The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis.

BACKGROUND: Child maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems. OBJECTIVES: To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment. STUDY DESIGN: For effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views. PARTICIPANTS: Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months. INTERVENTIONS: Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment. MAIN OUTCOME MEASURES: Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability. METHODS: Young Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible. RESULTS: We identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive-behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) -0.44 (95% CI -4.43 to -1.53)], depression [mean difference -2.83 (95% CI -4.53 to -1.13)] and anxiety [SMD -0.23 (95% CI -0.03 to -0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist-child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself. CONCLUSIONS: It is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions. LIMITATIONS: Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses. FUTURE WORK: Studies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013003889. FUNDING: The National Institute for Health Research Health Technology Assessment programme

Preventing Domestic Abuse for Children and Young People (PEACH): A Mixed Knowledge Scoping Review

Background: A range of interventions that aim to prevent domestic abuse has been developed for children and young people in the general population. While these have been widely implemented, few have been rigorously evaluated. This study aimed to discover what was known about these interventions for children and what worked for whom in which settings. Review methods: This mixed knowledge review was informed by realist principles and comprised four overlapping phases: an online mapping survey to identify current provision; a systematic review of the existing literature; a review of the UK ‘grey’ literature; and consultation with young people and experts. Information from these four sources of evidence informed analysis of costs and benefits. Results: The evidence for interventions achieving changes in knowledge and attitudes was stronger than that for behavioural change. Shifting social norms in the peer group emerged as a key mechanism of change. Media campaigns act to influence the wider social climate within which more targeted interventions are received, and they are also a source for programme materials. While most interventions are delivered in secondary schools, they are increasingly targeted at younger children. The review emphasised the importance of a school’s ‘readiness’ to introduce preventative interventions which need to be supported across all aspects of school life. Involving young people in the design and delivery of programmes increases authenticity and this emerged as a key ingredient in achieving impact. Longer interventions delivered by appropriately trained staff appeared likely to be more effective. Teachers emerged as well placed to embed interventions in schools but they require training and support from those with specialist knowledge in domestic abuse. There was evidence that small groups of students who were at higher risk might have accounted for some results regarding effectiveness and that programme effectiveness may vary for certain subgroups. Increasingly, boys are being identified as a target for change. The study identified a need for interventions for disabled children and children and young people from black, Asian, minority ethnic and refugee groups and a particular lack of materials designed for lesbian, gay, bisexual and transgender young people. Limitations: Very little evidence was identified on costs and cost-effectiveness. Few studies showed an effect at the level of significance set for the review. Where it did exist, the effect size was small, except in respect of improved knowledge. The inability to calculate a response rate for the mapping survey, which used a snowballing approach, limits the ability to generalise from it. Conclusions: While it is appropriate to continue to deliver interventions to whole populations of children and young people, effectiveness appeared to be influenced by high-risk children and young people, who should be directed to additional support. Programmes also need to make provision to manage any resulting disclosures. Interventions appear to be context specific, and so those already being widely delivered in the UK and which are likely to be acceptable should be robustly tested. Funding: The National Institute for Health Research Public Health Research programme

Aspirin for prophylactic use in the primary prevention of cardiovascular disease and cancer : a systematic review and overview of reviews

Background: Prophylactic aspirin has been considered to be beneficial in reducing the risks of heart disease and cancer. However, potential benefits must be balanced against the possible harm from side effects, such as bleeding and gastrointestinal (GI) symptoms. It is particularly important to know the risk of side effects when aspirin is used as primary prevention - that is when used by people as yet free of, but at risk of developing, cardiovascular disease (CVD) or cancer. In this report we aim to identify and re-analyse randomised controlled trials (RCTs), systematic reviews and meta-analyses to summarise the current scientific evidence with a focus on possible harms of prophylactic aspirin in primary prevention of CVD and cancer. Objectives: To identify RCTs, systematic reviews and meta-analyses of RCTs of the prophylactic use of aspirin in primary prevention of CVD or cancer. To undertake a quality assessment of identified systematic reviews and meta-analyses using meta-analysis to investigate study-level effects on estimates of benefits and risks of adverse events; cumulative meta-analysis; exploratory multivariable meta-regression; and to quantify relative and absolute risks and benefits. Methods: We identified RCTs, meta-analyses and systematic reviews, and searched electronic bibliographic databases (from 2008 September 2012) including MEDLINE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, NHS Centre for Reviews and Dissemination, and Science Citation Index. We limited searches to publications since 2008, based on timing of the most recent comprehensive systematic reviews. Results: In total, 2572 potentially relevant papers were identified and 27 met the inclusion criteria. Benefits of aspirin ranged from 6% reduction in relative risk (RR) for all-cause mortality [RR 0.94, 95% confidence interval (CI) 0.88 to 1.00] and 10% reduction in major cardiovascular events (MCEs) (RR 0.90, 95% CI 0.85 to 0.96) to a reduction in total coronary heart disease (CHD) of 15% (RR 0.85, 95% CI 0.69 to 1.06). Reported pooled odds ratios (ORs) for total cancer mortality ranged between 0.76 (95% CI 0.66 to 0.88) and 0.93 (95% CI 0.84 to 1.03). Inclusion of the Women's Health Study changed the estimated OR to 0.82 (95% CI 0.69 to 0.97). Aspirin reduced reported colorectal cancer (CRC) incidence (OR 0.66, 95% CI 0.90 to 1.02). However, including studies in which aspirin was given every other day raised the OR to 0.91 (95% CI 0.74 to 1.11). Reported cancer benefits appeared approximately 5 years from start of treatment. Calculation of absolute effects per 100,000 patient-years of follow-up showed reductions ranging from 33 to 46 deaths (all-cause mortality), 60-84 MCEs and 47-64 incidents of CHD and a possible avoidance of 34 deaths from CRC. Reported increased RRs of adverse events from aspirin use were 37% for GI bleeding (RR 1.37, 95% CI 1.15 to 1.62), between 54% (RR 1.54, 95% CI 1.30 to 1.82) and 62% (RR 1.62, 95% CI 1.31 to 2.00) for major bleeds, and between 32% (RR 1.32, 95% CI 1.00 to 1.74) and 38% (RR 1.38, 95% CI 1.01 to 1.82) for haemorrhagic stroke. Pooled estimates of increased RR for bleeding remained stable across trials conducted over several decades. Estimates of absolute rates of harm from aspirin use, per 100,000 patient-years of follow-up, were 99-178 for non-trivial bleeds, 46-49 for major bleeds, 68-117 for GI bleeds and 8-10 for haemorrhagic stroke. Meta-analyses aimed at judging risk of bleed according to sex and in individuals with diabetes were insufficiently powered for firm conclusions to be drawn. Limitations: Searches were date limited to 2008 because of the intense interest that this subject has generated and the cataloguing of all primary research in so many previous systematic reviews. A further limitation was our potential over-reliance on study-level systematic reviews in which the person-years of follow-up were not accurately ascertainable. However, estimates of number of events averted or incurred through aspirin use calculated from data in study-level meta-analyses did not differ substantially from estimates based on individual patient data-level meta-analyses, for which person-years of follow-up were more accurate (although based on less-than-complete assemblies of currently available primary studies). Conclusions: We have found that there is a fine balance between benefits and risks from regular aspirin use in primary prevention of CVD. Effects on cancer prevention have a long lead time and are at present reliant on post hoc analyses. All absolute effects are relatively small compared with the burden of these diseases. Several potentially relevant ongoing trials will be completed between 2013 and 2019, which may clarify the extent of benefit of aspirin in reducing cancer incidence and mortality. Future research considerations include expanding the use of IPD meta-analysis of RCTs by pooling data from available studies and investigating the impact of different dose regimens on cardiovascular and cancer outcomes

Study Protocol for Investigating Physician Communication Behaviours that Link Physician Implicit Racial Bias and Patient Outcomes in Black Patients with Type 2 Diabetes Using an Exploratory Sequential Mixed Methods Design

Introduction Patient-physician racial discordance is associated with Black patient reports of dissatisfaction and mistrust, which in turn are associated with poor adherence to treatment recommendations and underutilisation of healthcare. Research further has shown that patient dissatisfaction and mistrust are magnified particularly when physicians hold high levels of implicit racial bias. This suggests that physician implicit racial bias manifests in their communication behaviours during medical interactions. The overall goal of this research is to identify physician communication behaviours that link physician implicit racial bias and Black patient immediate (patient-reported satisfaction and trust) and long-term outcomes (eg, medication adherence, self-management and healthcare utilisation) as well as clinical indicators of diabetes control (eg, blood pressure, HbA1c and history of diabetes complication). Methods and analysis Using an exploratory sequential mixed methods research design, we will collect data from approximately 30 family medicine physicians and 300 Black patients with type 2 diabetes mellitus. The data sources will include one physician survey, three patient surveys, medical interaction videos, video elicitation interviews and medical chart reviews. Physician implicit racial bias will be assessed with the physician survey, and patient outcomes will be assessed with the patient surveys and medical chart reviews. In video elicitation interviews, a subset of patients (approximately 20–40) will watch their own interactions while being monitored physiologically to identify evocative physician behaviours. Information from the interview will determine which physician communication behaviours will be coded from medical interactions videos. Coding will be done independently by two trained coders. A series of statistical analyses (zero-order correlations, partial correlations, regressions) will be conducted to identify physician behaviours that are associated significantly with both physician implicit racial bias and patient outcomes

Italian social psychiatry research: What gets published in peer reviewed journals?

Publisher version: http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8264025&fulltextType=RA&fileId=S1121189X0000231

A Conversation with Eugenio Regazzini

Eugenio Regazzini was born on August 12, 1946 in Cremona (Italy), and took his degree in 1969 at the University "L. Bocconi" of Milano. He has held positions at the universities of Torino, Bologna and Milano, and at the University "L. Bocconi" as assistant professor and lecturer from 1974 to 1980, and then professor since 1980. He is currently professor in probability and mathematical statistics at the University of Pavia. In the periods 1989-2001 and 2006-2009 he was head of the Institute for Applications of Mathematics and Computer Science of the Italian National Research Council (C.N.R.) in Milano and head of the Department of Mathematics at the University of Pavia, respectively. For twelve years between 1989 and 2006, he served as a member of the Scientific Board of the Italian Mathematical Union (U.M.I.). In 2007, he was elected Fellow of the IMS and, in 2001, Fellow of the "Istituto Lombardo---Accademia di Scienze e Lettere." His research activity in probability and statistics has covered a wide spectrum of topics, including finitely additive probabilities, foundations of the Bayesian paradigm, exchangeability and partial exchangeability, distribution of functionals of random probability measures, stochastic integration, history of probability and statistics. Overall, he has been one of the most authoritative developers of de Finetti's legacy. In the last five years, he has extended his scientific interests to probabilistic methods in mathematical physics; in particular, he has studied the asymptotic behavior of the solutions of equations, which are of interest for the kinetic theory of gases. The present interview was taken in occasion of his 65th birthday.Comment: Published in at http://dx.doi.org/10.1214/11-STS362 the Statistical Science (http://www.imstat.org/sts/) by the Institute of Mathematical Statistics (http://www.imstat.org

Epuraea imperialis (Reitter, 1877). New invasive species of Nitidulidae (Coleoptera) in Europe, with a checklist of sap beetles introduced to Europe and Mediterranean areas

Australian species Epuraea imperialis (Reitter, 1877), previously introduced to New Zealand, is recorded as a new invasive species from the Canary Islands, Continental Spain, Portugal, France, Belgium, and Italy. It is redescribed and figured, and its taxonomic position in the genus Epuraea Erichson, 1843 is discussed. A tentative checklist of sap beetles introduced to Europe and the Mediterranean areas is finally included