Using the nominal group technique to involve young people in an evidence synthesis which explored 'risk' in inpatient mental healthcare

Background In this paper we demonstrate how our application of the nominal group technique was used as a method of involving young people with previous experience of using inpatient mental health services in an evidence synthesis. Methods Nominal group technique is an approach to group decision-making that places weight on all participants having an equal opportunity to express a view, and to influence decisions which are made. It is an effective way to enable people who might otherwise be excluded from decision-making to contribute. Results In this study, the focus of the evidence synthesis was significantly shaped following using the nominal group technique in our stakeholder advisory group meeting. The young people present in the group invited the research group to think differently about which ‘risks’ were important, to consider how young people conceptualised risk differently, focussing on risks with long term impact and quality of life implications, rather than immediate clinical risks. Conclusions Using the nominal group technique with young people did offer a method of promoting the equality of decision making within a stakeholder advisory group to an evidence synthesis project, but care needs to be taken to invite sufficient young people to attend so they can be proportionally represented

Adjunctive rifampicin for Staphylococcus aureus bacteraemia (ARREST): a multicentre, randomised, double-blind, placebo-controlled trial.

BACKGROUND: Staphylococcus aureus bacteraemia is a common cause of severe community-acquired and hospital-acquired infection worldwide. We tested the hypothesis that adjunctive rifampicin would reduce bacteriologically confirmed treatment failure or disease recurrence, or death, by enhancing early S aureus killing, sterilising infected foci and blood faster, and reducing risks of dissemination and metastatic infection. METHODS: In this multicentre, randomised, double-blind, placebo-controlled trial, adults (≥18 years) with S aureus bacteraemia who had received ≤96 h of active antibiotic therapy were recruited from 29 UK hospitals. Patients were randomly assigned (1:1) via a computer-generated sequential randomisation list to receive 2 weeks of adjunctive rifampicin (600 mg or 900 mg per day according to weight, oral or intravenous) versus identical placebo, together with standard antibiotic therapy. Randomisation was stratified by centre. Patients, investigators, and those caring for the patients were masked to group allocation. The primary outcome was time to bacteriologically confirmed treatment failure or disease recurrence, or death (all-cause), from randomisation to 12 weeks, adjudicated by an independent review committee masked to the treatment. Analysis was intention to treat. This trial was registered, number ISRCTN37666216, and is closed to new participants. FINDINGS: Between Dec 10, 2012, and Oct 25, 2016, 758 eligible participants were randomly assigned: 370 to rifampicin and 388 to placebo. 485 (64%) participants had community-acquired S aureus infections, and 132 (17%) had nosocomial S aureus infections. 47 (6%) had meticillin-resistant infections. 301 (40%) participants had an initial deep infection focus. Standard antibiotics were given for 29 (IQR 18-45) days; 619 (82%) participants received flucloxacillin. By week 12, 62 (17%) of participants who received rifampicin versus 71 (18%) who received placebo experienced treatment failure or disease recurrence, or died (absolute risk difference -1·4%, 95% CI -7·0 to 4·3; hazard ratio 0·96, 0·68-1·35, p=0·81). From randomisation to 12 weeks, no evidence of differences in serious (p=0·17) or grade 3-4 (p=0·36) adverse events were observed; however, 63 (17%) participants in the rifampicin group versus 39 (10%) in the placebo group had antibiotic or trial drug-modifying adverse events (p=0·004), and 24 (6%) versus six (2%) had drug interactions (p=0·0005). INTERPRETATION: Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S aureus bacteraemia. FUNDING: UK National Institute for Health Research Health Technology Assessment

Issues affecting trans* young people:considerations for mental health nurses

Trans* is an umbrella term that is used to describe a wide range of individuals who identify with a gender that is different from their assigned sex at birth. Many young trans* people are being referred to gender identity services and/or child and adolescent mental health services (CAMHS) with gender dysphoria and coexisting mental health issues such as depression, anxiety, suicidal ideation and self-harm. This group of young people are at risk of experiencing various challenges, such as stigma, discrimination and lack of understanding from their families, wider communities, educational institutions and healthcare services.This article discusses the growing body of research and best practice guidelines related to the mental health and social needs of young people identifying as trans*. It aims to support mental health nurses to enhance their knowledge and awareness of the unique needs of these young people. It may also provide useful information to parents and/or carers, education providers, policymakers and mental health practitioners

An evidence synthesis of risk identification, assessment and management for young people using tier 4 inpatient child and adolescent mental health services

Background Inpatient child and adolescent mental health services are one part of a complex system, and exist to meet the needs of young people with the greatest mental health difficulties. Objectives The research question was ‘What is known about the identification, assessment and management of risk (where “risk” is broadly conceived) in young people (aged 11–18 years) with complex mental health needs entering, using and exiting inpatient child and adolescent mental health services in the UK?’ Data sources The two-phase Evidence for Policy and Practice Information and Co-ordinating Centre approach was used. In phase 1, scoping searches were made using two databases with an end date of March 2013. Phase 2 centred on the search for citations relating to the risks to young people of ‘dislocation’ and ‘contagion’. Searches were made using 17 databases, with time limits from 1995 to September 2013. Websites were searched, a call for evidence circulated and references of included citations reviewed. Review methods Priority risk areas for phase 2 were decided in collaboration with stakeholders including through consultations with young people and the mother of a child who had been in hospital. All types of evidence relating to outcomes, views and experiences, costs and cost-effectiveness, policies, and service and practice responses in the areas of ‘dislocation’ and ‘contagion’ for young people (11–18 years) using inpatient mental health services were considered. A staged approach to screening was used. Data were extracted into tables following guidance from the Centre for Reviews and Dissemination or tables developed for the review. Quality was assessed using appraisal checklists from the Effective Public Health Practice Project or the Critical Skills Appraisal Programme or devised by previous reviewers. No papers were excluded on the grounds of quality, and all materials identified were narratively synthesised. Results In phase 1, 4539 citations were found and 124 included. Most were concerned with clinical risks. In phase 2, 15,662 citations were found and 40 addressing the less obvious risks of ‘dislocation’ and ‘contagion’ were included, supplemented by 20 policy and guidance documents. These were synthesised using these categories: Dislocation: Normal Life; Dislocation: Identity; Dislocation: Friends; Dislocation: Stigma; Dislocation: Education; Dislocation: Families; and Contagion. No studies included an economic analysis or economic evaluation. The importance to stakeholders of these less obvious risks contrasted with the limited quantity and quality of research capable of informing policy, services and practice in these areas. Limitations Included studies were of variable quality. Data derived could not be used to inform an economic modelling of NHS costs or to analyse cost-effectiveness. Other limitations were the search for only English-language materials and the use of umbrella concepts (‘dislocation’ and ‘contagion’). Conclusions The less obvious risks are important, but little evidence exists to support their identification, assessment and management. This has implications for services, and a programme of research is recommended to generate new knowledge. Funding The National Institute for Health Research Health Services and Delivery Research programme

A study protocol: the role of relational orientation in the relationship between social media use and mental health in adolescents

There is a complex relationship between social media use and mental health outcomes. To explore this complexity and understand how social media influence adolescent mental health, a two-phase, explanatory sequential mixed-method study will be conducted. Firstly, the quantitative phase will involve surveying a healthy sample of 400 adolescents attending secondary schools in the UK (n=200) and Turkey (n=200). We will use the survey to investigate the moderating effect of relational orientation in a cross-sectional study, in which participants will be selected from secondary schools in England or the United Kingdom and in Turkey. Secondly, the qualitative phase will involve interviewing a mixed sample of 12 clinical and non-clinical adolescents in England or the UK. In these interviews we will explore key quantitative findings in more detail, for example, how and why adolescents use social media, and the role of social media in the development and maintenance of mental health well-being. The strengths and limitations of the study proposal have been discussed

The influence of personality disorder on outcome in adolescent self-harm

Background: Little is currently known about the presence and impact of personality disorder in adolescents who self-harm. Aims: To evaluate personality disorder in repeated self-harm in adolescence and its impact on self-harm psychopathology and adaptation outcomes over 1 year. Method: A clinical referral sample (n = 366) of adolescents presenting with repeated self-harm aged 12–17 years, as part of a randomised controlled trial (Assessment of Treatment in Suicidal Teenagers study, ASSIST). Personality disorder was assessed using the Structured Clinical Interview for DSM-IV Axis II (SCID-II). One-year outcomes included frequency and severity of repeat self-harm, self-reported suicidality, mood and functional impairment. Results: About 60% of the referred adolescents showed one or more forms of personality disorder. Personality disorder was associated with significantly greater severity of self-harm, overall psychopathology and impairment. There was a complex association with treatment adherence. Personality disorder predicted worse 1-year outcomes in relation to self-harm frequency and severity, as well as impairment, suicidality and depressive symptoms. Conclusions: Personality disorder can be reliably measured in adolescence and showed high prevalence in this clinical self-harm sample. Controlling for other variables, it showed a strong independent association with self-harm severity at referral and predicted adherence to treatment and clinical outcomes (independent of treatment) over 1 year. Consideration of personality disorder diagnosis is indicated in the assessment and management of adolescents who repeatedly self-harm

Group therapy for repeated deliberate self-harm in adolescents: Failure of replication of a randomized trial

Objective: To replicate a study, which found group therapy superior to routine care in preventing the recurrence of self-harming behavior in adolescents who had deliberately harmed themselves on at least two occasions. Method: Single blind study with parallel randomized groups undertaken in three sites in Australia. The primary outcome measure was repetition of self-harm, assessed on average after 6 and 12 months. Secondary outcome measures included suicidal ideation, psychiatric disorder, and service use. Results: Seventy-two adolescents aged 12 to 16 years (91% female subjects) were randomized to group therapy or routine care. Primary outcome data were available for 68 of the 72 randomized participants. More adolescents randomized to group therapy than those randomized to routine care had self-harmed by 6 months (30/34 versus 23/34, chi(2) = 4.19, p = .04), and there was a statistically nonsignificant trend for this pattern to be repeated in the interval of 6 to 12 months (30/34 versus 24/34, chi(2) = 3.24, p = .07). There were few differences between the treatment groups on secondary outcome measures, other than a trend for greater improvement over time on global symptom ratings among the experimental group compared with the control group. Conclusions: Our findings contradict those of the original study. Some differences in participant characteristics between the studies, along with less experience at the Australian sites in delivering the intervention, may have accounted for the different outcome. The benefit of group therapy for deliberate self-harm is unproven outside the environment in which it was originally developed. J. Am. Acad. Child Addlesc. Psychiatry, 2009;48(6):662-670

The haemotoxicity of mitomycin in a repeat dose study in the female CD-1 mouse

Mitomycin (MMC), like many antineoplastic drugs, induces a predictable, dose-related, bone marrow depression in man and laboratory animals; this change is generally reversible. However, there is evidence that MMC may also cause a late-stage or residual bone marrow injury. The present study in female CD-1 mice investigated the haematological and bone marrow changes induced by MMC in a repeat dose study lasting 50 days. Control and MMC-treated mice were dosed intraperitoneally on eight occasions over 18 days with vehicle, or MMC at 2.5 mg/kg, autopsied (n = 6–12) at 1, 7, 14, 28, 42 and 50 days after the final dose and haematological changes investigated. Femoral nucleated bone marrow cell counts and levels of apoptosis were also evaluated and clonogenic assays carried out; serum levels of FLT3 ligand (FL) were assessed. At day 1 post-dosing, MMC induced significant reductions in RBC, Hb and haematocrit (HCT) values, and there were decreases in reticulocyte, platelet, and femoral nucleated cell counts (FNCC); neutrophil, lymphocyte and monocyte values were also significantly reduced. On days 7 and 14 post-dosing, all haematological parameters showed evidence of a return towards normal values, but at these times, and at day 28, values for RBC and FNCC remained significantly reduced in comparison with controls. At days 42 and 50 post-dosing, many haematological parameters in MMC-treated mice had returned to control levels; however, there remained evidence of late-stage effects on RBC, Hb and HCT values, and FNCC also continued to be significantly decreased. Results for granulocyte-macrophage colony-forming units and erythroid colonies showed a profound decrease immediately post-dosing, but a return to normal values was evident at day 50. Serum FL concentrations demonstrated very significant increases in the immediate post-dosing period, but a return to normal was seen at day 50 post-dosing; a relatively similar pattern was seen in the number of apoptotic femoral marrow nucleated cells. The histopathological examination of kidney tissues from MMC animals at day 42 and 50 post-dosing showed evidence of hydronephrosis with cortical glomerular/tubular atrophy and degeneration. It is therefore concluded that MMC administered on eight occasions over 18 days to female CD-1 mice at 2.5 mg/kg induced profound changes in haematological and bone marrow parameters in the immediate post-dosing period with a return to normal levels at day 50 post-dosing; however, there was evidence of mild but significant late-stage/residual effects on RBC and FNCC, and on cells of the erythroid lineage in the bone marrow