Valerie Seagroatt

Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial

Abstract Objective: To evaluate the acceptability and efficacy of adding cognitive behaviour therapy to the medical care of patients presenting with the chronic fatigue syndrome. Design: Randomised controlled trial with final assessment at 12 months. Setting: An infectious diseases outpatient clinic. Subjects: 60 consecutively referred patients meeting consensus criteria for the chronic fatigue syndrome. Interventions: Medical care comprised assessment, advice, and follow up in general practice. Patients who received cognitive behaviour therapy were offered 16 individual weekly sessions in addition to their medical care. Main outcome measures: The proportions of patients (a) who achieved normal daily functioning (Karnofsky score 80 or more) and (b) who achieved a clinically significant improvement in functioning (change in Karnofsky score 10 points or more) by 12 months after randomisation. Results: Only two eligible patients refused to participate. All randomised patients completed treatment. An intention to treat analysis showed that 73% (22/30) of recipients of cognitive behaviour therapy achieved a satisfactory outcome as compared with 27% (8/30) of patients who were given only medical care (difference 47 percentage points; 95% confidence interval 24 to 69). Similar differences were observed in subsidiary outcome measures. The improvement in disability among patients given cognitive behaviour therapy continued after completion of therapy. Illness beliefs and coping behaviour previously associated with a poor outcome changed more with cognitive behaviour therapy than with medical care alone. Conclusion: Adding cognitive behaviour therapy to the medical care of patients with the chronic fatigue syndrome is acceptable to patients and leads to a sustained reduction in functional impairment. Key messages Key messages There is no generally accepted form of treatment New findings show that patients referred to hospital for the chronic fatigue syndrome have a better outcome if they are given a course of cognitive behaviour therapy than if they receive only basic medical care Clinical improvement with cognitive behaviour therapy may be slow but often continues after treatment has ended Cognitive behaviour therapy should be considered as an option for patients presenting with the chronic fatigue syndrome

Suicide after discharge from psychiatric inpatient care

People with a history of psychiatric disorder are at higher risk of suicide than people without such a history. The policy of reducing inpatient care in psychiatry has probably meant that some of the risk of suicide has shifted from the hospital to the community setting. We have quantified the risk of suicide within a year of psychiatric discharge in a population-based study in the Oxford health region, UK. We calculated suicide rates per 1000 person-years at risk (time from discharge to death, subsequent readmission, or the end of the study) and the standardised mortality ratio (SMR) for suicide, taking the value among the general population as 1. Among male patients the SMR for suicide (defined by coroners verdict of suicide) in the first 28 days after discharge from inpatient care was 213 (95% CI 137-317); the equivalent SMR for female patients was 134 (67-240). The result was similar when we defined suicide more broadly as a suicide, open, or misadventure verdict. The suicide rate in the first 28 days after discharge was 7.1 (4.1-12) times higher for male patients and 3.0 (1.5-6.0) times higher for female patients than the rate during the remaining 48 weeks of the first year after discharge. Most of the patients studied (both those who committed suicide and those who did not) had been psychiatric inpatients for only a short time. The findings confirm that there is significant clustering of suicide soon after discharge from psychiatric care. Skilled support after discharge for high-risk patients in the community is essential. Audit of suicides that occur soon after discharge may help identify the patients at highest risk and thereby reduce the number of avoidable deaths.

Elective total hip replacement: incidence, emergency readmission rate, and postoperative mortality.

OBJECTIVES--To report the incidence of elective total hip replacement and postoperative mortality, emergency readmission rates, and the demographic factors associated with these rates in a large defined population. DESIGN--Analysis of linked, routine abstracts of hospital inpatient records and death certificates. SETTING--10 hospitals in six districts in Oxford Regional Health Authority covered by the Oxford record linkage study. SUBJECTS--Records for 11,607 total hip replacements performed electively in 1976-85. MAIN OUTCOME MEASURES--Incidence of operation, postoperative mortality, relative mortality ratios, and incidence of emergency readmission. RESULTS--NHS operation rates increased over time from 43 to 58 operations/100,000 population. Variation in operation rates between districts reduced over time. Operation rates were on average 25% higher in women than men. There were 93 deaths (11/1000 operations) within 90 days of the operation and 208 emergency readmissions (28/1000 operations) within 28 days of discharge. Postoperative mortality and emergency readmission rates increased with age. No significant trend with time was found. Mortality in the 90 days after the operation was 2.5-fold higher (1.9 to 3.0) than in the rest of the first postoperative year. This represented an estimated excess of 6.5 (4.2 to 8.8) early postoperative deaths/1000 operations. Most deaths were ascribed to cardiovascular events. Thromboembolic disease was the commonest reason for emergency readmission. CONCLUSIONS--The pronounced increase in operations in districts with initially low rates suggests a trend towards greater equity in the local provision of NHS hip arthroplasty. The early postoperative clusters of deaths attributed to cardiovascular disease and of readmissions for thromboembolic disease suggest that there is scope for investigating ways of reducing the incidence of major adverse postoperative events.

Follow up of patients presenting with fatigue to an infectious diseases clinic.

OBJECTIVES--To determine the symptomatic and functional status during follow up of patients referred to hospital with unexplained fatigue and to identify patient variables associated with persistent functional impairment. DESIGN--Follow up by postal questionnaire six weeks to four years (median 1 year) after initial clinical assessment of patients referred to hospital during 1984-8. SETTING--Infectious diseases outpatient clinic in a teaching hospital. PATIENTS--200 consecutive patients with fatigue of uncertain cause for at least six weeks; 177 fulfilled the inclusion criteria. MAIN OUTCOME MEASURES--Findings at initial assessment; current symptoms, beliefs about the cause of illness, coping behaviours emotional disorder, social variables including membership of self help organizations, and degrees of recovery and functional impairment from questionnaire responses. RESULTS--144 (81%) patients returned completed questionnaires. Initial assessment did not indicate the cause of fatigue, other than preceding infection. The proportion of patients with functional impairment was significantly smaller with longer follow up (33% (11/33) at two to four years, 73% (29/40) at six weeks to six months; chi 2 for trend = 12.5, df = 1; p less than 0.05). Functional impairment was significantly associated with belief in a viral cause of the illness (odds ratio = 3.9; 95% confidence interval 1.5 to 9.9), limiting exercise (3.2; 1.5 to 6.6), avoiding alcohol (4.5; 1.8 to 11.3), changing or leaving employment (3.1; 1.4 to 6.9), belonging to a self help organization (7.8; 2.5 to 23.9), and current emotional disorder (4.4; 2.0 to 9.3). CONCLUSIONS--Short term prognosis for recovery of function was poor but improved with time. Most patients had made a functional recovery by two years after initial clinic attendance. Impaired functioning was more likely with certain patient characteristics. Prospective studies are required to clarify whether these associations are the consequences of a more disabling illness or indicate factors contributing to impaired function.

Cancers and immune related diseases associated with Down’s syndrome: a record linkage study

Objective: To determine the risk of cancers and selected immune related diseases in people with Down’s syndrome, relative to risk in other people. Design: Cohort analysis of a linked dataset of abstracts of hospital and death records; results expressed as the ratios of rates of disease in people with and without Down’s syndrome. Setting: The former Oxford health region, England, 1963–1999. Subjects: Cohort of 1453 people with Down’s syndrome and cohort of 460 000 people with other conditions for comparison. Main outcomes: As expected, the rate ratio for leukaemia was substantially elevated in people with Down’s syndrome: it was 19-fold higher (95% confidence intervals 10.4 to 31.5) than the rate in the comparison cohort. For other cancers combined, excluding leukaemia, the rate ratio was not significantly elevated (1.2; 0.6 to 2.2). The risk of testicular cancer was increased (12.0; 2.5 to 35.6), although this was based on only three cases in the cohort of subjects with Down’s syndrome. Significantly elevated risks were found for coeliac disease (4.7; 1.3 to 12.2), acquired hypothyroidism (9.4; 3.4, 20.5), other thyroid disorders, and type 1 diabetes mellitus (2.8; 1.0 to 6.1). A decreased risk was found for asthma (0.4; 0.2 to 0.6). Conclusions: Our data add to the body of information on the risks of co-morbidity in people with Down’s syndrome. The finding on asthma needs to be confirmed or refuted by other studies.

Olive oil, diet and colorectal cancer: an ecological study and a hypothesis

STUDY OBJECTIVES Colorectal cancer (CRC) is a common cancer in many western countries and is probably caused in part by dietary factors. Southern European countries have lower incidence rates of CRC than many other western countries. It was postulated that, because olive oil is thought to influence bile salt secretion patterns in rats, it may influence the occurrence of CRC. The purpose of this study was to compare national levels of dietary factors, with particular reference to olive oil, with national differences in CRC incidence. DESIGN Ecological study using existing international databases. Incidence rates for CRC, food supply data, and olive oil consumption data were extracted from published sources, combined, and analysed to calculate the correlations between CRC and 10 dietary factors. Associations were then explored using stepwise multiple regression. SETTING 28 countries from four continents. MAIN RESULTS 76% of the intercountry variation in CRC incidence rates was explained by three significant dietary factors—meat, fish and olive oil—in combination. Meat and fish were positively associated, and olive oil was negatively associated, with CRC incidence. CONCLUSION Olive oil may have a protective effect on the development of CRC. The proposed hypothesis is that olive oil may influence secondary bile acid patterns in the colon that, in turn, might influence polyamine metabolism in colonic enterocytes in ways that reduce progression from normal mucosa to adenoma and carcinoma.

Increase in emergency admissions to hospital for children aged under 15 in England, 1999–2010: national database analysis

Objective To investigate a reported rise in the emergency hospital admission of children in England for conditions usually managed in the community. Setting and design Population-based study of hospital admission rates for children aged under 15, based on analysis of Hospital Episode Statistics and population estimates for England, 1999–2010. Main outcome Trends in rates of emergency admission to hospital. Results The emergency admission rate for children aged under 15 in England has increased by 28% in the past decade, from 63 per 1000 population in 1999 to 81 per 1000 in 2010. A persistent year-on-year increase is apparent from 2003 onwards. A small decline in the rates of admissions lasting 1 day or more has been offset by a twofold increase in short-term admissions of <1 day. Considering the specific conditions where high emergency admission rates are thought to be inversely related to primary care quality, admission rates for upper respiratory tract infections rose by 22%, lower respiratory tract infections by 40%, urinary tract infections by 43% and gastroenteritis by 31%, while admission rates for chronic conditions fell by 5.6%. Conclusions The continuing increase in very-short-term admission of children with common infections suggests a systematic failure, both in primary care (by general practice, out-of-hours care and National Health Service Direct) and in hospital (by emergency departments and paediatricians), in the assessment of children with acute illness that could be managed in the community. Solving the problem is likely to require restructuring of the way acute paediatric care is delivered.

Skin cancer in people with multiple sclerosis: a record linkage study

Objective: The prevalence of multiple sclerosis (MS) varies with latitude: it increases with distance from the equator in both hemispheres. To seek evidence on whether solar radiation is a protective factor for MS, this study investigated whether skin cancer, as an indicator of solar radiation, is less common in people with MS than in others. Design: Analysis of a database of linked hospital records and death certificates. Setting: The Oxford Region of the National Health Service, England. Subjects: A cohort comprising all people in the database with MS, and comparison cohorts of people with other diseases. Results: Skin cancer was significantly less common in people with MS than in the main comparison cohort (rate ratio 0.49; 95% confidence interval 0.24 to 0.91). There was no general deficit of cancer in the MS cohort, and no deficit of skin cancer in cohorts of people with other autoimmune or neurological diseases. Conclusion: The findings support the hypothesis that solar radiation may have a protective influence on the development of MS.

Cancer in patients with ulcerative colitis, Crohn's disease and coeliac disease: record linkage study.

Objective The objective of this study was to determine the risk of cancers in cohorts of patients with ulcerative colitis, Crohns disease, or coeliac disease, compared with the risk in a control cohort. Method The method used was the analysis of a linked statistical database of hospital and mortality data in an area in southern England. Results Rate ratios for cancer (excluding cases occurring within the first year of follow-up), compared with the value of 1 in the control cohort, were 1.25 [95% confidence interval (CI), 1.13–1.39] in patients with ulcerative colitis, 1.27 (95% CI, 1.11–1.45) with Crohns disease, and 1.16 (95% CI, 0.94–1.43) with coeliac disease. In patients with ulcerative colitis or Crohns disease, there was a significantly high risk of cancer of the colon [2.22 (95% CI, 1.71–2.83) and 1.64 (95% CI, 1.09–2.39), respectively]. In patients with ulcerative colitis there was a significantly high risk of cancer of the rectum [1.84 (95% CI, 1.27–2.58)]. In patients with ulcerative colitis or Crohns disease, who did not undergo partial or total colectomy for it, the rate ratios for colon cancer were, respectively, 5.52 (95% CI, 4.39–6.71) and 4.81 (95% CI, 3.52–6.47). In ulcerative colitis, there was an elevated risk of cancer of the rectum, liver and ovary. The rate ratio for lung cancer was low, but of borderline significance [0.72 (95% CI, 0.50–0.98)]. In Crohns disease, the rate ratio was high for cancer of the cervix [2.63 (95% CI, 1.12–5.29)]. In patients with coeliac disease, the high-risk cancer was non-Hodgkins lymphoma [rate ratio 3.28 (95% CI, 1.49–6.28)]. Conclusion All three diseases carry an increased risk of cancer overall when the first year cases are included, though fairly modest in scale, and the increased risk seen in coeliac disease reduces when first year cases are excluded. Each has a distinctive pattern of individual high-risk cancers.

Incidence of disease after vasectomy: a record linkage retrospective cohort study.

OBJECTIVE--To determine whether vasectomy is associated with an increased risk of several diseases, and in particular testicular cancer, after operation. DESIGN--Retrospective cohort study using linked medical record abstracts. SETTING--Six health districts in Oxford region. SUBJECTS--13,246 men aged 25-49 years who had undergone vasectomy between 1970 and 1986, and 22,196 comparison subjects who had been admitted during the same period for one of three specified elective operations, appendicitis, or injuries. MAIN OUTCOME MEASURES--Hospital admission and death after vasectomy or comparison event. RESULTS--The mean durations of follow up were 6.6 years for men with a vasectomy and 7.5 years for men with a comparison condition. The relative risk of cancer of the testis in the vasectomy cohort (4 cases) compared with that in the other cohorts (17 cases) was 0.46 (95% confidence interval 0.1 to 1.4), that of cancer of the prostate (1 v 5 cases) 0.44 (0.1 to 4.0), and that of myocardial infarction (97 v 226 cases) 1.00 (0.8 to 1.3). There was no evidence of an increase associated with vasectomy in the incidence of a range of other diseases. CONCLUSIONS--Vasectomy was not associated with an increased risk of testicular cancer or the other diseases studied. With respect to prostatic cancer, while we found no cause for concern, longer periods of observation on large numbers of men are required.