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\"The study of dissociation is relevant to anyone undertaking research or treatment of mental health problems. Cognitive Behavioural Approaches to the Understanding and Treatment of Dissociation uses a cognitive approach to de-mystify the processes involved in linking traumatic incidents to their effects. Kennedy, Kennerley and Pearson present a full and comprehensive understanding of mental health problems involving dissociative disorders and their treatment, bringing together an international range of experts. Each chapter addresses a single topic in full, including assessment of previous research from a cognitive perspective, recommendations for treatment and case studies to illustrate clinical approaches. Using an evidence-based scientific approach combined with the wisdom of clinical experience, the authors make the relevance of dissociation immediately recognisable to those familiar with PTSD, dissociative identity disorder, eating disorders, hallucinations and a wide range of psychological and non-organic physical health disorders. Designed to provide new perspectives on both research and treatment, Cognitive Behavioural Approaches to the Understanding and Treatment of Dissociation includes a wide range of material that will appeal to clinicians, academics and students\"-- Provided by publisher.

To plan for pensions and health and social services, future mortality and life expectancy need to be forecast. Consistent forecasts for all subnational units within a country are very rare. Our aim was to forecast mortality and life expectancy for England and Wales' districts. We developed Bayesian spatiotemporal models for forecasting of age-specific mortality and life expectancy at a local, small-area level. The models included components that accounted for mortality in relation to age, birth cohort, time, and space. We used geocoded mortality and population data between 1981 and 2012 from the Office for National Statistics together with the model with the smallest error to forecast age-specific death rates and life expectancy to 2030 for 375 of England and Wales' 376 districts. We measured model performance by withholding recent data and comparing forecasts with this withheld data. Life expectancy at birth in England and Wales was 79·5 years (95% credible interval 79·5–79·6) for men and 83·3 years (83·3–83·4) for women in 2012. District life expectancies ranged between 75·2 years (74·9–75·6) and 83·4 years (82·1–84·8) for men and between 80·2 years (79·8–80·5) and 87·3 years (86·0–88·8) for women. Between 1981 and 2012, life expectancy increased by 8·2 years for men and 6·0 years for women, closing the female–male gap from 6·0 to 3·8 years. National life expectancy in 2030 is expected to reach 85·7 (84·2–87·4) years for men and 87·6 (86·7–88·9) years for women, further reducing the female advantage to 1·9 years. Life expectancy will reach or surpass 81·4 years for men and reach or surpass 84·5 years for women in every district by 2030. Longevity inequality across districts, measured as the difference between the 1st and 99th percentiles of district life expectancies, has risen since 1981, and is forecast to rise steadily to 8·3 years (6·8–9·7) for men and 8·3 years (7·1–9·4) for women by 2030. Present forecasts underestimate the expected rise in life expectancy, especially for men, and hence the need to provide improved health and social services and pensions for elderly people in England and Wales. Health and social policies are needed to curb widening life expectancy inequalities, help deprived districts catch up in longevity gains, and avoid a so-called grand divergence in health and longevity. UK Medical Research Council and Public Health England.

IntroductionPatients presenting to primary care with site-specific alarm symptoms can be referred onto urgent suspected cancer pathways, whereas those with non-specific symptoms currently have no dedicated referral routes leading to delays in cancer diagnosis and poorer outcomes. Pilot Multidisciplinary Diagnostic Centres (MDCs) provide a referral route for such patients in England.ObjectivesThis work aimed to use linked primary care and cancer registration data to describe diagnostic pathways for patients similar to those being referred into MDCs and compare them to patients presenting with more specific symptoms.MethodsThis cross-sectional study linked primary care data from the National Cancer Diagnosis Audit (NCDA) to national cancer registration and Route to Diagnosis records. Patient symptoms recorded in the NCDA were used to allocate patients to one of two groups - those presenting with symptoms mirroring referral criteria of MDCs (non-specific but concerning symptoms (NSCS)) and those with at least one site-specific alarm symptom (non-NSCS). Descriptive analyses compared the two groups and regression analysis by group investigated associations with long primary care intervals (PCIs).ResultsPatients with NSCS were more likely to be diagnosed at later stage (32% stage 4, compared with 21% in non-NSCS) and via an emergency presentation (34% vs 16%). These patients also had more multiple pre-referral general practitioner consultations (59% vs 43%) and primary care-led diagnostics (blood tests: 57% vs 35%). Patients with NSCS had higher odds of having longer PCIs (adjusted OR: 1.24 (1.11 to 1.36)). Patients with lung and urological cancers also had higher odds of longer PCIs overall and in both groups.ConclusionsDifferences in the diagnostic pathway show that patients with symptoms mirroring the MDC referral criteria could benefit from a new referral pathway.

ObjectiveThis study defined a retrospective cohort of patients in England with primary advanced or recurrent (A/R) endometrial cancer (EC) who may have been eligible for clinical trials evaluating immune checkpoint inhibitors (ICIs) in the first-line (1L) setting within a real-world dataset, and described the characteristics, treatment patterns and outcomes within this cohort.DesignThis was a retrospective, population-based study.SettingRoutine population-level data from the National Cancer Registration and Analysis Service in England were used. Patients diagnosed with A/R EC between 1 January 2013 and 31 December 2019 were included (follow-up until 23 August 2021). ICI-eligible patients who received any 1L therapy (defined as first systemic treatment for A/R EC with or without radiotherapy) and met key eligibility criteria for the RUBY trial (NCT03981796; 1L cohort) were included. A subpopulation who solely received carboplatin–paclitaxel at 1L (carboplatin–paclitaxel subcohort) was identified.MethodsDemographics, characteristics and therapy received were reported. Overall survival (OS), time to next treatment (TTNT) and time to treatment discontinuation (TTD) from 1L chemotherapy initiation were assessed using Kaplan-Meier methodology.ResultsOf 13 954 patients identified, 2376 ICI-eligible patients were included in the 1L cohort (median [range] age: 67.9 [26.7–94.0] years); 902 patients received solely carboplatin–paclitaxel at 1L. Demographics and disease characteristics were generally similar between cohorts. Median (95% CI) OS, TTNT and TTD from 1L chemotherapy were 27.2 (24.7, 30.2), 16.9 (15.8, 18.5) and 3.4 (3.4, 3.4) months, respectively, in the 1L cohort, and 17.2 (15.5, 19.0), 12.4 (11.6, 13.5) and 3.4 (3.4, 3.4) months, respectively, in the carboplatin–paclitaxel subcohort.ConclusionLong-term outcomes were poor for both cohorts, particularly the carboplatin–paclitaxel subcohort, where patients did not receive radiotherapy and had predominantly metastatic disease. This reflects the unmet need for more durable treatment options to prevent relapse and prolong survival in this patient population. This real-world study will help contextualise outcomes from ongoing phase III clinical trials investigating 1L ICI treatments.

IntroductionPCCRC is a key quality indicator for the detection and prevention of colorectal adenocarcinoma (CRC). It is not known whether rates of PCCRC are changing over time. There is limited evidence of factors associated with PCCRC that might be amenable to quality improvement interventions.This study investigated trends in rates of PCCRC in the NHS in England; the extent of variation between NHS trusts; and potential causal associations with PCCRC.MethodsUsing linked national Hospital Episode Statistics and National Cancer Registration and Analysis Service data all individuals who had undergone a colonoscopy procedure between 1/1/2006 and 31/12/2012 and who developed a CRC to 31/12/2015 were identified. NHS trust provider status and potential associations with PCCRC were included in the analysis.International consensus methodology was used to calculate the PCCRC – 3 year rate (PCCRC-3 yr).1 2 Colonoscopies were labelled as true positive (CRC within 0 to 6 months of the procedure), false negative (CRC within 6 to 36 months) and true negative (CRC beyond 36 months). The PCCRC-3 yr rate was calculated as: false negatives/(true positive +false negative) x 100%.The PCCRC-3 yr rate was calculated for each year from 2006 to 2012. In addition, the rate in each colonoscopy provider was calculated, and organisations grouped using quintiles. PCCRC rates were calculated in relation to patient and tumour characteristics.ResultsBetween 2006 and 2012 1 08 908 colonoscopies followed by a diagnosis of CRC were identified. Of these, 93 240 (86%) were labelled true positive, 7781 (7%) were false negatives, and 7887 (7%) were true negative tests. There was a significant reduction in PCCRC-3 yr rates, from 8.6% in 2006 to 7.5% in 2012 (Chi2 for trend p<0.01). There was variation in unadjusted, mean PCCRC-3 yr rate between NHS Trusts from 5% (SD ±2%) in the highest performing quintile to 11% (SD ±2%) in the lowest. PCCRCs were significantly associated with female sex, right-sided colonic lesions, inflammatory bowel disease and diverticular disease diagnosis, mucinous CRC and in individuals with metachronous CRC.ConclusionThere has been a significant reduction in PCCRC-3 yr rates from 2006 to 2012, likely to be related to improvements in colonoscopic quality: particularly improved caecal intubation and bowel preparation resulting in improved lesion recognition and removal. There appears to be unwarranted variation of PCCRC-3 yr rates across NHS trusts. Reasons for this variation need to be explored and subject to quality improvement projects. Evidence from this study can be used to help target those at highest risk of PCCRC.References. Morris EJA, et al. Gut2014;64:1248–56.. Beintaris I, et al. UEG J2017;5:PO436.

Estimates of the cost of cancer care are crucial for the economic evaluation of screening interventions and other early cancer diagnosis initiatives. However, data on the cost of cancer is scarce. This study estimated National Health Service (NHS) hospital care costs for eight cancer types by stage at diagnosis in England. This national, retrospective, population-based cohort study used individual patient-level data collated by the National Disease Registration Service, NHS England. We included patients aged 50–79 years who were diagnosed with a colorectal, head and neck, liver and bile duct, lung, lymphoma, oesophageal, ovarian, or pancreatic cancer in England between Jan 1, 2014, and Dec 31, 2017. For each patient, we obtained linked national health-care records, incorporating all inpatient hospital care, outpatient activity, and accident and emergency department attendances, and costed these using a payer perspective. Patients were excluded if registration was death certificate only, records related only to a secondary metastatic site, sex and cancer type were incompatible, death status or date were uncertain, or there were zero health-care costs from 6 months before diagnosis to end of follow-up. Net, cancer-related, regression-adjusted hospital care costs were reported for each cancer type and stage overall, annually, and by phase of care. Within each annual period and phase, mean monthly costs were also estimated. Of 359 106 cancer records registered, 345 629 cancers were available for analysis, and 333 657 cancers were included in the analysis (147 334 [44·2%] occurred in female patients and 186 323 [55·8%] in male patients; 303 227 [90·9%] among participants of White ethnicity, 4452 [1·3%] among participants of mixed or other ethnicity, 7870 [2·3%] among participants of Asian ethnicity, 4179 [1·3%] among participants of Black ethnicity, and 13 929 [4·2%] among participants of unknown ethnicity). Overall costs were higher at later stages for colorectal, head and neck, lymphoma, and ovarian cancers with mean stage IV costs of £37 838, £36 657, £42 667, and £45 871, respectively. Costs for liver and bile duct, lung, oesophageal, and pancreatic cancers were highest for those diagnosed at stage II (£28 356, £29 553, £33 640, and £39 351, respectively), and slightly lower at stages I, III, and IV. Health-care costs were highest in the initial treatment and the end-of-life phases of care. Within each phase, mean cost per month increased with stage for most cancer types studied, though fewer months of follow-up were observed in each phase for liver and bile duct, lung, oesophageal, and pancreatic cancers. Cancer-related NHS hospital care costs by stage at diagnosis differed between cancer types; this heterogeneous pattern could inform detailed and nuanced economic evaluations of early detection initiatives. GRAIL Bio UK.

BackgroundThe increasing burden of cancer has economic implications for the healthcare system in England. However, there is limited evidence on the cost of cancer treatment. We calculated the costs of initial cancer treatment (resection, radiotherapy, systemic anti-cancer therapy [SACT]) based on stage at diagnosis.MethodsData from England’s National Cancer Registration Dataset were matched to English Hospital, Radiotherapy and SACT data for breast, lung, prostate, colon and rectal cancers diagnosed between 2016 and 2018. Treatment data were matched to National Schedule of Reference Costs data to calculate the cost of each treatment event.ResultsBreast, colon and rectal cancers treated with resection, radiotherapy or SACT had increasing costs with later stage at diagnosis; costs for lung and prostate cancers were lower at stages 1 and 4 compared to stages 2 and 3. In general, surgery and SACT were the most expensive treatments. Radiotherapy and SACT costs showed little change across stages 1–3; radiotherapy costs decreased in stage 4, while SACT costs increased.ConclusionsThis analysis estimates initial treatment costs by stage based on observed data. Future research can build on this to provide more comprehensive costings associated with cancer; this is important for future planning of cancer services.

BackgroundAlthough 1 billion people live in informal (slum) settlements, the consequences for respiratory health of living in these settlements remain largely unknown. This study investigated whether children living in an informal settlement in Nairobi, Kenya are at increased risk of asthma symptoms.MethodsChildren attending schools in Mukuru (an informal settlement in Nairobi) and a more affluent area (Buruburu) were compared. Questionnaires quantified respiratory symptoms and environmental exposures; spirometry was performed; personal exposure to particulate matter (PM2.5) was estimated.Results2373 children participated, 1277 in Mukuru (median age, IQR 11, 9–13 years, 53% girls), and 1096 in Buruburu (10, 8–12 years, 52% girls). Mukuru schoolchildren were from less affluent homes, had greater exposure to pollution sources and PM2.5. When compared with Buruburu schoolchildren, Mukuru schoolchildren had a greater prevalence of symptoms, ‘current wheeze’ (9.5% vs 6.4%, p=0.007) and ‘trouble breathing’ (16.3% vs 12.6%, p=0.01), and these symptoms were more severe and problematic. Diagnosed asthma was more common in Buruburu (2.8% vs 1.2%, p=0.004). Spirometry did not differ between Mukuru and Buruburu. Regardless of community, significant adverse associations were observed with self-reported exposure to ‘vapours, dusts, gases, fumes’, mosquito coil burning, adult smoker(s) in the home, refuse burning near homes and residential proximity to roads.ConclusionChildren living in informal settlements are more likely to develop wheezing symptoms consistent with asthma that are more severe but less likely to be diagnosed as asthma. Self-reported but not objectively measured air pollution exposure was associated with increased risk of asthma symptoms.

Whole-genome sequencing (WGS) information has played a crucial role in the SARS-CoV-2 (COVID-19) pandemic by providing evidence about variants to inform public health policy. The purpose of this study was to assess the representativeness of sequenced cases compared with all COVID-19 cases in England, between March 2020 and August 2021, by demographic and socio-economic characteristics, to evaluate the representativeness and utility of these data in epidemiological analyses. To achieve this, polymerase chain reaction (PCR)-confirmed COVID-19 cases were extracted from the national laboratory system and linked with WGS data. During the study period, over 10% of COVID-19 cases in England had WGS data available for epidemiological analysis. With sequencing capacity increasing throughout the period, sequencing representativeness compared to all reported COVID-19 cases increased over time, allowing for valuable epidemiological analyses using demographic and socio-economic characteristics, particularly during periods with emerging novel SARS-CoV-2 variants. This study demonstrates the comprehensiveness of England’s sequencing throughout the COVID-19 pandemic, rapidly detecting variants of concern, and enabling representative epidemiological analyses to inform policy.

Emissions of ammonia (NH3) from agricultural activities are a major threat to ecosystems and human health. Its quantification via emissions inventories is vital to the understanding of mitigation strategies and policy formation. South Asia, specifically the South Asian Association for Regional Cooperation (SAARC), is a global hotspot of NH3 emissions from agriculture but also an area of great uncertainty due to a lack of data that are representative of local practices. This study presents a single implementation of a framework into which indigenous data can be ingested to adjust such estimates, to provide spatially distributed (0.1° × 0.1°) emissions in five agricultural sectors for improved input data for atmospheric chemistry transport models, by moving away from Tier 1 methods for emission inventories (Tomlinson et al., 2025; https://doi.org/10.5285/e0114a4f-32c2-41d9-9c2a-c46f365d4c30). Results incorporate data such as lower emission factors of NH3 following the application of Urea (13 % of total nitrogen lost as NH3-N) to provide a total estimated emission of NH3 in the SAARC of ∼ 6 Tg (±1.2 Tg), with high values (>5 g NH3 m−2 a−1) in the Indian states Haryana, Punjab and Uttar Pradesh in the Indo-Gangetic Plain (IGP).