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Background: Loneliness and struggles with unmet social needs are a common experience among people with 'personality disorder' diagnoses/traits. Given the impact of loneliness and poor perceived social support on mental health, and the importance of a sense of belonging for recovery, a systematic review examining the prevalence/severity of loneliness and deficits in perceived social support among people with 'personality disorder' diagnoses/traits is an essential step towards developing an intervention targeting the social needs of people with diagnoses/traits 'personality disorder'. Despite an extensive literature on loneliness and deficits of perceived social support among people with 'personality disorder' diagnosis/traits, to date there has been no systematic review of this evidence. Method: We conducted a systematic review synthesising quantitative data on the prevalence/severity of loneliness and deficits of perceived social support among people with diagnoses/traits of 'personality disorder' in comparison with other clinical groups and the general population. We searched Medline, Embase, PsycINFO, Web of Social Science, Google scholar and Ethos British Library from inception to December 2021. We conducted quality appraisals using the Joanna Briggs Critical appraisal tools and rated the certainty of evidence using the Grading of Recommendation, Assessment, Development and Evaluation approach. A narrative synthesis was used describing the direction and strength of associations prioritising high quality studies. Findings: A final set of 70 studies are included in this review, most of which are cross-sectional studies (n = 55), based in the United States (51%) and focused on community samples. Our synthesis of evidence found that, across all types of 'personality disorders' (except 'narcissistic personality' traits), people with traits associated with 'personality disorder' or meeting criteria for a diagnosis of 'personality disorder', have higher levels of loneliness, lower perceived relationship satisfaction, and poorer social support than the general population or other clinical samples. Conclusion: The quality of evidence is judged as low quality. However, given the distressing nature of loneliness and the known negative effects of loneliness on mental health and recovery, it is important for future research to explore mechanisms by which loneliness may exacerbate 'personality disorder' symptoms and the impact this has on recovery. [ABSTRACT FROM AUTHOR]

Purpose: Consultation services are recommended to support mental health staff working with service users diagnosable with personality disorder. However, there is scarce literature examining the impact of delivering and receiving consultation services. This study aims to investigate the impact of a pilot co-produced consultation service aiding clinical teams in the engagement of service users diagnosable with personality disorder. Design/methodology/approach: This is a qualitative evaluation using a focus group and five semi-structured interviews to explore the experience of delivering and receiving the consultation service. Data were analysed using thematic analysis. Clinical and demographic characteristics were obtained on service users referred. Findings: The consultation staff focus group produced two overarching themes: "Disrupting the system" and "Mirroring the service and the service users consulted". The staff consultee semi-structured interviews produced two overarching themes: "Experience of working with personality disorder" and "Experience of the consultation service". Staff described working with personality disorder as challenging. The consultation process was experienced as a helpful and reassuring space to gain a new perspective on the work. However, the service was felt to be limited; in that, it lacked follow-on treatment. Originality/value: This study adds to the body of literature on consultation for service users diagnosable with personality disorder and demonstrates its function in service provision. It sheds light on staff experience of delivering and receiving a consultation service, including the use of a co-production model. [ABSTRACT FROM AUTHOR]

Working with patients who end their lives through suicide is one of the greatest challenges and fears a clinician might face. This paper explores the experience of working with such patients in the course of psychiatric care and Jungian analysis. Jungian theory is used to explore a conceptual understanding of the dilemmas faced. Such theory points to an intractable conflict between Self and ego giving rise to unbearable distress, partly through difficulties arising in achieving individuation. The paper proposes that our difficulties in dealing with a patient's suicide might reflect a manifestation of relentless hope and, perhaps contentiously, these patients made a more considered decision in their final acts than prevailing clinical opinion suggests. [ABSTRACT FROM AUTHOR]

Introduction: The need to improve the quality of community mental health services for people with Complex Emotional Needs (CEN) (who may have a diagnosis of 'personality disorder') is recognised internationally and has become a renewed policy priority in England. Such improvement requires positive engagement from clinicians across the service system, and their perspectives on achieving good practice need to be understood. Aim: To synthesise qualitative evidence on clinician perspectives on what constitutes good practice, and what helps or prevents it being achieved, in community mental health services for people with CEN. Methods: Six bibliographic databases were searched for studies published since 2003 and supplementary citation tracking was conducted. Studies that used any recognised qualitative method and reported clinician experiences and perspectives on community-based mental health services for adults with CEN were eligible for this review, including generic and specialist settings. Meta-synthesis was used to generate and synthesise over-arching themes across included studies. Results: Twenty-nine papers were eligible for inclusion, most with samples given a 'personality disorder' diagnosis. Six over-arching themes were identified: 1. The use and misuse of diagnosis; 2. The patient journey into services: nowhere to go; 3. Therapeutic relationships: connection and distance; 4. The nature of treatment: not doing too much or too little; 5. Managing safety issues and crises: being measured and proactive; 6. Clinician and wider service needs: whose needs are they anyway? The overall quality of the evidence was moderate. Discussion: Through summarising the literature on clinician perspectives on good practice for people with CEN, over-arching priorities were identified on which there appears to be substantial consensus. In their focus on needs such as for a long-term perspective on treatment journeys, high quality and consistent therapeutic relationships, and a balanced approach to safety, clinician priorities are mainly congruent with those found in studies on service user views. They also identify clinician needs that should be met for good care to be provided, including for supervision, joint working and organisational support. [ABSTRACT FROM AUTHOR]

Background: Individuals with Complex Emotional Needs (CEN) services, a working description to refer to the needs experienced by people who may have been diagnosed with a "personality disorder", face premature mortality, high rates of co-morbidity, service user and treatment costs. Service provision for this population is recurrently identified as needing to be transformed: there are serious concerns about quality, accessibility, fragmentation of the service system and the stigma and therapeutic pessimism service users encounter. Understanding clinician perspectives is vital for service transformation, as their views and experiences shed light on potential barriers to achieving good care, and how these might be overcome. In this study, we aimed to explore these views. Methods: We used a qualitative interview design. A total of fifty participants from a range of professions across specialist and generic community mental health services across England who provide care to people with CEN took part in six focus groups and sixteen one-to-one interviews. We analysed the data using a thematic approach. Findings: Main themes were: 1) Acknowledging the heterogeneity of needs: the need for a person-centred care approach and flexibility when working with CEN, 2) 'Still a diagnosis of exclusion': Exploring the healthcare provider-level barriers to providing care, and 3) Understanding the exclusionary culture: exploring the system-based barriers to providing care for CEN. Across these themes, staff highlighted in particular the need for care that was person-centred, relational, empathic, and trauma informed. Major barriers to achieving this are stigmatising attitudes and behaviour towards people with CEN, especially in generic mental health services, lack of development of coherent service systems offering clear long-term pathways and ready access to high quality treatment, and lack of well-developed structures for staff training and support. Discussion: Overall, the findings point towards clinician views as generally congruent with those of service users, reinforcing the need for priorities towards systemwide change to ensure that best practice care is provided for people with CEN. Particularly prominent is the need to put in place systemwide training and support for clinicians working with CEN, encompassing generic and specialist services, and to challenge the stigma still experienced throughout the system. Conclusions: Staff working with this service user group report that delivering best practice care requires services to be flexible, integrated, and sustainably funded, and for staff to be supported through ongoing training and supervision. [ABSTRACT FROM AUTHOR]

Background: There is consensus that services supporting people with complex emotional needs are part of a mental health care system in which change is needed. To date, service users' views and co-production initiatives have had little impact on the development of interventions and care. This needs to change, and our paper evidences the experiences and perspectives of a diverse range of people on how community services can best address the needs of people with complex emotional needs. Methods: A co-produced qualitative research study. Lived experience researchers led data collection and analysis. Individual interviews were conducted with 30 people across England who had a diverse range of experiences and perspectives of using community services for complex emotional needs. Participants were asked about their experiences of using community services for their mental health, and views on how community services can best address their needs. Thematic analysis was used to analyse the data. Results: Participants reported some experiences of good practice but also of experiences of severely stigmatising interventions, a lack of effective support and service fragmentation. Relational Practice was identified as the central overarching theme and describes how community services can best support people with complex emotional needs. This approach involves care delivered in a non-stigmatising, individualised and compassionate way and care that is trauma-informed. It involves care that is planned collaboratively with service users to ensure their multiple needs are addressed in a flexible, holistic and consistent way which accounts for the long-term and fluctuating nature of their needs. Conclusions: Relational practice approaches have potential to facilitate better community care for people with complex emotional needs. Research and service development are needed to examine how best to implement such approaches across the mental health service system. This work must be co-produced with people with relevant lived experience, their carers and the professionals who support them. [ABSTRACT FROM AUTHOR]

Purpose: National Institute for Clinical and Health Excellence guidelines (2009) state that low intensity psychological interventions should not be used for borderline personality disorder. However, an emerging body of evidence suggests brief interventions such as psychoeducation may be relevant for those presenting with borderline personality difficulties. The purpose of this study is to evaluate the benefit of learning about thinking, emotions and relationships (LATER), a co-produced psychoeducation programme for borderline personality difficulties in a community-based setting. Design/methodology/approach: Participants (n = 125) self-referred to LATER, a group-based psychoeducation programme delivered at the [NHS Trust] Recovery College. Participants were assessed pre- and post-intervention using the tailor-made psychological education group evaluation scale, the borderline evaluation of severity over time and work and social adjustment scale. Paired t-tests were conducted on pre- and post-scores, and effect sizes were calculated. Findings: After LATER, participants reported a significant decrease in negative thoughts and feelings, destructive behaviours and overall borderline symptom severity, but no significant increase in positive behaviours. Significant decreases were found in areas of work and social impairment. Participants' overall understanding of personality difficulties significantly improved. Effect sizes were small to moderate. Research limitations/implications: Limitations of the study include the lack of a control group, adjustment for confounders and follow-up. Replication with a more robust methodology is needed. Originality/value: This study contributes to the evidence for the usefulness of brief interventions for personality difficulties, particularly in the context of a stepped model of care and adds to the research on co-production. [ABSTRACT FROM AUTHOR]

Over the last two decades there has been a gradual shift from the traditional microscopic approach toward the use of endoscopic endonasal approach for resection of pituitary adenomas. Multiple medical and surgical complications can occur following endoscopic transsphenoidal resection of adenomas. We discuss the evolution of the surgical practice from the use of the 'microscope' to the 'endoscope' in the resection of pituitary adenomas. We present a comprehensive review of the medical and surgical complications following surgery with particular emphasis on both the prevention and management of electrolyte disturbance, cerebrospinal fluid leak and the rare but dreaded complication of internal carotid injury (ICA). We also searched the PubMed database to identify relevant literature between 1984 and 2019. Use of endoscope compared with microscope may be associated with better preservation of pituitary gland function with similar extent of resection. Overall medical and surgical complications can be safely managed in high volume centers in association with endocrinologists and skull base trained otolaryngologists. Understanding of anatomico-technical nuances and meticulous surgical technique are important toward preventing ICA injury. Ongoing surgical and technical developments coupled with imaging advances will likely lead to better future outcomes for patients with functioning and nonfunctioning adenomas. [ABSTRACT FROM AUTHOR]

Purpose: Mental health professionals working with patients with personality disorder are at risk of burnout. Burnout can adversely affect workforce retention and the delivery of high-quality care. The purpose of this paper is to investigate the impact of the three-day Knowledge and Understanding Framework (KUF) awareness-level personality disorder training on burnout, knowledge and attitudes in staff working in mental health settings. Design/methodology/approach: A total of 253 mental health professionals attended the KUF training, delivered through a co-production model (i.e. co-delivered by a mental health professional and service user consultant with lived experience). Questionnaires were administered at pre- and post-training to assess changes in burnout symptoms and understanding, perceived capabilities and emotional reactions concerning personality disorder. Findings: There were improvements in two burnout domains: decreases in emotional exhaustion (p = 0.009) and increases in personal accomplishment (p < 0.001) between pre-and post-training. Significant improvements were found in understanding, perceived capabilities and emotional reactions (p < 0.001). Research limitations/implications: This evaluation is limited by a lack of a control group and long-term follow-up. Further research is required to investigate the sustainability of reductions in burnout for mental health professionals attending training and supervision structures. Originality/value: KUF training may contribute to reductions in the high levels of burnout often experienced amongst staff working in mental health settings and could form a part of a broader strategy focussing on continued supervision and opportunities to integrate learning into practice. [ABSTRACT FROM AUTHOR]

Objectives: This paper aims to provide contemporary epidemiological data on squamous cell carcinoma (SCC) of the nasal cavity, which represents a rare type of head and neck cancer. Design, Setting & Participants: A descriptive analysis of people with nasal cavity SCC treated with curative intent from the Head and Neck 5000 study; a multicentre clinical cohort study of people from the UK with head and neck cancer. People with tumours of the nasopharynx, paranasal sinuses and other sub‐sites of the head and neck were excluded. Main outcome measures: Demographic data and treatment details are presented for all participants. The main outcomes were overall survival and survival according to categories of characteristics (eg, smoker vs non‐smoker); these were explored using Kaplan‐Meier plots. Results: Thirty people with nasal cavity SCC were included in the study, of which most were male (67%) and current or ex‐smokers (70%). The majority (70%) presented with early‐stage (T1/2, N0) tumours. Cervical lymph node metastases at presentation were rare, occurring in only one person. Nine people died during the follow‐up period (30%). Worse survival outcomes were seen in people with moderate or severe co‐morbidities. Conclusions: This paper provides epidemiological data on nasal cavity SCC in the UK. Patterns of disease and survival outcomes are described, identifying high‐risk groups. Further studies should explore whether primary treatment modality alters survival. [ABSTRACT FROM AUTHOR]

Objective: The authors examined whether lamotrigine is a clinically effective and cost-effective treatment for people with borderline personality disorder.Method: This was a multicenter, double-blind, placebo-controlled randomized trial. Between July 2013 and November 2016, the authors recruited 276 people age 18 or over who met diagnostic criteria for borderline personality disorder. Individuals with coexisting bipolar affective disorder or psychosis, those already taking a mood stabilizer, and women at risk of pregnancy were excluded. A web-based randomization service was used to allocate participants randomly in a 1:1 ratio to receive either an inert placebo or up to 400 mg/day of lamotrigine. The primary outcome measure was score on the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) at 52 weeks. Secondary outcome measures included depressive symptoms, deliberate self-harm, social functioning, health-related quality of life, resource use and costs, side effects of treatment, and adverse events.Results: A total of 195 (70.6%) participants were followed up at 52 weeks, at which point 49 (36%) of those in the lamotrigine group and 58 (42%) of those in the placebo group were taking study medication. The mean ZAN-BPD score was 11.3 (SD=6.6) among those in the lamotrigine group and 11.5 (SD=7.7) among those in the placebo group (adjusted difference in means=0.1, 95% CI=-1.8, 2.0). There was no evidence of any differences in secondary outcomes. Costs of direct care were similar in the two groups.Conclusions: The results suggest that treating people with borderline personality disorder with lamotrigine is not a clinically effective or cost-effective use of resources. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to describe the evolution of the field of personality disorder since the publication of “Personality disorder: no longer a diagnosis of exclusion” in 2003.Design/methodology/approach A review of both the academic literature contained within relevant databases alongside manual searches of policy literature and guidance from the key stakeholders was undertaken.Findings The academic and policy literature concentrates on treating borderline and antisocial personality disorders. It seems unlikely that evidence will resolutely support any one treatment modality over another. Criticism has arisen that comparison between modalities misses inter and intra patient heterogeneity and the measurement of intervention has become conflated with overall service design and the need for robust care pathways. Apparent inconsistency in service availability remains, despite a wealth of evidence demonstrating the availability of cost-effective interventions and the significant inequality of social and health outcomes for this population.Research limitations/implications The inclusion of heterogeneous sources required pragmatic compromises in methodological rigour.Originality/value This paper charts the recent developments in the field with a wealth of wide-ranging evidence and robust guidance from institutions such as NICE. The policy literature has supported the findings of this evidence but current clinical practice and what patients and carers can expect from services remains at odds. This paper lays bare the disparity between what we know and what is being delivered. The authors argue for the need for greater research into current practice to inform the setting of minimum standards for the treatment of personality disorder. [ABSTRACT FROM AUTHOR]

Objective: To investigate the assessment and treatment of physical health in patients with personality disorder and compare this to the care received in schizophrenia. Method: We collected data from a random sample of 246 patients with personality disorder on monitoring and intervention for seven key aspects of physical health. We compared the results with those from a random sample with schizophrenia. Results: In our sample, 160 (65%) people had the diagnosis of emotionally unstable personality disorder. In total, 104 (42.3%) people with personality disorder were being prescribed antipsychotic medication; 23 (9.3%) participants had all seven aspects of physical health recorded. Alcohol was most frequently recorded (76%); BMI (38.6%), blood glucose (25.2%) and blood cholesterol (20.7%) were less likely to be recorded. Interventions were not given to all those requiring them. Compared to people with schizophrenia, a lower proportion had evidence of assessment of smoking, illicit drug use, blood glucose and blood lipid levels. Smoking cessation advice was more likely to be offered to people with schizophrenia (difference = 29.4%, 95% CI = 12.5 to 44.7). Conclusion: Physical health is under‐assessed and under‐treated in patients with personality disorder. Medical staff must do more to help tackle increased morbidity among this group. Copyright © 2015 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Head and neck squamous cell carcinomas (HNSCC) are treated with surgery, radiotherapy and cisplatin-based chemotherapy, but survival from locally-advanced disease remains poor, particularly in patients whose tumors are negative for Human papillomavirus (HPV). Type 1 IGF receptor (IGF-1R) is known to promote tumorigenesis and resistance to cancer therapeutics. Here, we assessed IGF-1R immunohistochemistry on tissue microarrays containing 852 cores from 346 HNSCC patients with primary tumors in the oropharynx (n = 231), larynx (85), hypopharynx (28), oral cavity (2). Of these, 236 (68%) were HPV-negative, 110 (32%) positive. IGF-1R was detected in the cell membrane of 36% and cytoplasm of 92% of HNSCCs; in 64 cases with matched normal tonsillar epithelium, IGF-1R was overexpressed in the HNSCCs (P < 0.001). Overall survival (OS) and disease-specific survival (DSS) were reduced in patients whose tumors contained high membrane IGF-1R [OS: hazard ratio (HR) = 1.63, P = 0.006; DSS: HR = 1.63, P = 0.016], cytoplasmic IGF-1R (OS: HR = 1.58, P = 0.009; DSS: HR = 1.58, P = 0.024) and total IGF-1R (OS: HR = 2.02, P < 0.001; DSS: HR = 2.2, P < 0.001). High tumor IGF-1R showed significant association with high-tumor T-stage (P < 0.001) and HPV-negativity (P < 0.001), and was associated with shorter OS when considering patients with HPV-positive (P = 0.01) and negative (P = 0.006) tumors separately. IGF-1R was independently associated with survival in multivariate analysis including HPV, but not when lymphovascular invasion, perineural spread and T-stage were included. Of these factors, only IGF-1R can be manipulated; the association of IGF-1R with aggressive disease supports experimental incorporation of anti-IGF-1R agents into multimodality treatment programs for HPV-negative and high IGF-1R HPV-positive HNSCC. [ABSTRACT FROM AUTHOR]

Introduction: It is common practice to irrigate the operative site following tumor resection during major head and neck surgery. A variety of irrigation solutions are used, but there are few data on their relative efficacies in this context. Methods: The effect of different irrigation solutions on cell survival was assessed by clonogenic survival assay in 5 head and neck squamous cell carcinoma cell lines at different time points. Results: Saline had no effect on cell survival in any of the cell lines tested. Hydrogen peroxide, povidone-iodine, and a hydrogen peroxide/povidone-iodine mix caused complete cell death in all cell lines. Irrigation with distilled water caused a significant reduction in cell survival in 3 cell lines. Duration of exposure showed no effect on cell survival. Conclusion: These data suggest a significant difference in the cytocidal effect of commonly used irrigation solutions on head and neck cancer cells in an in vitro model. [ABSTRACT FROM AUTHOR]

Oculopharyngeal muscular dystrophy (OPMD) is a rare autosomal dominant, progressive degenerative muscle disorder featuring dysphagia with limited therapeutic options. The aim of this study was to evaluate the safety and efficacy of repeated endoscopic dilatation for OPMD over a 15-year period. All patients seen at our Regional Swallowing Clinic with OPMD confirmed by genetic analysis were included. Cricopharyngeal dilatation was performed as an outpatient procedure using a wire-guided 18-mm (54 Fr) Savary-Gilliard bougie with the patient under sedation. Patients were offered repeat endoscopic dilatation when symptoms recurred. Symptom severity prior to initial dilatation and at follow-up was evaluated using the Sydney Swallow Questionnaire (SSQ). Nine patients (7 female, 2 male) were included for analysis. Median total treatment period was 13 years (range = 3-15), median number of dilatations per patient was 7.2 (range = 1-16), and median interval between treatments was 15 months (range = 4.5-45). All patients recorded sustained symptom improvement. Mean SSQ score (out of 1,700) was 1,108.11 (SD ± 272.85) prior to first dilatation and 297.78 (SD ± 189.14) at last follow-up, representing a 73% decrease (95% CI = 52-94) in degree of dysphagia symptoms (paired t-test, P = 0.0001). All mean scores for individual questions also showed significant improvement ( P < 0.05). No adverse events were reported with all patients maintaining oral feeding at last follow-up. Repeated cricopharyngeal dilatation is a safe, effective, well-tolerated, and long-lasting treatment for dysphagia in OPMD. [ABSTRACT FROM AUTHOR]

Pharyngeal pouches are common, particularly in the elderly population, in whom they can cause significant morbidity. The advanced age of many patients and existing comorbidities mean that in some cases neither open nor endoscopic pouch stapling is possible. We present a technique of combined open and endoscopic pharyngeal pouch surgery, which may be used when other therapeutic options are limited. Laryngoscope, 2012 [ABSTRACT FROM AUTHOR]

A letter to the editor is presented about rectal foreign body in situ.

Objective: Oculopharyngeal muscular dystrophy (OPMD) is a rare, autosomal dominant, progressive degenerative muscle disorder featuring dysphagia with limited therapeutic options. Cricopharyngeal myotomy improves symptoms, yet dysphagia frequently recurs, failing to prevent aspiration and enteral feeding. The objective is to evaluate safety and efficacy of repeated endoscopic dilatation for OPMD over a 15‐year period. Method: All patients at our unit with genetically confirmed OPMD were included. Cricopharyngeal dilatation was performed with a wire‐guided 18 mm Savary‐Gilliard bougie. Repeat dilatation was offered when symptoms recurred. Symptom severity prior to initial dilatation and at follow‐up was evaluated using the Sydney Swallow Questionnaire (SSQ). Results: Nine patients (7 female, 2 male) were included. Median total treatment period was 13 years (range, 3‐15 years), median number of dilatations per patient was 7.2 (1‐16), and median interval between treatments was 15 months (range, 4.5‐45 months). All patients recorded sustained symptom improvement. Mean SSQ score was 1108 out of 1700 (SD ± 272.9) prior to first dilatation and 298 out of 1700 (SD ± 189.1) at last follow‐up, representing a 73% decrease (95% CI 52‐94) in degree of dysphagia symptoms (Paired t test, P =. 0001). All mean scores for individual questions also showed significant improvement (P <. 05). No adverse events were reported with all patients maintaining oral feeding at last follow‐up. Conclusion: Repeated cricopharyngeal dilatation is a safe, effective, well‐tolerated, and long‐lasting treatment for dysphagia in OPMD. [ABSTRACT FROM AUTHOR]

Background: No drug treatments are currently licensed for the treatment of borderline personality disorder (BPD). Despite this, people with this condition are frequently prescribed psychotropic medications and often with considerable polypharmacy. Preliminary studies have indicated that mood stabilisers may be of benefit to people with BPD., Objective: To examine the clinical effectiveness and cost-effectiveness of lamotrigine for people with BPD., Design: A two-arm, double-blind, placebo-controlled individually randomised trial of lamotrigine versus placebo. Participants were randomised via an independent and remote web-based service using permuted blocks and stratified by study centre, the severity of personality disorder and the extent of hypomanic symptoms., Setting: Secondary care NHS mental health services in six centres in England., Participants: Potential participants had to be aged ≥ 18 years, meet diagnostic criteria for BPD and provide written informed consent. We excluded people with coexisting psychosis or bipolar affective disorder, those already taking a mood stabiliser, those who spoke insufficient English to complete the baseline assessment and women who were pregnant or contemplating becoming pregnant., Interventions: Up to 200 mg of lamotrigine per day or an inert placebo. Women taking combined oral contraceptives were prescribed up to 400 mg of trial medication per day., Main Outcome Measures: Outcomes were assessed at 12, 24 and 52 weeks after randomisation. The primary outcome was the total score on the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) at 52 weeks. The secondary outcomes were depressive symptoms, deliberate self-harm, social functioning, health-related quality of life, resource use and costs, side effects of treatment and adverse events. Higher scores on all measures indicate poorer outcomes., Results: Between July 2013 and October 2015 we randomised 276 participants, of whom 195 (70.6%) were followed up 52 weeks later. At 52 weeks, 49 (36%) of those participants prescribed lamotrigine and 58 (42%) of those prescribed placebo were taking it. At 52 weeks, the mean total ZAN-BPD score was 11.3 [standard deviation (SD) 6.6] among those participants randomised to lamotrigine and 11.5 (SD 7.7) among those participants randomised to placebo (adjusted mean difference 0.1, 95% CI -1.8 to 2.0; p  = 0.91). No statistically significant differences in secondary outcomes were seen at any time. Adjusted costs of direct care for those prescribed lamotrigine were similar to those prescribed placebo., Limitations: Levels of adherence in this pragmatic trial were low, but greater adherence was not associated with better mental health., Conclusions: The addition of lamotrigine to the usual care of people with BPD was not found to be clinically effective or provide a cost-effective use of resources., Future Work: Future research into the treatment of BPD should focus on improving the evidence base for the clinical effectiveness and cost-effectiveness of non-pharmacological treatments to help policy-makers make better decisions about investing in specialist treatment services., Trial Registration: Current Controlled Trials ISRCTN90916365., Funding: Funding for this trial was provided by the Health Technology Assessment programme of the National Institute for Health Research (NIHR) and will be published in full in Health Technology Assessment ; Vol. 22, No. 17. See the NIHR Journals Library website for further project information. The Imperial Biomedical Research Centre Facility, which is funded by NIHR, also provided support that has contributed to the research results reported within this paper. Part of Richard Morriss' salary during the project was paid by NIHR Collaboration for Leadership in Applied Health Research and Care East Midlands., Competing Interests: Peter Tyrer is a member of the Health Technology Assessment (HTA) Commissioning Board. Joseph G Reilly has received project funding from the Drug Safety Research Unit as part of an unrestricted grant provided by Merck Pharmaceuticals. Alan Montgomery is part of the HTA Clinical Evaluation and Trials Board. Institutions for all authors have received funding from the National Institute for Health Research for other studies.

Aims and method We aimed to evaluate the availability and nature of services for people affected by personality disorder in England by conducting a survey of English National Health Service (NHS) mental health trusts and independent organisations. Results In England, 84% of organisations reported having at least one dedicated personality disorder service. This represents a fivefold increase compared with a 2002 survey. However, only 55% of organisations reported that patients had equal access across localities to these dedicated services. Dedicated services commonly had good levels of service use and carer involvement, and engagement in education, research and training. However, a wider multidisciplinary team and a greater number of biopsychosocial interventions were available through generic services. Clinical implications There has been a substantial increase in service provision for people affected by personality disorder, but continued variability in the availability of services is apparent and it remains unclear whether quality of care has improved., Competing Interests: Declaration of interest None.

Objectives/hypothesis: As survival rates in oropharyngeal cancer improve, long-term functional outcomes are increasingly important to understand. We report long-term functional outcomes in a cohort of surviving patients with oropharyngeal squamous cell carcinoma treated with primary surgery ± radiotherapy., Study Design: Cross-sectional study., Methods: Patients undergoing primary surgery for oropharyngeal cancer in Oxford, United Kingdom, between 2000 and 2010 were identified. The University of Washington Quality-of- Life and MD Anderson Dysphagia Inventory questionnaires were sent to all patients. Multivariate analysis was performed to determine the relationship between clinical factors and swallowing outcomes., Results: Twenty percent of patients required gastrostomy-tube placement (mean feed duration, 114 days). On multivariate analysis, increased age, advanced T stage, and an open surgical approach were associated with significantly reduced quality-of-life scores., Conclusions: Mean functional scores were comparable to previously published series of patients treated with primary surgery. Gastrostomy insertion rate was lower than in many previously published studies. Furthermore, specific variables have been identified that are associated with adverse functional outcome., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Somatostatin potently inhibits insulin secretion from pancreatic beta-cells. It does so via activation of ATP-sensitive K+-channels (KATP) and G protein-regulated inwardly rectifying K+-channels, which act to decrease voltage-gated Ca2+-influx, a process central to exocytosis. Because KATP channels, and indeed insulin secretion, is controlled by glucose oxidation, we investigated whether somatostatin inhibits insulin secretion by direct effects on glucose metabolism. Oxidative metabolism in beta-cells was monitored by measuring changes in the O2 consumption (DeltaO2) of isolated mouse islets and MIN6 cells, a murine-derived beta-cell line. In both models, glucose-stimulated DeltaO2, an effect closely associated with inhibition of KATP channel activity and induction of electrical activity (r > 0.98). At 100 nm, somatostatin abolished glucose-stimulated DeltaO2 in mouse islets (n = 5, P < 0.05) and inhibited it by 80 +/- 28% (n = 17, P < 0.01) in MIN6 cells. Removal of extracellular Ca2+, 5 mm Co2+, or 20 microm nifedipine, conditions that inhibit voltage-gated Ca2+ influx, did not mimic but either blocked or reduced the effect of the peptide on DeltaO2. The nutrient secretagogues, methylpyruvate (10 mm) and alpha-ketoisocaproate (20 mm), also stimulated DeltaO2, but this was unaffected by somatostatin. Somatostatin also reversed glucose-induced hyperpolarization of the mitochondrial membrane potential monitored using rhodamine-123. Application of somatostatin receptor selective agonists demonstrated that the peptide worked through activation of the type 5 somatostatin receptor. In conclusion, somatostatin inhibits glucose metabolism in murine beta-cells by an unidentified Ca2+-dependent mechanism. This represents a new signaling pathway by which somatostatin can inhibit cellular functions regulated by glucose metabolism.