12% (95% CI: -0.90%, 0.66%); by age group it was - 0.06% (95% CI: -0.41%, 0.28%); and by deprivation it was 0.03% (95% CI: -0.74%, 0.79%)., Conclusions: Living within a mile of an outreach clinic was not associated with higher vaccine uptake. Evaluation of future outreach clinics should consider the relative importance of travel amongst other barriers to accessing vaccines., (© 2024. The Author(s).)

Objectives: The aim of this review was to identify factors associated with multiple visits to emergency department (ED) services for mental health care in adolescents., Methods: Electronic databases (MEDLINE, PsycINFO, Embase, CINAHL, Web of Science and ProQuest Dissertations & Thesis Global) were searched for evidence that presented an association between risk factors or correlates of multiple visits to the emergency departmental for mental health care by 10-24 year olds. High impact use was defined as at least one return ED visit for mental health care. Primary studies of any quantitative design were included, with no exclusions based on language or country and all possible risk factors were considered. Data were extracted and synthesised using quantitative methods; frequencies of positive, negative and null associations were summarised for categories of potential risk factors., Results: Sixty-five studies were included in the review. Most studies were from North America and reported a wide range of measures of high impact ED use, the most common being a binary indicator of multiple ED visits. Sex/gender and age were the most frequently reported risk factors. Measure of previous or concurrent access to mental health care was consistently positively associated with high impact use. Having private health insurance, compared with public or no insurance, was generally negatively associated with high impact use. Proxy measures of socioeconomic position (SEP) showed associations between lower SEP and more high impact use in a small number of studies. No other factors were consistently or uniformly associated with high impact use., Conclusions: The review identified a substantial evidence base but due to the variability in study design and measurement of both risk factors and outcomes, no consistent risk factors emerged. More research is needed, particularly outside North America, using robust methods and high quality routinely collected data., Competing Interests: Declaration of competing interest RW, AJ, MTR, KS, SD, MDL, JS, BS report no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic resulted in the implementation of strict public health and social measures (PHSMs) (including mobility restrictions, social distancing, mask-wearing and hand hygiene), limitations on non-essential healthcare services, and public fear of COVID-19 infection, all of which potentially affected transmission and healthcare use for other diseases such as lower respiratory tract infections (LRTIs)., Objective: To determine changes in LRTI hospital admissions and in-facility mortality in children aged <5 years in the Western Cape Province during the pandemic., Methods: We conducted a retrospective analysis of LRTI admissions and in-facility deaths from January 2019 to November 2021. We estimated changes in rates and trends of LRTI admissions during the pandemic compared with pre-pandemic period using interrupted time series analysis, adjusting for key characteristics., Results: There were 36 277 children admitted for LRTIs during the study period, of whom 58% were male and 51% were aged 28 days - 1 year. COVID-19 restrictions were associated with a 13% step reduction in LRTI admissions compared with the pre-COVID-19 period (incidence rate ratio (IRR) 0.87, 95% confidence interval (CI)) 0.80 - 0.94). The average LRTI admission trend increased on average by 2% per month during the pandemic (IRR 1.02, 95% CI 1.02 - 1.04)., Conclusions: The COVID-19 surges and their associated measures were linked to declining LRTI admissions and in-facility deaths, likely driven by a combination of reduced infectious disease transmission and reduced use of healthcare services, with effects diminishing over time. These findings may inform future pandemic response policies.

Background and Hypothesis: Antipsychotics are first-line drug treatments for schizophrenia. When antipsychotic monotherapy is ineffective, combining two antipsychotic drugs is common although treatment guidelines warn of possible increases in side effects. Risks of metabolic side effects with antipsychotic polypharmacy have not been fully investigated. This study examined associations between antipsychotic polypharmacy and risk of developing diabetes, hypertension, or hyperlipidemia in adults with schizophrenia, and impact of co-prescription of first- and second-generation antipsychotics., Study Design: A population-based prospective cohort study was conducted in the United Kingdom using linked primary care, secondary care, mental health, and social deprivation datasets. Cox proportional hazards models with stabilizing weights were used to estimate risk of metabolic disorders among adults with schizophrenia, comparing patients on antipsychotic monotherapy vs polypharmacy, adjusting for demographic and clinical characteristics, and antipsychotic dose., Study Results: Median follow-up time across the three cohorts was approximately 14 months. 6.6% developed hypertension in the cohort assembled for this outcome, with polypharmacy conferring an increased risk compared to monotherapy, (adjusted Hazard Ratio = 3.16; P = .021). Patients exposed to exclusive first-generation antipsychotic polypharmacy had greater risk of hypertension compared to those exposed to combined first- and second-generation polypharmacy (adjusted HR 0.29, P = .039). No associations between polypharmacy and risk of diabetes or hyperlipidemia were found., Conclusions: Antipsychotic polypharmacy, particularly polypharmacy solely comprised of first-generation antipsychotics, increased the risk of hypertension. Future research employing larger samples, follow-up longer than the current median of 14 months, and more complex methodologies may further elucidate the association reported in this study., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Objectives: Previous studies have suggested that fibrates and glitazones may have a role in brain tumour prevention. We examined if there is support for these observations using primary care records from the UK Clinical Practice Research Datalink (CPRD)., Design: We conducted two nested case-control studies using primary and secondary brain tumours identified within CPRD between 2000 and 2016. We selected cases and controls among the population of individuals who had been treated with any anti-diabetic or anti-hyperlipidaemic medication to reduce confounding by indication., Setting: Adults older than 18 years registered with a general practitioner in the UK contributing data to CPRD., Results: We identified 7496 individuals with any brain tumour (4471 primary; 3025 secondary) in total. After restricting cases and controls to those prescribed any anti-diabetic or anti-hyperlipidaemic medication, there were 1950 cases and 7791 controls in the fibrate and 480 cases with 1920 controls in the glitazone analyses. Longer use of glitazones compared with all other anti-diabetic medications was associated with a reduced risk of primary (adjusted OR (aOR) 0.89 per year, 95% CI 0.80 to 0.98), secondary (aOR 0.87 per year, 95% CI 0.77 to 0.99) or combined brain tumours (aOR 0.88 per year, 95% CI 0.81 to 0.95). There was little evidence that fibrate exposure was associated with risk of either primary or secondary brain tumours., Conclusions: Longer exposure to glitazones was associated with reduced primary and secondary brain tumour risk. Further basic science and population-based research should explore this finding in greater detail, in terms of replication and mechanistic studies., Competing Interests: Competing interests: JWR receives funding from Biogen for unrelated research. All other authors declare no conflicts of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Men at risk of suicide often face difficulties with finances, employment, or housing, yet support services are usually psychologically based. This study evaluated the Hope service which provides integrated psychosocial support alongside practical, financial and specialist advice., Aims: To examine how the Hope service supports men at risk of suicide and factors that influence its impact and usefulness., Methods: Twenty-six qualitative interviews with 16 service users, six Hope staff, two specialist money advice workers funded to work for Hope and two NHS referral staff, thematically analysed., Results: The Hope service provided an essential service for men at risk of suicide, with complex needs including addiction, job loss, homelessness, debt, relationship-breakdown and bereavement who often would otherwise have fallen through service provision gaps. Working in a person-centred, non-judgemental way elicited trust and specialist advice tackled problems such as housing needs, debt, benefit claims and employment, enabling men to regain a sense of control over their lives. Some men shared histories of abuse, for which specialist counselling was hard to access., Conclusions: Hope provides an effective integrated support package for suicidal men. Funding for services like Hope are important to tackle structural issues such as homelessness and debt, alongside emotional support.

Objective: To compare two quality improvement (QI) interventions to improve antenatal magnesium sulphate (MgSO 4 ) uptake in preterm births for the prevention of cerebral palsy., Design: Unblinded cluster randomised controlled trial., Setting: Academic Health Sciences Network, England, 2018., Sample: Maternity units with ≥10 preterm deliveries annually and MgSO 4 uptake of ≤70%; 40 (27 NPP, 13 enhanced support) were included (randomisation stratified by MgSO 4 uptake)., Methods: The National PReCePT Programme (NPP) gave maternity units QI materials (clinical guidance, training), regional support, and midwife backfill funding. Enhanced support units received this plus extra backfill funding and unit-level QI coaching., Main Outcome Measures: MgSO 4 uptake was compared using routine data and multivariable linear regression. Net monetary benefit was estimated, based on implementation costs, lifetime quality-adjusted life-years and societal costs. The implementation process was assessed through qualitative interviews., Results: MgSO 4 uptake increased in all units, with no evidence of any difference between groups (0.84 percentage points lower uptake in the enhanced group, 95% CI -5.03 to 3.35). The probability of enhanced support being cost-effective was <30%. NPP midwives gave more than their funded hours for implementation. Units varied in their support needs. Enhanced support units reported better understanding, engagement and perinatal teamwork., Conclusions: PReCePT improved MgSO 4 uptake in all maternity units. Enhanced support did not further improve uptake but may improve teamwork, and more accurately represented the time needed for implementation. Targeted enhanced support, sustainability of improvements and the possible indirect benefits of stronger teamwork associated with enhanced support should be explored further., (© 2023 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Objectives: This study aimed to develop a simulation model to support orthopaedic elective capacity planning., Methods: An open-source, generalisable discrete-event simulation was developed, including a web-based application. The model used anonymised patient records between 2016 and 2019 of elective orthopaedic procedures from a National Health Service (NHS) Trust in England. In this paper, it is used to investigate scenarios including resourcing (beds and theatres) and productivity (lengths of stay, delayed discharges and theatre activity) to support planning for meeting new NHS targets aimed at reducing elective orthopaedic surgical backlogs in a proposed ring-fenced orthopaedic surgical facility. The simulation is interactive and intended for use by health service planners and clinicians., Results: A higher number of beds (65-70) than the proposed number (40 beds) will be required if lengths of stay and delayed discharge rates remain unchanged. Reducing lengths of stay in line with national benchmarks reduces bed utilisation to an estimated 60%, allowing for additional theatre activity such as weekend working. Further, reducing the proportion of patients with a delayed discharge by 75% reduces bed utilisation to below 40%, even with weekend working. A range of other scenarios can also be investigated directly by NHS planners using the interactive web app., Conclusions: The simulation model is intended to support capacity planning of orthopaedic elective services by identifying a balance of capacity across theatres and beds and predicting the impact of productivity measures on capacity requirements. It is applicable beyond the study site and can be adapted for other specialties., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Aims: Elective hip and knee replacement operations were suspended in April 2020 due to the COVID-19 pandemic. The impact of this suspension and continued disruption to the delivery of joint replacement surgery is still emerging. We describe the impact of the pandemic on the provision of publicly funded elective hip and knee replacement surgery at one teaching hospital in England and on which patients had surgery., Methods: We included all elective primary and revision hip and knee replacements performed at one hospital between January 2016 and June 2021. Using data for the years 2016-2019, we estimated the expected number of operations and beds occupied per month in January 2020 to June 2021 using time series linear models (adjusting for season and trend). We compared the predictions with the real data for January 2020 to June 2021 to assess the impact of the pandemic on the provision of elective hip and knee replacements. We compared the length of stay and characteristics (age, gender, number of comorbidities, index of multiple deprivation) of patients who had surgery before the pandemic with those who had surgery during the pandemic., Results: We included 6,964 elective primary and revision hip and knee replacements between January 2016 and June 2021. Between January 2020 and June 2021 primary hip replacement volume was 59% of predicted, and 47% for primary knee replacements. Revision hip replacement volume was 77% of predicted, and 42% for revision knee replacement. Median length of stay was one day shorter for primary (4 vs 3 days) and revision (6 vs 5 days) operations during the pandemic compared with before. Patients operated on during the pandemic were younger and had slightly more comorbidities than those operated on before the pandemic., Conclusions: The restricted provision of elective hip and knee replacements during the COVID-19 pandemic changed the patient casemix, but did not introduce new inequalities in access to these operations. Patients were younger, had more comorbidities, and stayed in hospital for less time than those treated before the pandemic. Approximately half the number of operations were performed during the pandemic than would have been expected and the effect was greatest for revision knee replacements., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: AB (Stryker) has received research and other financial support from companies or suppliers outside the submitted work. AJ declares advisory board positions with receipt of fees (Anthera Pharmaceuticals, INC.) and paid consultancy work (Freshfields Bruckhaus Deringer) for companies outside the submitted work. All other authors declare no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Penfold et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: To determine whether a dementia wellbeing service (DWS) signposting people with dementia to community services decreases the rate of avoidable hospital admissions, in-hospital mortality, complexity of admissions (number of comorbidities) or length of stay., Methods: Interrupted time series analysis to estimate the effects of the DWS on hospital outcomes. We included all unplanned admissions for ambulatory care sensitive conditions ('avoidable hospital admissions') with a dementia diagnosis recorded in the Hospital Episode Statistics. The intervention region was compared with a demographically similar control region in the 2 years before and 3 years after the implementation of the new service (October 2013 to September 2018)., Results: There was no strong evidence that admission rates reduced and only weak evidence that the trend in average length of stay reduced slowly over time. In-hospital mortality decreased immediately after the introduction of the dementia wellbeing service compared to comparator areas (x0.64, 95% CI 0.42, 0.97, p = 0.037) but attenuated over the following years. The rate of increase in comorbidities also appeared to slow after the service began; they were similar to comparator areas by September 2018., Conclusions: We found no major impact of the DWS on avoidable hospital admissions, although there was weak evidence for slightly shorter length of stay and reduced complexity of hospital admissions. These findings may or may not reflect a true benefit of the service and require further investigation. The DWS was established to improve quality of dementia care; reducing hospital admissions was never its sole purpose. More targeted interventions may be required to reduce hospital admissions for people with dementia.

Background: Adults living with overweight/obesity are eligible for publicly funded weight management (WM) programmes according to national guidance. People with the most severe and complex obesity are eligible for bariatric surgery. Primary care plays a key role in identifying overweight/obesity and referring to WM interventions. This study aimed to (1) describe the primary care population in England who (a) are referred for WM interventions and (b) undergo bariatric surgery and (2) determine the patient and GP practice characteristics associated with both., Methods and Findings: An observational cohort study was undertaken using routinely collected primary care data in England from the Clinical Practice Research Datalink linked with Hospital Episode Statistics. During the study period (January 2007 to June 2020), 1,811,587 adults met the inclusion criteria of a recording of overweight/obesity in primary care, of which 54.62% were female and 20.10% aged 45 to 54. Only 56,783 (3.13%) were referred to WM, and 3,701 (1.09% of those with severe and complex obesity) underwent bariatric surgery. Multivariable Poisson regression examined the associations of demographic, clinical, and regional characteristics on the likelihood of WM referral and bariatric surgery. Higher body mass index (BMI) and practice region had the strongest associations with both outcomes. People with BMI ≥40 kg/m2 were more than 6 times as likely to be referred for WM (10.05% of individuals) than BMI 25.0 to 29.9 kg/m2 (1.34%) (rate ratio (RR) 6.19, 95% confidence interval (CI) [5.99,6.40], p < 0.001). They were more than 5 times as likely to undergo bariatric surgery (3.98%) than BMI 35.0 to 40.0 kg/m2 with a comorbidity (0.53%) (RR 5.52, 95% CI [5.07,6.02], p < 0.001). Patients from practices in the West Midlands were the most likely to have a WM referral (5.40%) (RR 2.17, 95% CI [2.10,2.24], p < 0.001, compared with the North West, 2.89%), and practices from the East of England least likely (1.04%) (RR 0.43, 95% CI [0.41,0.46], p < 0.001, compared with North West). Patients from practices in London were the most likely to undergo bariatric surgery (2.15%), and practices in the North West the least likely (0.68%) (RR 3.29, 95% CI [2.88,3.76], p < 0.001, London compared with North West). Longer duration since diagnosis with severe and complex obesity (e.g., 1.67% of individuals diagnosed in 2007 versus 0.34% in 2015, RR 0.20, 95% CI [0.12,0.32], p < 0.001), and increasing comorbidities (e.g., 2.26% of individuals with 6+ comorbidities versus 1.39% with none (RR 8.79, 95% CI [7.16,10.79], p < 0.001) were also strongly associated with bariatric surgery. The main limitation is the reliance on overweight/obesity being recorded within primary care records to identify the study population., Conclusions: Between 2007 and 2020, a very small percentage of the primary care population eligible for WM referral or bariatric surgery according to national guidance received either. Higher BMI and GP practice region had the strongest associations with both. Regional inequalities may reflect differences in commissioning and provision of WM services across the country. Multi-stakeholder qualitative research is ongoing to understand the barriers to accessing WM services and potential solutions. Together with population-wide prevention strategies, improved access to WM interventions is needed to reduce obesity levels., Competing Interests: HP has received speaker honoraria from Johnson & Johnson and Novo Nordisk for educational events. Honoraria received for participating in the development and presentation of an algorithm for the management of obesity in primary care supported by arm’s length sponsorship from Novo Nordisk. She is a co-author on a publication of UK data from a study funded by Novo Nordisk (no honorarium)., (Copyright: © 2023 Coulman et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To evaluate the effectiveness and cost-effectiveness of the National PReCePT Programme (NPP) in increasing use of magnesium sulfate (MgSO 4 ) in preterm births., Design: Before-and-after study., Setting: Maternity units (N=137) within NHS England and the Academic Health Science Network (AHSN) in 2018., Participants: Babies born ≤30 weeks' gestation admitted to neonatal units in England., Interventions: The NPP was a quality improvement (QI) intervention including the PReCePT (Preventing Cerebral Palsy in Pre Term labour) QI toolkit and materials (preterm labour proforma, staff training presentations, parent leaflet, posters for the unit and learning log), regional AHSN-level support, and up to 90 hours funded backfill for a midwife 'champion' to lead implementation., Main Outcome Measures: MgSO 4 uptake post implementation was compared with pre-NPP implementation uptake. Implementation and lifetime costs were estimated., Results: Compared with pre-implementation estimates, the average MgSO 4 uptake for babies born ≤30 weeks' gestation, in 137 maternity units in England, increased by 6.3 percentage points (95% CI 2.6 to 10.0 percentage points) to 83.1% post implementation, accounting for unit size, maternal, baby and maternity unit factors, time trends, and AHSN. Further adjustment for early/late initiation of NPP activities increased the estimate to 9.5 percentage points (95% CI 4.3 to 14.7 percentage points). From a societal and lifetime perspective, the health gains and cost savings associated with the NPP effectiveness generated a net monetary benefit of £866 per preterm baby and the probability of the NPP being cost-effective was greater than 95%., Conclusion: This national QI programme was effective and cost-effective. National programmes delivered via coordinated regional clinical networks can accelerate uptake of evidence-based therapies in perinatal care., Competing Interests: Competing interests: GAF received grant funding from the NIHR and the British Heart Foundation and is a party to partnership agreements with industry partners as CEO of the Oxford Academic Health Science Network. He is chair of the Buckinghamshire, Oxfordshire and West Berkshire Integrated Stroke Delivery Network, the Academic Health Science Network, the European Stroke Organisation Council of Fellows and the Academy of Medical Sciences Fellowship Sectional Committee 7. He is Director of the Cogentis and Accelerate companies and Non-Executive Director of the National Institute for Health and Care Excellence, and serves on the Board of Trustees of the Picker Institute and Health Services Research UK, and the governing body of Green Templeton College, Oxford University. He is data monitoring committee member for the PREVENT-SVD study, trial steering group member for OPTIMAS, R4VaD, ATTEST-2 and SENIOR-RITA trials, grants review panel member for Pfizer/Bristol Myers Squibb, and round table member for the Bristol Myers Squibb/Price Waterhouse Cooper Life Sciences 2030 Cancer Moonshot and Astellas Company Conference. KT acted as expert witness to the High Court in England, called by the UK MHRA, defendant in a case on hormonal pregnancy tests and congenital anomalies in 2021/2022. All other authors in this manuscript have no conflict of interest to declare aside from funding from NIHR ARC West, AHSN, NHS England and Health Foundation. The authors declare that the study management group has no competing financial, professional or personal interests that might have influenced the study design or conduct., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objective: To identify demographic, premorbid and injury-related factors, or biomarkers associated with long-term (≥3 months) adverse outcomes in children after mild traumatic brain injury (mTBI)., Design: Scoping review of literature., Patients: Children and adolescents with mTBI., Risk Factors: Any demographic, premorbid and injury-related factors, or biomarkers were included. We excluded genetic and treatment-related factors., Main Outcome Measures: Postconcussion syndrome (PCS), recovery., Results: Seventy-three publications were included, reporting 12 long-term adverse outcomes, including PCS in 12 studies and recovery in 29 studies. Additional outcomes studied were symptom scores/severity (n=22), quality of life (n=9) and cognitive function (n=9). Forty-nine risk factors were identified across studies. Risk factors most often assessed were sex (n=28), followed by age (n=23), injury mechanism = (n=22) and prior mTBI (n=18). The influence of these and other risk factors on outcomes of mTBI were inconsistent across the reviewed literature., Conclusions: The most researched risk factors are sex, age and mechanism of injury, but their effects have been estimated inconsistently and did not show a clear pattern. The most studied outcomes are recovery patterns and symptom severity. However, these may not be the most important outcomes for clinicians and patients. Future primary studies in this area should focus on patient-important outcomes. Population-based prospective studies are needed that address prespecified hypotheses on the relationship of risk factors with given outcomes to enable reliable prediction of long-term adverse outcomes for childhood mTBI., Competing Interests: Competing interests: SI, LS, RW, SD, JJ, MTR, and JS report grant funding from NIHR (NIHR ARC West) during the conduct of the study. JS reports personal fees from Core Models Limited, UK (for teaching introductory systematic review methods at an online course), unrelated to the submitted work., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To explore the impact of a temporary cancellation of elective surgery in winter 2017 on trends in primary hip and knee replacement at a major National Health Service (NHS) Trust, and whether lessons can be learnt about efficient surgery provision., Design and Setting: Observational descriptive study using interrupted time series analysis of hospital records to explore trends in primary hip and knee replacement surgery at a major NHS Trust, as well as patient characteristics, 2016-2019., Intervention: A temporary cancellation of elective services for 2 months in winter 2017., Outcomes: NHS-funded hospital admissions for primary hip or knee replacement, length of stay and bed occupancy. Additionally, we explored the ratio of elective to emergency admissions at the Trust as a measure of elective capacity, and the ratio of public to private provision of NHS-funded hip and knee surgery., Results: After winter 2017, there was a sustained reduction in the number of knee replacements, a decrease in the proportion of most deprived people having knee replacements and an increase in average age for knee replacement and comorbidity for both types of surgery. The ratio of public to private provision dropped after winter 2017, and elective capacity generally has reduced over time. There was clear seasonality in provision of elective surgery, with less complex patients admitted during winter., Conclusions: Declining elective capacity and seasonality has a marked effect on the provision of joint replacement, despite efficiency improvements in hospital treatment. The Trust has outsourced less complex patients to independent providers, and/or treated them during winter when capacity is most limited. There is a need to explore whether these are strategies that could be used explicitly to maximise the use of limited elective capacity, provide benefit to patients and value for money for taxpayers., Competing Interests: Competing interests: TJ, EE and MTR had financial support from NIHR ARC West for the submitted work. AJ has had financial support in the previous 3 years through institutional grants from NIHR, HDR UK, Versus Arthritis, Healthcare Quality Improvement Partnership (HQIP), Royal College of Physicians (RCP) and Health Foundation, had unpaid committee or leadership roles relating to musculoskeletal conditions for NIHR, Nuffield Foundation, Warwick CTU, and Versus Arthritis and a paid expert panel role for Nuffield Foundation Oliver Bird Fund; no other financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: Routinely collected population-wide health data are often used to understand mortality trends including child mortality, as these data are often available more readily or quickly and for lower geographic levels than population-wide mortality data. However, understanding the completeness and accuracy of routine health data sources is essential for their appropriate interpretation and use. This study aims to assess the accuracy of diagnostic coding for public sector in-facility childhood (age < 5 years) infectious disease deaths (lower respiratory tract infections [LRTI], diarrhoea, meningitis, and tuberculous meningitis [TBM]) in routine hospital information systems (RHIS) through comparison with causes of death identified in a child death audit system (Child Healthcare Problem Identification Programme [Child PIP]) and the vital registration system (Death Notification [DN] Surveillance) in the Western Cape, South Africa and to calculate admission mortality rates (number of deaths in admitted patients per 1000 live births) using the best available data from all sources., Methods: The three data sources: RHIS, Child PIP, and DN Surveillance are integrated and linked by the Western Cape Provincial Health Data Centre using a unique patient identifier. We calculated the deduplicated total number of infectious disease deaths and estimated admission mortality rates using all three data sources. We determined the completeness of Child PIP and DN Surveillance in identifying deaths recorded in RHIS and the level of agreement for causes of death between data sources., Results: Completeness of recorded in-facility infectious disease deaths in Child PIP (23/05/2007-08/02/2021) and DN Surveillance (2010-2013) was 70% and 69% respectively. The greatest agreement in infectious causes of death were for diarrhoea and LRTI: 92% and 84% respectively between RHIS and Child PIP, and 98% and 83% respectively between RHIS and DN Surveillance. In-facility infectious disease admission mortality rates decreased significantly for the province: 1.60 (95% CI: 1.37-1.85) to 0.73 (95% CI: 0.56-0.93) deaths per 1000 live births from 2007 to 2020., Conclusion: RHIS had accurate causes of death amongst children dying from infectious diseases, particularly for diarrhoea and LRTI, with declining in-facility admission mortality rates over time. We recommend integrating data sources to ensure the most accurate assessment of child deaths., (© 2023. The Author(s).)

Objectives: To evaluate the impact of a new clinic-based rapid sexually transmitted infection testing, diagnosis and treatment service on healthcare delivery and resource needs in an integrated sexual health service., Design: Controlled interrupted time series study., Setting: Two integrated sexual health services (SHS) in UK: Unity Sexual Health in Bristol, UK (intervention site) and Croydon Sexual Health in London (control site)., Participants: Electronic patient records for all 58 418 attendances during the period 1 year before and 1 year after the intervention., Intervention: Introduction of an in-clinic rapid testing system for gonorrhoea and chlamydia in combination with revised treatment pathways., Outcome Measures: Time-to-test notification, staff capacity, cost per episode of care and overall service costs. We also assessed rates of gonorrhoea culture swabs, follow-up attendances and examinations., Results: Time-to-notification and the rate of gonorrhoea swabs significantly decreased following implementation of the new system. There was no evidence of change in follow-up visits or examination rates for patients seen in clinic related to the new system. Staff capacity in clinics appeared to be maintained across the study period. Overall, the number of episodes per week was unchanged in the intervention site, and the mean cost per episode decreased by 7.5% (95% CI 5.7% to 9.3%)., Conclusions: The clear improvement in time-to-notification, while maintaining activity at a lower overall cost, suggests that the implementation of clinic-based testing had the intended impact, which bolsters the case for more widespread rollout in sexual health services., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To identify risk factors associated with prolonged length of hospital stay and staying in hospital longer than medically necessary following primary knee replacement surgery., Design: Retrospective, longitudinal observational study., Setting: Elective knee replacement surgeries between 2016 and 2019 were identified using routinely collected data from an NHS Trust in England., Participants: There were 2295 knee replacement patients with complete data included in analysis. The mean age was 68 (SD 11) and 60% were female., Outcome Measures: We assessed a binary length of stay outcome (>7 days), a continuous length of stay outcome (≤30 days) and a binary measure of whether patients remained in hospital when they were medically fit for discharge., Results: The mean length of stay was 5.0 days (SD 3.9), 15.4% of patients were in hospital for >7 days and 7.1% remained in hospital when they were medically fit for discharge. Longer length of stay was associated with older age ( b= 0.08, 95% CI 0.07 to 0.09), female sex ( b =0.36, 95% CI 0.06 to 0.67), high deprivation ( b =0.98, 95% CI 0.47 to 1.48) and more comorbidities ( b =2.48, 95% CI 0.15 to 4.81). Remaining in hospital beyond being medically fit for discharge was associated with older age (OR=1.07, 95% CI 1.05 to 1.09), female sex (OR=1.71, 95% CI 1.19 to 2.47) and high deprivation (OR=2.27, 95% CI 1.27 to 4.06)., Conclusions: The regression models could be used to identify which patients are likely to occupy hospital beds for longer. This could be helpful in scheduling operations to aid hospital efficiency by planning these patients' operations for when the hospital is less busy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Paediatric abusive head trauma (AHT) occurs in young children due to violent shaking or blunt impact. Educational and behavioural programmes modifying parent/infant interactions may aid primary prevention. This systematic review aims to assess the effectiveness of such interventions to prevent AHT in infants., Methods: We searched Embase, MEDLINE, PsycINFO, The Cochrane library, CINAHL databases and trial registries to September 2021, for studies assessing the effectiveness of educational and behavioural interventions in preventing AHT. Eligible interventions had to include messaging about avoiding or dangers of infant shaking. Randomised controlled trials (RCTs) reporting results for primary (AHT, infant shaking) or secondary outcomes (including parental responses to infant crying, mental wellbeing), and non-randomised studies (NRSs) reporting primary outcomes were included. Evidence from combinable studies was synthesised using random-effects meta-analyses. Certainty of evidence was assessed using GRADE framework. PROSPERO registration CRD42020195644., Findings: Of 25 identified studies, 16 were included in meta-analyses. Five NRSs reported results for AHT, of which four were meta-analysed (summary odds ratio [OR] 0.95, 95 % confidence intervals [CI] 0.80-1.13). Two studies assessed self-reported shaking (one cluster-RCT, OR 0.11, 95 % CI 0.02-0.53; one cohort study, OR 0.36, 95 % CI 0.20-0.64, not pooled). Meta-analyses of secondary outcomes demonstrated marginal improvements in parental response to inconsolable crying (summary mean difference 1.58, 95 % CI 0.11-3.06, on a 100-point scale) and weak evidence that interventions increased walking away from crying infants (summary incidence rate ratio 1.52, 95 % CI 0.94-2.45). No intervention effects were found in meta-analyses of parental mental wellbeing or other responses to crying., Interpretation: Low certainty evidence suggests that educational programmes for AHT prevention are not effective in preventing AHT. There is low to moderate certainty evidence that educational interventions have no effect or only marginally improve some parental responses to infant crying., Competing Interests: Declaration of competing interest LJS, RW, PD, SI, MTR, SD and JS report grant funding from NIHR (NIHR ARC West) during the conduct of the study. JS reports personal fees from Core Models Limited, UK (for teaching introductory systematic review methods at an online course), unrelated to the submitted work. Other authors have no competing interests to declare., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: To help resolve high suicide rates in Bristol, North Somerset and South Gloucestershire, the charity Second Step was commissioned to roll-out the Hope service offering a psychosocial intervention for men, supporting them through acute distress and addressing financial difficulties. This study evaluated the impact of the Hope service on men at risk of suicide experiencing financial and other difficulties., Methods: Mixed methods study using: (i) a prospective cohort study design to compare depression, suicidal ideation and financial self-efficacy scores of men aged 30-64, referred to the service between October 2018 and July 2020, at baseline and 6 months follow-up and between low and moderate to high-intensity service users; and (ii) a qualitative interview study to evaluate the acceptability and impact of the Hope service to Hope service users., Results: There was a 49% reduction in depression score (mean reduction - 10.0, 95% CI - 11.7 to - 8.3) and in the proportion of service users with suicidal ideation (percent reduction - 52.5, 95% CI - 64.1% to - 40.9%) at 6 months follow-up compared to baseline. Financial self-efficacy scores increased by 26% (mean increase 2.9, 95% CI 1.8 to 3.9). Qualitative accounts illustrated how 'Hope saved my life' for several men interviewed; most respondents described being able to move forward and tackle challenges with more confidence following the Hope intervention. Professional advice to tackle financial and other difficulties such as housing helped to relieve anxiety and stress and enable practical issues to be resolved., Conclusions: The Hope service offered practical and emotional support to men who have experienced suicidal feelings, redundancy, homelessness and poverty and occupies an important space between mental health and social care provision. Hope demonstrates the value of an intervention which cuts across traditional boundaries between psychiatric care and social advice agencies to provide, what is, in effect, an integrated care service., (© 2022. The Author(s).)

Objectives: The main objective of the study was to develop more accurate and precise short-term forecasting models for admissions and bed occupancy for an NHS Trust located in Bristol, England. Subforecasts for the medical and surgical specialties, and for different lengths of stay were realised DESIGN: Autoregressive integrated moving average models were specified on a training dataset of daily count data, then tested on a 6-week forecast horizon. Explanatory variables were included in the models: day of the week, holiday days, lagged temperature and precipitation., Setting: A secondary care hospital in an NHS Trust in South West England., Participants: Hospital admissions between September 2016 and March 2020, comprising 1291 days., Primary and Secondary Outcome Measures: The accuracy of the forecasts was assessed through standard measures, as well as compared with the actual data using accuracy thresholds of 10% and 20% of the mean number of admissions or occupied beds., Results: The overall Autoregressive Integrated Moving Average (ARIMA) admissions forecast was compared with the Trust's forecast, and found to be more accurate, namely, being closer to the actual value 95.6% of the time. Furthermore, it was more precise than the Trust's. The subforecasts, as well as those for bed occupancy, tended to be less accurate compared with the overall forecasts. All of the explanatory variables improved the forecasts., Conclusions: ARIMA models can forecast non-elective admissions in an NHS Trust accurately on a 6-week horizon, which is an improvement on the current predictive modelling in the Trust. These models can be readily applied to other contexts, improving patient flow., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: The first 4 weeks after initiation and cessation of opioid agonist treatment for opioid dependence are associated with an increased risk of all-cause mortality and overdose. We aimed to investigate whether the rate of self-harm and suicide among people who were prescribed opioid agonist treatment differs during initiation, cessation, and the remainder of time on and off treatment., Methods: We did a retrospective cohort study and used health-care records from UK Clinical Practice Research Datalink, linked to mortality and hospital admission data, for adults (age 18-75 years at cohort entry) who were prescribed opioid agonist treatment at least once in primary care in England between Jan 2, 1998, and Nov 30, 2018. We estimated rates and adjusted risk ratios (aRRs) of hospital admissions for self-harm and death by suicide, comparing time during and after treatment, as well as comparing stable periods of time on treatment with treatment initiation, cessation, and the remaining time off treatment., Findings: Between Jan 2, 1998, and Nov 30, 2018, 8070 patients (5594 [69·3%] men and 2476 [30·7%] women) received 17 004 episodes of opioid agonist treatment over 40 599 person-years. Patients were mostly of White ethnicity (7006 [86·8%] patients). 807 episodes of self-harm (1·99 per 100 person-years) and 46 suicides (0·11 per 100 person-years) occurred during the study period. The overall age-standardised and sex-standardised mortality ratio for suicide was 7·5 times (95% CI 5·5-10·0) higher in the study cohort than in the general population. Opioid agonist treatment was associated with a reduced risk of self-harm (aRR in periods off treatment 1·50 [95% CI 1·21-1·88]), but was not significantly associated with suicide risk (aRR in periods off treatment 1·21 [0·64-2·28]). Risk of self-harm (aRR 2·60 [95% CI 1·83-3·70]) and suicide (4·68 [1·63-13·42]) were both elevated in the first 4 weeks after stopping opioid agonist treatment compared with stable periods on treatment., Interpretation: Stable periods of opioid agonist treatment are associated with reduced risk of self-harm, emphasising the importance of improving retention of patients in treatment. The first month following cessation of opioid agonist treatment is a period of increased risk of suicide and self-harm, during which additional psychosocial support is required., Funding: Medical Research Council., Competing Interests: Declaration of interests LD reports investigator-initiated educational grant funding from Indivior, Mundipharma, Seqirus, and Reckitt Benckiser, outisde of the submitted work. MH reports speaker honoraria from MSD, Gillead, and Abbvie, outside of the submitted work. BW reports honoraria from and has been a member of an advisory board for Takeda, outside of the submitted work. DG is a member of England's National Suicide Prevention Strategy Advisory Group. PM was the chief investigator, and PP was a co-applicant, on a grant awarded to University of Bristol by Bristol and Weston Hospitals Charity (formerly known as Above & Beyond) focusing on suicide prevention for people presenting to the Emergency Department with self-harm and harmful substance use. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objectives: The study aims to explore the use of regression discontinuity analysis (RDA) to examine effects of prescription of statins on total cholesterol and adverse outcomes (type 2 diabetes, rhabdomyolysis and myopathy, myalgia and myositis, liver disease, CVD, and mortality)., Study Design and Setting: We conducted a prospective cohort study using the Clinical Practice Research Datalink including patients with QRISK scores of 10 to 30 in 2010 to 2013 who were last followed-up in October 2016. Comparing patients with QRISK≥20 and QRISK<20, we explored RDA assumptions, provided proof of concept analyses (total cholesterol as outcome), and investigated the effect of statins prescription on adverse outcomes., Result: RDA confirmed statin prescription reduced total cholesterol (Mean difference (MD) -1.33 mmol/L, 95%Confidence Interval (CI) -1.93 to -0.73). RDA provided little evidence for adverse effects on diabetes, myalgia and myositis, liver disease, CVD, or mortality. The RDA analysis findings are similar to RCT results. Findings from non-RDA analysis agree with published observational studies., Conclusion: RDA can be used with large routine clinical datasets to provide evidence on effects of medications which are prescribed according to a threshold. Testable RDA assumptions were satisfied, but confidence intervals were wide, partly due to the low compliance with the prescribing threshold., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Hospital admissions for Ambulatory Care Sensitive Conditions (ACSCs) are potentially avoidable. Dementia is one of the leading chronic conditions in terms of variability in ACSC admissions by general practice, as well as accounting for around a third of UK emergency admissions., Methods: Using Bayesian multilevel linear regression models, we examined the ecological association of organizational characteristics of general practices (ACSC n=7076, non-ACSC n=7046 units) and Clinical Commissioning Groups (CCG n=212 units) in relation to ACSC and non-ACSC admissions for people with dementia in England., Results: The rate of hospital admissions are variable between GP practices, with deprivation and being admitted from home as risk factors for admission for ACSC and non-ACSC admissions. The budget allocated by the CCG to mental health shows diverging effects for ACSC versus non-ACSC admissions, so it is likely there is some geographic variation., Conclusions: A variety of factors that could explain avoidable admissions for PWD at the practice level were examined; most were equally predictive for avoidable and non-avoidable admissions. However, a high amount of variation found at the practice level, in conjunction with the diverging effects of the CCG mental health budget, implies that guidance may be applied inconsistently, or local services may have differences in referral criteria. This indicates there is potential scope for improvement.

The UK's National Institute for Health and Care Excellence Preterm labour and birth guideline recommends use of magnesium sulfate (MgSO 4 ) in deliveries below 30 weeks' gestation to prevent cerebral palsy and other neurological problems associated with preterm delivery. Despite national guidance, the uptake of MgSO 4 administration in eligible women has been slow. National Health Service England has rolled out the PReCePT (PRevention of Cerebral Palsy in Pre-Term labour) quality improvement (QI) toolkit to increase uptake of MgSO 4 in preterm deliveries. The toolkit is designed to increase maternity staff knowledge about MgSO 4 and provides training and practical tools to help staff consider use in eligible women. The PReCePT trial compares the effectiveness of two different methods of implementing the QI toolkit (standard versus enhanced support). The standard support arm (control) receives the QI toolkit and regional-level support for a midwife/obstetric 'champion'. The enhanced support arm (intervention) receives this plus additional clinical backfill funding and unit-level QI microcoaching. It is funded by The Health Foundation. This is a cluster randomised controlled trial designed to include 48 maternity units randomised (2:1 ratio) to standard or enhanced support. Units are eligible for inclusion if they have 10 or more preterm (<30 weeks' gestation) deliveries annually and MgSO 4 uptake of 70% or less. Randomisation is stratified by previous level of MgSO 4 uptake. The QI intervention is implemented over 9 months. All units are followed up for a further 9 months. Blinding is not possible due to the nature of the intervention. The primary outcome is the proportion of MgSO 4 uptake among eligible women at follow-up, adjusting for uptake before implementation of the toolkit. The effectiveness of the intervention will be assessed using weighted linear regression on data from the National Neonatal Research Database. Semistructured qualitative staff interviews will inform understanding of the process and outcomes. Economic evaluation will describe total costs and cost-effectiveness. Trial registration number SRCTN 40938673., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In September 2014, as part of a national initiative to increase access to liaison psychiatry services, the liaison psychiatry services at Bristol Royal Infirmary received new investment of £250 000 per annum, expanding its availability from 40 to 98 h per week. The long-term impact on patient outcomes and costs, of patients presenting to the emergency department with self-harm, is unknown., Aims: To assess the long-term impact of the investment on patient care outcomes and costs, of patients presenting to the emergency department with self-harm., Method: Monthly data for all self-harm emergency department attendances between 1 September 2011 and 30 September 2017 was modelled using Bayesian structural time series to estimate expected outcomes in the absence of expanded operating hours (the counterfactual). The difference between the observed and expected trends for each outcome were interpreted as the effects of the investment., Results: Over the 3 years after service expansion, the mean number of self-harm attendances increased 13%. Median waiting time from arrival to psychosocial assessment was 2 h shorter (18.6% decrease, 95% Bayesian credible interval (BCI) -30.2% to -2.8%), there were 45 more referrals to other agencies (86.1% increase, 95% BCI 60.6% to 110.9%) and a small increase in the number of psychosocial assessments (11.7% increase, 95% BCI -3.4% to 28.5%) per month. Monthly mean net hospital costs were £34 more per episode (5.3% increase, 95% BCI -11.6% to 25.5%)., Conclusions: Despite annual increases in emergency department attendances, investment was associated with reduced waiting times for psychosocial assessment and more referrals to other agencies, with only a small increase in cost per episode.

Background: The risk of acute kidney injury (AKI) attributable to renin angiotensin aldosterone (RAAS) inhibitors and diuretics remains unclear., Methods: We conducted a prospective cohort study using the Clinical Practice Research Datalink (2008-2015) linked to Hospital Episode Statistics - Admitted Patient Care and Office for National Statistics mortality data. Patients were included if they had one or more chronic diagnoses requiring medication. Exposed patients had a first ever prescription for RAAS inhibitors/diuretics during the study period. AKI risk associated with exposure was determined by multivariable Cox regression, propensity score-adjusted Cox regression and a prior event rate ratio (PERR) analysis., Results: One hundred forty thousand nine hundred fifty-two individuals were included. Increased AKI risk in the exposed group was demonstrated in both the multivariable and propensity score-adjusted cox regressions (HR 1.23 (95% CI 1.04-1.45) and HR 1.24 (1.05-1.47) respectively). The PERR analysis provided a similar overall hazard ratio with a wider confidence interval (HR 1.29 (0.94-1.63)). The increased AKI risk in the exposed group was present only in those receiving two or more antihypertensives. Absolute AKI risk was small., Conclusions: RAAS inhibitors/diuretics result in an increased risk of AKI. The absolute increase in AKI risk is small, however, and needs to be considered in the context of any potential benefits.

Background: Evidence of an association between exposure to domestic violence and abuse (DVA) and use of emergency contraception (EC) is lacking in the UK., Aim: To quantify the association between exposure to DVA and consultations for EC in general practice., Design and Setting: Nested case-control study in UK general practice., Method: Using the Clinical Practice Research Datalink, the authors identified all women all women aged 15-49 years registered with a GP between 1 January 2011 and 31 December 2016. Cases with consultations for EC ( n = 43 570) were each matched on age and GP against four controls with no consultations for EC ( n = 174 280). The authors calculated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between exposure to DVA in the previous year and consultations for EC. Covariates included age, ethnicity, socioeconomic status, pregnancy, children, alcohol misuse, and depression., Results: Women exposed to DVA were 2.06 times more likely to have a consultation for EC than unexposed women (95% CI = 1.64 to 2.61). Women aged 25-39 years with exposure to DVA were 2.8 times more likely to have a consultation for EC, compared with unexposed women (95% CI = 2.08 to 3.75). The authors found some evidence of an independent effect of exposure to DVA on the number of consultations for EC (OR 1.48, 95% CI = 0.99 to 2.21)., Conclusion: A request for EC in general practice can indicate possible exposure to DVA. Primary care consultation for EC is a relevant context for identifying and responding to DVA as recommended by the World Health Organization and National Institute for Health and Care Excellence guidelines. DVA training for providers of EC should include this new evidence., (© British Journal of General Practice 2019.)

Objectives: To ascertain the challenges associated with implementation of the 2-week wait referral criteria and waiting time targets for colorectal cancer and to identify recommendations for improvements to the pathway., Design: Qualitative research using semistructured interviews and applying thematic analysis using the method of constant comparison., Setting: 10 primary care surgeries and 6 secondary care centres from 3 geographical areas in the England., Participants: Purposive sample of 24 clinicians (10 general practitioners (GPs), 7 oncologists and 7 colorectal surgeons)., Results: GPs and specialists highlighted delays in patient help-seeking, difficulties applying the colorectal cancer referral criteria due to their low predictive value, and concerns about the stringent application of targets because of potential impact on individual care and associated penalties for breaching. Promoting patient awareness and early presentation, clarifying predictive symptoms, allowing flexibility, optimising resources and maximising care coordination were suggested as improvements., Conclusions: Challenges during diagnosis and treatment persist, with guidelines and waiting time targets producing the perception of unintended harms at individual and organisational levels. This has led to variations in how guidelines are implemented. These require urgent evaluation, so that effective practices can be adopted more widely., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: There remains uncertainty in whether vitamin D status affects cancer survival. We investigated whether vitamin D (± calcium) supplementation affects cancer survival in women., Methods: Participants were women aged ≥55 years identified from the UK Clinical Practice Research Datalink (CPRD) with a first diagnosis of breast, colorectal, lung, ovarian or uterine cancer between 2002 and 2009, and at least 5 years of CPRD data prior to diagnosis. Cox proportional hazards were used to estimate hazard ratios (HR) and 95 % confidence intervals (CI) of the relationship between pre-diagnostic vitamin D supplementation and all-cause mortality. To avoid confounding by indication, the primary analysis compared women with 3+ to 1-2 (but no more) vitamin D prescriptions. Models were adjusted for pre-diagnostic body mass index, smoking, alcohol and deprivation. A sensitivity analysis excluded supplements prescribed in the year prior to diagnosis., Results: Exposure to 3 or more versus 1 to 2 prescriptions of vitamin D was not associated with survival from any of the cancers studied. Any vitamin D prescription, compared to never having been prescribed one, was associated with a better survival from breast cancer (HR 0.78, 95 % CI 0.70 to 0.88). The sensitivity analysis suggested a possible detrimental effect of vitamin D supplementation on lung cancer outcomes (HR for 3 versus 1 or 2 prescriptions 1.22 (95 % CI 0.94 to 1.57); HR for any versus no prescriptions 1.09 (0.98 to 1.22))., Conclusions: We found no evidence that vitamin D supplementation is associated with survival among women with cancer. Previous observational findings of beneficial effects of vitamin D supplementation on cancer survival may be confounded.

Background: Chronic lymphocytic leukemia (CLL) and chronic myeloid leukemia (CML) are highly treatable conditions occurring primarily in older patients. Lower survival among older people has been reported in both conditions, but newer treatments may change both the overall survival rate and the relative risk associated with aging. Here, we examine survival for patients with CLL and CML in the United States (US) and England., Methods: Patients with CLL and CML were identified from the Surveillance, Epidemiology, and End Results (US) and National Cancer Registry (England). Five-year relative survival was calculated by major age group. Excess hazard ratios (EHR) by age were calculated for each condition, and multivariable analysis was performed to adjust for the following potential confounders: gender, race or ethnic group (US only), period of diagnosis, and a measure of socioeconomic deprivation (England only)., Results: Five-year relative survival increased for both CLL and CML in both England and the US between 1996-2000 and 2006-2010. However, relative age-related disparities persisted. For CLL, the EHR for death was 9.44 (7.84-11.36) in the US and 6.14 (5.65-6.68) in England for ages 85+ compared to ages 55-64. For CML, the EHR was 3.52 (3.17-3.90) in the US and 4.54 (4.13-4.98) in England for ages 75+ compared to ages 45-64., Conclusions: Survival improved for patients with chronic leukemias in the early 21st century. However, age-related disparities persist, despite clinical trial evidence that treatment in older adults with chronic leukemia can be safe and effective. Further research to determine the reasons for the lower survival in older patients and greater awareness of this problem may improve survival for older patients with chronic leukemia., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Rapid diagnostic pathways for cancer have been implemented, but evidence whether shorter diagnostic intervals (time from primary care presentation to diagnosis) improves survival is lacking. Using the Clinical Practice Research Datalink, we identified patients diagnosed with female breast (8,639), colorectal (5,912), lung (5,737) and prostate (1,763) cancers between 1998 and 2009, and aged >15 years. Presenting symptoms were classified as alert or non-alert, according to National Institute for Health and Care Excellence guidance. We used relative survival and excess risk modeling to determine associations between diagnostic intervals and five-year survival. The survival of patients with colorectal, lung and prostate cancer was greater in those with alert, compared with non-alert, symptoms, but findings were opposite for breast cancer. Longer diagnostic intervals were associated with lower mortality for colorectal and lung cancer patients with non-alert symptoms, (colorectal cancer: Excess Hazards Ratio, EHR >6 months vs <1 month: 0.85; 95% CI: 0.72-1.00; Lung cancer: EHR 3-6 months vs <1 month: 0.87; 95% CI: 0.80-0.95; EHR >6 months vs <1 month: 0.81; 95% CI: 0.74-0.89). Prostate cancer mortality was lower in patients with longer diagnostic intervals, regardless of type of presenting symptom. The association between diagnostic intervals and cancer survival is complex, and should take into account cancer site, tumour biology and clinical practice. Nevertheless, unnecessary delay causes patient anxiety and general practitioners should continue to refer patients with alert symptoms via the cancer pathways, and actively follow-up patients with non-alert symptoms in the community.

Survival for patients with acute leukemias (acute myeloblastic leukemia, AML; acute lymphoblastic leukemia, ALL) decreases with age, but whether the extent of disparity varies by country is unknown. We compared age-related disparities in survival in patients with ALL and AML in the USA and England. Five-year relative survival was calculated using period analysis. Excess mortality modeling was used to determine excess hazard ratios (EHRs). Age inequalities were similar in England and the USA, although survival among younger patients with AML was better in England. Compared to patients aged 30-44 years, people with AML diagnosed age 75 + had higher EHRs in the USA (5.43, 95% confidence interval [CI]: 4.97-5.93) and England (6.22, 95% CI: 5.83-6.64). People with ALL diagnosed age 65 + had higher EHRs in the USA (2.95, 95% CI: 2.56-3.41) and England (2.79, 95% CI: 2.47-3.14). Survival continues to be poor for older patients with acute leukemia, but does not differ markedly between the USA and England.

Background: Colorectal cancer survival in the UK is lower than in other developed countries, but the association of time interval between diagnosis and treatment on excess mortality remains unclear., Methods: Using data from cancer registries in England, we identified 46,511 patients with localised colorectal cancer between 1996-2009, who were 15 years and older, and who underwent a major surgical resection within 62 days of diagnosis. We used relative survival and excess risk modeling to investigate the association of time between diagnosis and major resection (exposure) with survival (outcome)., Results: Compared to patients who had major resection within 25-38 days of diagnosis, patients with a shorter time interval between diagnosis and resection and those waiting longer for resection had higher excess mortality (Excess Hazards Ratio, EHR <25 vs 25-38 days: 1.50; 95% Confidence Interval, CI: 1.37 to 1.66; EHR 39-62 vs 25-38 days : 1.16; 95% CI: 1.04 to 1.29). Excess mortality was associated with age (EHR 75+ vs. 15-44 year olds: 2.62; 95% CI: 2.00 to 3.42) and deprivation (EHR most vs. least deprived: 1.27; 95% CI: 1.12 to 1.45), but time between diagnosis and resection did not explain these differences., Conclusion: Within 62 days of diagnosis, a U-shaped association of time between diagnosis and major resection with excess mortality for localised colorectal cancer was evident. This indicates a complicated treatment pathway, particularly for patients who had resection earlier than 25 days, and requires further investigation.

Population-level survival in older patients with lymphoma is significantly lower than in younger patients. In this study, data were obtained from cancer registries in England and the United States (US) for patients diagnosed with Hodgkin lymphoma (HL), non-Hodgkin lymphoma (NHL) and myeloma. Five-year relative survival was calculated using period analysis. Generalised linear models were used to determine excess hazard ratios (EHR) for older compared to younger patients. Five-year relative survival was lower for older patients diagnosed with HL, NHL and myeloma in both countries. The greatest age-related survival inequality was observed for patients with HL: in 2006-10 the EHR comparing patients aged 75 + years with those aged 15-24 years was 14·02 in the US and 15·69 in England. For NHL, the EHR was 1·91 in the US and 3·81 in England. For myeloma, comparing patients aged 75 + years with those aged 25-44 years, the EHR was 2·79 in the US and 3·60 in England. Survival of patients with lymphoma is lower for older patients in both the US and England but the discrepancy is less in the US. Physicians should be encouraged to evaluate patients' frailty and co-morbidities as well as their age when considering treatment options for patients with lymphoma and myeloma., (© 2014 John Wiley & Sons Ltd.)

Abstract Survival for patients with multiple myeloma has increased during the first decade of the 21st century. However, it is unknown whether the improvements in survival have extended equally in all ethnic groups. Using data from the United States Surveillance, Epidemiology and End Results Program, we assessed trends in survival and disease-related mortality for patients with myeloma by ethnic group, including non-Hispanic whites (nHw), African-Americans (AA), Hispanics and people of Asian and Pacific Islander descent (API) from 1998-2001 to 2006-2009. Overall, age adjusted 5-year relative survival increased, from 35.6% in 1998-2001 to 44% in 2006-2009. The greatest improvements were observed for patients aged 15-49, for whom survival increased by + 16.8% units for nHw and + 14.4% units for AA, whereas improvement was less pronounced and not statistically significant in Hispanics and API. Excess mortality hazard ratios were 1.20 (95% confidence interval [CI]: 1.09-1.33) for AA and 1.25 (95% CI: 1.11-1.41) for Hispanics compared to nHw in 2006-2009. Although survival increased greatly for nHw with myeloma between 1998-2001 and 2006-2009, smaller increases were observed for people of other ethnic groups. Persistent excess mortality was seen for AA and Hispanic patients with myeloma. Ethnic inequalities persisted or even increased from earlier periods to 2006-2009. The results suggest that ethnic minorities may not have benefited from newer treatments to the same extent as nHw patients have.

Purpose: There is inconclusive evidence on whether vitamin D therapy reduces cancer risk. We investigated the effect of vitamin D (±calcium) supplementation on the risk of breast, ovarian, uterine, colorectal, and lung cancer in women., Methods: We conducted a case-control study using the UK Clinical Practice Research Datalink (CPRD); cases were women aged ≥55 years with a first diagnosis of either breast, colorectal, lung, ovarian, or uterine cancer between 2002 and 2009, with at least 5 years of CPRD follow-up prior to the date of diagnosis, and controls were women without cancer, frequency-matched to cases by year of birth, date of study entry, length of follow-up, and general practice. The association of vitamin D supplementation with the odds of developing each cancer was determined using multivariable logistic regression, controlling for body mass index, smoking, alcohol, and deprivation., Results: Ninety-seven percent of women took vitamin D with a calcium supplement. Exposure to three or more prescriptions of vitamin D was associated with a 17 % reduced odds (95 % CI 0.71-0.97) of breast cancer versus 1-2 prescriptions, but this effect disappeared when omitting women first exposed within a year of diagnosis (OR 1.0, 95 % CI 0.82-1.23). Having more than 10 prescriptions of vitamin D was associated with a 17 % lower odds (95 % CI 0.65-1.06) of colorectal cancer, but the estimates are imprecise. There was little evidence of associations of supplements with lung or gynecological cancers., Conclusion: We found little evidence that vitamin D (largely with calcium) supplementation is associated with decreased breast, lung, ovarian, and uterine cancer risk. There is a possible protective association between having more than 10 prescriptions of vitamin D supplements and colorectal cancer, but it requires further investigation.

Background: A diagnosis of prostate cancer leads to emotional distress and anxiety, prompting calls for rapid diagnostic pathways. Nevertheless, it remains unclear what impact time between diagnosis and surgery has upon prostate cancer survival., Methods: Using national databases for England (cancer registries, Hospital Episode Statistics and Office of National Statistics), we identified 17,043 men with prostate cancer, aged 15 years and older, diagnosed in 1996-2009, and who had surgical resection with curative intent within 6 months of diagnosis. We used relative survival to investigate associations between waiting times and five- and ten-year survival., Results: Five- and ten-year relative survival estimates for the total study sample were 1.04 (95% CI: 1.04 to 1.05) and 1.08 (95% CI: 1.06-1.09), respectively. There were no notable differences in survival between patients who had surgery at 0-3 and 4-6 months after diagnosis. Relative survival was higher among the elderly (>65) and those with well and moderately differentiated tumours., Conclusion: The high relative survival in our cohort probably reflects adherence to selection criteria for surgery among men with localised prostate cancer. Among men treated with surgery within 6 months of diagnosis, we found little evidence of an association between time from diagnosis to surgery and survival.

Background: Survival from breast cancer in the United Kingdom is lower than in other developed countries. It is unclear to what extent waiting times for curative surgery affect survival., Methods: Using national databases for England (cancer registries, Hospital Episode Statistics and Office of National Statistics), we identified 53 689 women with localised breast cancer, aged ≥ 15 years, diagnosed between 1996 and 2009, who had surgical resection with curative intent within 62 days of diagnosis. We used relative survival and excess risk modelling to determine associations between waiting times and 5-year survival., Results: The median diagnosis to curative surgery waiting time among breast cancer patients was 22 days (interquartile range (IQR): 15-30). Relative survival was similar among women waiting between 25 and 38 days (RS: 93.5%; 95% CI: 92.8-94.2%), <25 days (RS: 93.0%; 95% CI: 92.5-93.4%) and between 39 and 62 days (RS: 92.1%; 95% CI: 90.8-93.4%). There was little evidence of an increase in excess mortality with longer waiting times (excess hazard ratio (EHR): 1.06; 95% CI: 0.88-1.27 comparing waiting times 39-62 with 25-38 days). Excess mortality was associated with age (EHR 65-74 vs 15-44 year olds: 1.23; 95% CI: 1.07-1.41) and deprivation (EHR most vs least deprived: 1.28; 95% CI: 1.09-1.49), but waiting times did not explain these differences., Conclusion: Within 62 days of diagnosis, decreasing waiting times from diagnosis to surgery had little impact on survival from localised breast cancer.

Background: Teenagers and young adults (TYA, 15-24 years) diagnosed with cancer report repeated visits to primary care before referral. We investigated associations of symptoms and consultation frequency in primary care with TYA cancers., Methods: Population-based, case-control study was carried out using data from the Clinical Practice Research Datalink (CPRD). A total of 1064 TYA diagnosed with cancer were matched to 13,206 controls. Symptoms independently associated with specific cancers were identified. Likelihood ratios (LRs) and positive predictive values (PPVs) were calculated., Results: In the 3 months before diagnosis, 397 (42.9%) cases consulted > or =4 times vs 593(11.5%) controls (odds ratio (OR): 12.1; 95% CI: 9.7, 15.1), yielding a PPV for any cancer of 0.018%. The LR of lymphoma with a head/neck mass was 434 (95% CI: 60, 3158), with a PPV of 0.5%. Corresponding figures in other cancers included - LR of leukaemia with lymphadenopathy (any site): 29 (95% CI: 8, 112), PPV 0.015%; LR of CNS tumour with seizure: 56 (95% CI: 19, 163), PPV 0.024%; and LR of sarcoma with lump/mass/swelling: 79 (95% CI: 24, 264), PPV 0.042%., Conclusion: Teenagers and young adults with cancer consulted more frequently than controls in the 3 months before diagnosis. Primary care features of cancer match secondary care reports, but were of very low risk; nonetheless, some features increased the likelihood of cancer substantially and should be taken seriously when assessing TYA.

The survival of younger patients with acute leukemia has improved in the early 21(st) century, but it is unknown whether people of all ethnic and racial backgrounds have benefited equally. Using cancer registry data from the Surveillance, Epidemiology and End Results Program, we assessed trends in 5-year relative survival for patients aged 15 years or more with acute lymphoblastic leukemia and acute myeloblastic leukemia divided by racial and ethnic group, including non-Hispanic whites, African-Americans, Hispanics, and Asian-Pacific Islanders in the 1990s and the early 21(st) century. Modeled period analysis was used to obtain the most up-to-date estimates of survival. Overall, the 5-year survival increased from 31.6% in 1997-2002 to 39.0% in 2003-2008 for patients with acute lymphoblastic leukemia and from 15.5% in 1991-1996 to 22.5% in 2003-2008 for those with acute myeloblastic leukemia. Nevertheless, among patients with acute lymphoblastic leukemia, age-adjusted 5-year relative survival rates remained lower for African-Americans and Hispanics than for non-Hispanic whites. Among patients with acute myeloblastic leukemia, the increase in survival was greatest (from 32.6% in 1991-1996 to 47.1% in 2003-2008) for younger patients (15-54 years), and was more pronounced for non-Hispanic whites (+16.4% units) than for other patients (+10.8% units). Increases in survival are observed in all ethnic or racial groups. Nevertheless, among patients with acute leukemias, disparities in survival persist between non-Hispanic white people and people of other ethnic or racial groups. Disparities are increasing in younger patients with acute myeloblastic leukemia. Improvements in access to treatment, especially for minority patients, may improve outcomes.

Background: Patients of minority race/ethnicity have lower survival after diagnosis with most types of cancer. Little data are available concerning changes in disparity over time. Here, we examine changes in survival by race/ethnicity of patients with common cancers in two recent time periods., Patients and Methods: We used modeled period analysis to determine relative survival (RS) for non-Hispanic white (nHw), African-American (AA), and Hispanic patients in the Surveillance, Epidemiology, and End Results database diagnosed with common solid and hematological malignancies., Results: Five-year RS improved overall and for nHw for each tumor examined, ranging from + 2% points (pancreatic cancer) to + 16.4% points [non-Hodgkin's lymphoma, (NHL)]. Greater improvement was observed for AA and Hispanics than nHw in breast and prostate cancer and NHL. Less improvement was observed for AA and Hispanics than for nHw for lung and pancreatic cancer. No statistically significant improvement was observed for AA and Hispanics with myeloma or acute leukemia. Survival disparities ranging from 0.5% points (myeloma) to 13.1% points (breast) between nHw and AA remained., Conclusions: Progress has been made in decreasing disparities in survival between nHw and minorities in breast cancer, prostate cancer, and NHL. Little progress has been made in reducing disparities for the other studied cancers.

Background: This study investigated the risk of cancer in children with alert symptoms identified in current UK guidance, or with increased consultation frequency in primary care., Methods: A population-based, nested case-control study used data from the General Practice Research Database. In all, 1267 children age 0-14 years diagnosed with childhood cancer were matched to 15,318 controls. Likelihood ratios and positive predictive values (PPVs) were calculated to assess risk., Results: Alert symptoms recorded in the 12 and 3 months before diagnosis were present in 33.7% and 27.0% of cases vs 5.4% and 1.4% of controls, respectively. The PPV of having cancer for any alert symptom in the 3 months before diagnosis was 0.55 per 1000 children. Cases consulted more frequently particularly in the 3 months before diagnosis (86% cases vs 41% controls). Of these, 36% of cases and 9% of controls had consulted 4 times or more. The PPV for cancer in a child consulting 4 times or more in 3 months was 0.13 per 1000 children., Conclusion: Alert symptoms and frequent consultations are associated with childhood cancer. However, individual symptoms and consultation patterns have very low PPVs for cancer in primary care (e.g., of 10,000 children with a recorded alert symptom, approximately 6 would be diagnosed with cancer within 3 months).

Background: Suicide prevention is given a low priority in many Western Pacific countries due to competing health problems, stigma and poor understanding of its incidence and aetiology. Little is known about the epidemiology of suicide and suicidal behaviour in the Philippines and although its incidence is reported to be low, there is likely to be under-reporting because of its non-acceptance by the Catholic Church and the associated stigma to the family. This study aims to investigate trends in the incidence of suicide in the Philippines, assess possible underreporting and provide information on the methods used and the reasons for suicide., Methods: Data for suicide deaths occurring between 1974 and 2005 were obtained from Philippine Health Statistics. Age- and sex-specific trends were examined graphically. Underreporting was investigated by comparing trends in suicides, accidents and deaths of undetermined intent. To provide a fuller picture of suicide in the Philippines, a comprehensive search for published papers, theses and reports on the epidemiology of suicide in the Philippines was undertaken., Results: The incidence of suicide in males increased from 0.23 to 3.59 per 100,000 between 1984 and 2005. Similarly, rates rose from 0.12 to 1.09 per 100,000 in females. Amongst females, suicide rates were highest in 15-24 year olds, whilst in males rates were similar in all age groups throughout the study period. The most commonly used methods of suicide were hanging, shooting and organophosphate ingestion. In non-fatal attempts, the most common methods used were ingestion of drugs, specifically isoniazid and paracetamol, or organophosphate ingestion. Family and relationship problems were the most common precipitants. While rates were lower compared to other countries, there is suggestive evidence of underreporting and misclassification to undetermined injury. Recent increases may reflect either true increase or better reporting of suicides., Conclusions: While suicide rates are low in the Philippines, increases in incidence and relatively high rates in adolescents and young adults point to the importance of focused suicide prevention programs. Improving data quality and better reporting of suicide deaths is likewise imperative to inform and evaluate prevention strategies.

Background: The EUROCARE study has disclosed large variations of survival across Europe, with the magnitude varying, depending on cancer site. Comparisons of these rates with those from the developing countries are rare, but important in evaluating international cancer care discrepancies. This study aimed to provide up-to-date estimates of cancer survival in a Philippine urban population, and to compare these with those observed in the European countries., Methods: Using the results from the EUROCARE-4 study, the survival estimates of the European patients who were diagnosed in 1995-99 and followed till December 2003 were abstracted. From randomly selected samples drawn from the Manila and Rizal Cancer Registries, 5-year survival was estimated for nine common cancers. Age-adjusted survival estimates were then compared between the Philippine population and Europeans., Results: In comparison to the European mean, survival estimates for the Philippine residents were lower for most cancers, with differences ranging from 2 to 40% units. Differences with European country-specific estimates were large for cancers of the breast and cervix, where early detection is possible, and for leukaemia, where treatment regimens are costly, highlighting the importance of health care. Smaller discrepancies were observed for stomach, liver and lung cancers, with the 5-year relative survival being similar to the Philippines and to many European countries. A survival advantage was seen though for the Philippine residents for ovarian cancer., Conclusion: Apart from efforts to prevent cancers, improvements in cancer control and making early diagnosis and treatment more accessible remain major challenges, both in the Philippines and in the European nations.