Outcomes among youth attending inpatient treatment for co-occurring disorders

AIM

An emerging body of research is identifying effective outpatient integrated treatment approaches for youth with co-occurring psychiatric and substance use disorders, though few studies exist examining inpatient treatment. The current study aimed to address this gap by examining response to treatment during admission to, and in the year following discharge from, a specialized inpatient program for youth with co-occurring disorders.

METHODS

A single-cohort longitudinal design examined change in adaptive functioning, mental health symptoms, and substance use frequency among N = 142 youth (69.1% female) aged 14-21 (M = 16.9, SD = 1.5) attending the program. Participants completed self-report measures at admission, discharge, and 1-, 6- and 12-months post-discharge.

RESULTS

Analyses indicated significant improvements in adaptive functioning, internalizing and externalizing symptoms, and substance use frequency during admission. There was some loss of gains in adaptive functioning over the 12-months post-discharge. Improvements were maintained in internalizing symptoms and substance use frequency, and improvements in externalizing symptoms continued over the 12-months post-discharge. There was no significant interaction between change in functioning and internalizing symptoms at admission or type of substance use disorder diagnosis. There was a significant interaction with externalizing symptoms, such that those with clinically significant levels of externalizing symptoms at admission experienced greater improvement in functioning, though the groups ended treatment with comparable functioning scores.

CONCLUSIONS

The results provide preliminary support for integrated treatment for co-occurring disorders delivered in an inpatient setting. However, the results also reflect the significant needs of youth with co-occurring disorders and the importance of ongoing care post-discharge from intensive treatment settings.

Economic evaluations of treatment of depressive disorders in adolescents: Protocol for a scoping review

AIM

Depressive disorders in adolescents are common and impairing. Evidence-based treatments are available; however, at a cost. In the context of the COVID-19 pandemic, we anticipate increased demand for treatment services for adolescents with depression. We also anticipate that economic resources will be strained. Identifying cost-effective strategies to optimally treat depression in adolescents is imperative. This protocol for a scoping review aims to describe the literature with respect to economic evaluations of treatments for depression in adolescents.

METHODS

We will conduct a scoping review using established methods and reporting guidelines. MEDLINE, Embase, PsyclNFO, Econlit, and the International HTA Database will be searched from inception to June 13, 2023, with an update closer to time of manuscript submission, while the NHS Economic Evaluation Database archives will be searched from inception to December 2014. Publications that contain economic evaluations, in the context of a clinical trial or a model-based study, testing a treatment of depression in adolescents will be selected for inclusion. Extracted data items will include: economic evaluation perspectives, health outcome variables and costs used in economic evaluations, types of analyses performed, as well as quality of reporting and methodology.

RESULT

A narrative synthesis with summary tables will be used to describe our findings.

CONCLUSION

Our findings will help identify gaps in the literature with respect to economic analyses for the treatment of depression such that these gaps can be filled with future research. Policy-makers, funders and administrators may also use our findings to inform their decisions around provision of various treatments for depression in adolescents.

REGISTRATION

osf.io/5fteb (note that information on this link will be updated upon acceptance for publication based on reviewer comments).

Development, reach, acceptability and associated clinical changes of a group intervention to improve caregiver-adolescent relationships in the context of adolescent depression

Background

Adolescents with depression often experience relationship problems with their caregivers, which predict poorer treatment outcomes. Personalising interventions by targeting factors associated with poor treatment outcomes may enhance the effectiveness of interventions. We report the development and initial evaluation of an intervention designed to target caregiver-adolescent relationship problems in the context of adolescent depression.

Methods

Following a literature search to identify established caregiver interventions, we developed a new group intervention for caregivers through an iterative process including six rounds of the group with n = 53 caregivers of adolescents age 13-18 in the context of an integrated care pathway for adolescent depression. Caregivers rated their family functioning at the beginning and end of the program and provided anonymous satisfaction ratings. Enrolment and attendance data were examined. Youth with lived experience of depression and their caregivers provided input that was incorporated in the final version of the intervention.

Results

The final intervention consists of 8 weekly, 1.5 h group sessions, delivered face-to-face, addressing: psychoeducation, the cognitive-behavioural model and caregiving, positive caregiving, listening and validation, expressing emotions effectively, and problem solving. Reach (56%), attendance (M = 63%, SD = 31%), and satisfaction (M = 92%; SD = 7%) supported the feasibility of the program. Caregivers reported significant improvements in family functioning, t(21) = 2.68, p = .014, d z = 0.56 [95% CI 0.11-1.0].

Discussion

A group intervention is acceptable to caregivers of adolescents with depression and may be associated with improved family functioning. Further research is needed, including a randomised controlled trial to test effects of the intervention on various dimensions of the caregiver-youth relationship and on youth depression outcomes.

Comparing analytical strategies for balancing site-level characteristics in stepped-wedge cluster randomized trials: a simulation study

BACKGROUND

Stepped-wedge cluster randomized trials (SWCRTs) are a type of cluster-randomized trial in which clusters are randomized to cross-over to the active intervention sequentially at regular intervals during the study period. For SWCRTs, sequential imbalances of cluster-level characteristics across the random sequence of clusters may lead to biased estimation. Our study aims to examine the effects of balancing cluster-level characteristics in SWCRTs.

METHODS

To quantify the level of cluster-level imbalance, a novel imbalance index was developed based on the Spearman correlation and rank regression of the cluster-level characteristic with the cross-over timepoints. A simulation study was conducted to assess the impact of sequential cluster-level imbalances across different scenarios varying the: number of sites (clusters), sample size, number of cross-over timepoints, site-level intra-cluster correlation coefficient (ICC), and effect sizes. SWCRTs assumed either an immediate "constant" treatment effect, or a gradual "learning" treatment effect which increases over time after crossing over to the active intervention. Key performance metrics included the relative root mean square error (RRMSE) and relative mean bias.

RESULTS

Fully-balanced designs almost always had the highest efficiency, as measured by the RRMSE, regardless of the number of sites, ICC, effect size, or sample sizes at each time for SWCRTs with learning effect. A consistent decreasing trend of efficiency was observed by increasing RRMSE as imbalance increased. For example, for a 12-site study with 20 participants per site/timepoint and ICC of 0.10, between the most balanced and least balanced designs, the RRMSE efficiency loss ranged from 52.5% to 191.9%. In addition, the RRMSE was decreased for larger sample sizes, larger number of sites, smaller ICC, and larger effect sizes. The impact of pre-balancing diminished when there was no learning effect.

CONCLUSION

The impact of pre-balancing on preventing efficiency loss was easily observed when there was a learning effect. This suggests benefit of pre-balancing with respect to impacting factors of treatment effects.

Associations over the COVID-19 pandemic period and the mental health and substance use of youth not in employment, education or training in Ontario, Canada: a longitudinal, cohort study

BACKGROUND

The economic shutdown and school closures associated with the COVID-19 pandemic have negatively influenced many young people's educational and training opportunities, leading to an increase in youth not in education, employment, or training (NEET) globally and in Canada. NEET youth have a greater vulnerability to mental health and substance use problems, compared to their counterparts who are in school and/or employed. There is limited evidence on the association between COVID-19 and NEET youth. The objectives of this exploratory study included investigating: longitudinal associations between the COVID-19 pandemic and the mental health and substance use (MHSU) of NEET youth; and MHSU among subgroups of NEET and non-NEET youth.

METHODS

618 youth (14-28 years old) participated in this longitudinal, cohort study. Youth were recruited from four pre-existing studies at the Centre for Addiction and Mental Health. Data on MHSU were collected across 11 time points during the COVID-19 pandemic (April 2020-August 2022). MHSU were measured using the CoRonavIruS Health Impact Survey Youth Self-Report, the Global Appraisal of Individual Needs Short Screener, and the PTSD Checklist for DSM-5. Linear Mixed Models and Generalized Estimating Equations were used to analyze associations of NEET status and time on mental health and substance use. Exploratory analyses were conducted to investigate interactions between sociodemographic characteristics and NEET status and time.

RESULTS

At baseline, NEET youth were significantly more likely to screen positive for an internalizing disorder compared to non-NEET youth (OR = 1.92; 95%CI=[1.26-2.91] p = 0.002). No significant differences were found between youth with, and without, NEET in MHSU symptoms across the study time frame. Youth who had significantly higher odds of screening positive for an internalizing disorder included younger youth (OR = 1.06, 95%CI=[1.00-1.11]); youth who identify as Trans, non-binary or gender diverse (OR = 8.33, 95%CI=[4.17-16.17]); and those living in urban areas (OR = 1.35, 95%CI=[1.03-1.76]), compared to their counterparts. Youth who identify as White had significantly higher odds of screening positive for substance use problems (OR = 2.38, 95%CI=[1.72-3.23]) compared to racialized youth.

CONCLUSIONS

Our findings indicate that sociodemographic factors such as age, gender identity, ethnicity and area of residence impacted youth MHSU symptoms over the course of the study and during the pandemic. Overall, NEET status was not consistently associated with MHSU symptoms over and above these factors. The study contributes to evidence on MHSU symptoms of NEET youth.

Multivariable Prediction Modeling of Antidepressant Initiation in Unipolar Depressed Adolescents: A Secondary Analysis of the IMPACT Trial

Introduction: This secondary analysis of data collected in a randomized controlled trial (RCT) for the treatment of depression in adolescents aimed to test prediction models relating antidepressant (AD) initiation to clinical variables. Methods: The primary study was an RCT where adolescents (ages 11-17) with depression were assigned one of three outpatient psychotherapies over 86 weeks. The current study tested five registered prediction models using data on adolescents not taking ADs at baseline (N = 337). Outcomes of interest included: AD initiation, change in depression severity, and self-injurious thoughts and behaviors (SITBs). Results: Findings from registered analytic strategies were not consistent with our a priori hypotheses; rather we unexpectedly observed a relationship between initiation of AD and increased risk of suicide attempts and suicidal ideation during the same time interval (p > 0.01). Sensitivity analyses found that: (1) higher depressive symptom severity and self-harm each predicted future AD initiation (p < 0.05), and (2) new-onset SITB was associated with AD initiation (p < 0.01). Conclusions: Taken together, our results suggest that depression symptoms severity and SITBs may prompt AD initiation. Researchers may wish to further explore causal pathways relevant to the association ADs between SITBs. Clinicians need to be cognizant of high-quality guideline recommendations when prescribing ADs to adolescents.

A Longitudinal Cohort Study of Youth Mental Health and Substance use Before and During the COVID-19 Pandemic in Ontario, Canada: An Exploratory Analysis

BACKGROUND

Youth mental health appears to have been negatively impacted by the COVID-19 pandemic. The impact on substance use is less clear, as is the impact on subgroups of youth, including those with pre-existing mental health or substance use challenges.

OBJECTIVE

This hypothesis-generating study examines the longitudinal evolution of youth mental health and substance use from before the COVID-19 pandemic to over one year into the pandemic among youth with pre-existing mental health or substance use challenges.

METHOD

A total of 168 youth aged 14-24 participated. Participants provided sociodemographic data, as well as internalizing disorder, externalizing disorder, and substance use data prior to the pandemic's onset, then every two months between April 2020-2021. Linear mixed models and Generalized Estimating Equations were used to analyze the effect of time on mental health and substance use. Exploratory analyses were conducted to examine interactions with sociodemographic and clinical characteristics.

RESULTS

There was no change in internalizing or externalizing disorder scores from prior to the pandemic to any point throughout the first year of the pandemic. Substance use scores during the pandemic declined compared to pre-pandemic scores. Exploratory analyses suggest that students appear to have experienced more mental health repercussions than non-students; other sociodemographic and clinical characteristics did not appear to be associated with mental health or substance use trajectories.

CONCLUSIONS

While mental health remained stable and substance use declined from before the COVID-19 pandemic to during the pandemic among youth with pre-existing mental health challenges, some youth experienced greater challenges than others. Longitudinal monitoring among various population subgroups is crucial to identifying higher risk populations. This information is needed to provide empirical evidence to inform future research directions.

A highly sensitive cell-based luciferase assay for high-throughput automated screening of SARS-CoV-2 nsp5/3CLpro inhibitors

Effective drugs against SARS-CoV-2 are urgently needed to treat severe cases of infection and for prophylactic use. The main viral protease (nsp5 or 3CLpro) represents an attractive and possibly broad-spectrum target for drug development as it is essential to the virus life cycle and highly conserved among betacoronaviruses. Sensitive and efficient high-throughput screening methods are key for drug discovery. Here we report the development of a gain-of-signal, highly sensitive cell-based luciferase assay to monitor SARS-CoV-2 nsp5 activity and show that it is suitable for the screening of compounds in a 384-well format. A benefit of miniaturisation and automation is that screening can be performed in parallel on a wild-type and a catalytically inactive nsp5, which improves the selectivity of the assay. We performed molecular docking-based screening on a set of 14,468 compounds from an in-house chemical database, selected 359 candidate nsp5 inhibitors and tested them experimentally. We identified two molecules which show anti-nsp5 activity, both in our cell-based assay and in vitro on purified nsp5 protein, and inhibit SARS-CoV-2 replication in A549-ACE2 cells with EC₅₀ values in the 4–8 μM range. The here described high-throughput-compatible assay will allow the screening of large-scale compound libraries for SARS-CoV-2 nsp5 inhibitors. Moreover, we provide evidence that this assay can be adapted to other coronaviruses and viruses which rely on a viral protease.

A highly sensitive cell-based luciferase assay for high-throughput automated screening of SARS-CoV-2 nsp5/3CLpro inhibitors

Effective drugs against SARS-CoV-2 are urgently needed to treat severe cases of infection and for prophylactic use. The main viral protease (nsp5 or 3CLpro) represents an attractive and possibly broad-spectrum target for drug development as it is essential to the virus life cycle and highly conserved among betacoronaviruses. Sensitive and efficient high-throughput screening methods are key for drug discovery. Here we report the development of a gain-of-signal, highly sensitive cell-based luciferase assay to monitor SARS-CoV-2 nsp5 activity and show that it is suitable for high-throughput screening of compounds in a 384-well format. A benefit of miniaturisation and automation is that screening can be performed in parallel on a wild-type and a catalytically inactive nsp5, which improves the selectivity of the assay. We performed molecular docking-based screening on a set of 14,468 compounds from an in-house chemical database, selected 359 candidate nsp5 inhibitors and tested them experimentally. We identified four molecules, including the broad-spectrum antiviral merimepodib/VX-497, which show anti-nsp5 activity and inhibit SARS-CoV-2 replication in A549-ACE2 cells with IC 50 values in the 4-21 µM range. The here described assay will allow the screening of large-scale compound libraries for SARS-CoV-2 nsp5 inhibitors. Moreover, we provide evidence that this assay can be adapted to other coronaviruses and viruses which rely on a viral protease.

Youth in a pandemic: a longitudinal examination of youth mental health and substance use concerns during COVID-19

OBJECTIVE

This study analyses longitudinal data to understand how youth mental health and substance use are evolving over the course of the COVID-19 pandemic, which is critical to adjusting mental health response strategies.

SETTING

Participants were recruited from among existing participants in studies conducted in an urban academic hospital in Ontario, Canada.

PARTICIPANTS

A total of 619 youth aged 14-28 years participated in the study (62.7% girls/young women; 61.4% Caucasian).

MEASURES

Data on mood, substance use and COVID-19-related worries were collected over four time points, that is, every 2 months beginning in the early stages of the pandemic in April 2020. Latent class analyses were conducted on the longitudinal data to identify distinct groups of youth who have different trajectory profiles of pandemic impact on their mood, substance use and COVID-19-related worries.

RESULTS

For the majority of participants, mood concerns increased early in the pandemic, declined over Canada's summer months and subsequently increased in autumn. Among the youth with the highest level of mood symptoms at the beginning of the pandemic, increases in mental health concerns were sustained. Substance use remained relatively stable over the course of the pandemic. COVID-19-related worries, however, followed a trajectory similar to that of mood symptoms. Girls/young women, youth living in urban or suburban areas, in larger households, and with poorer baseline mental and physical health are the most vulnerable to mental health concerns and worries during the pandemic.

CONCLUSIONS

Youth mental health symptom levels and concerns are evolving over the course of the COVID-19 pandemic, in line with the evolution of the pandemic itself, and longitudinal monitoring is therefore required. It is also essential that we engage directly with youth to cocreate pandemic response strategies and mental health service adaptations to best meet the needs of young people.

Impacts of COVID-19 on Youth Mental Health, Substance Use, and Well-being: A Rapid Survey of Clinical and Community Samples: Répercussions de la COVID-19 sur la santé mentale, l'utilisation de substances et le bien-être des adolescents : un sondage rapide d'échantillons cliniques et communautaires

OBJECTIVES

The current novel coronavirus disease of 2019 (COVID-19) pandemic presents a time-sensitive opportunity to rapidly enhance our knowledge about the impacts of public health crises on youth mental health, substance use, and well-being. This study examines youth mental health and substance use during the pandemic period.

METHODS

A cross-sectional survey was conducted with 622 youth participants across existing clinical and community cohorts. Using the National Institute of Mental Health-developed CRISIS tool and other measures, participants reported on the impacts of COVID-19 on their mental health, substance use, and other constructs.

RESULTS

Reports of prepandemic mental health compared to intrapandemic mental health show a statistically significant deterioration of mental health across clinical and community samples (P < 0.001), with greater deterioration in the community sample. A total of 68.4% of youth in the clinical sample and 39.9% in the community sample met screening criteria for an internalizing disorder. Substance use declined in both clinical and community samples (P < 0.001), although 23.2% of youth in the clinical sample and 3.0% in the community sample met screening criteria for a substance use disorder. Participants across samples report substantial mental health service disruptions (48.7% and 10.8%) and unmet support needs (44.1% and 16.2%). Participants report some positive impacts, are using a variety of coping strategies to manage their wellness, and shared a variety of ideas of strategies to support youth during the pandemic.

CONCLUSIONS

Among youth with histories of mental health concerns, the pandemic context poses a significant risk for exacerbation of need. In addition, youth may experience the onset of new difficulties. We call on service planners to attend to youth mental health during COVID-19 by bolstering the accessibility of services. Moreover, there is an urgent need to engage young people as coresearchers to understand and address the impacts of the pandemic and the short, medium, and long terms.

A Way through the woods: Development of an integrated care pathway for adolescents with depression

AIMS

Depression in adolescents is common and debilitating. Treatment approaches vary widely across clinics and may not reflect evidence-based care. Integrated care pathways (ICPs) are implementation tools to facilitate bridging the gap between rigorous but often complex clinical practice guidelines and what is actually practiced. We describe the development of an ICP for the treatment of Adolescents with Major Depressive Disorder (MDD-A) based on the best-available clinical practice guidelines and derived in collaboration with clinicians, administrators, youth partners and caregivers.

METHODS

With clinician and health service manager input, we took the recommendations from a high quality clinical practice guideline (the National Institute of Health and Care Excellence Clinical Practice Guideline for Depression in Children and Young People) and translated them into an ICP. Feedback from youth partners and clinicians was iteratively incorporated into the current version of the pathway using a collaborative approach.

RESULTS

The current iteration of the pathway at a Canadian tertiary care teaching hospital is described. All youth (and caregivers, if applicable) are offered a multi-family psychoeducation session, a 16-session Group Cognitive Behaviour Therapy and team reviews every 4 weeks that include measurement-based care. Conditional branches of the pathway include a medication algorithm and an 8-session group for caregivers.

CONCLUSIONS

The resulting ICP provides a tool to facilitate bridging the gap between evidence and clinical practice.

How have predictors, moderators, mediators, treatment response, remission and resistance been defined and measured in randomised controlled trials for adolescent depression? A scoping review protocol

INTRODUCTION

Among randomised controlled trials for depressed adolescents, the extent of variation in how depressive symptom outcomes are defined is unknown. The variability in which potential predictors of these outcomes are tested is also unclear. This paper is a protocol describing the methods of a planned scoping review. The scoping review will examine and summarise how change in depressive symptoms have been described in RCT treatment studies to date. This review will report the measures used to describe change in depressive symptoms and whether the measure was used as a continuous or binary outcome or both. This review will describe how dichotomous outcome terms are defined to describe change in depression severity. This review will also examine predictors, moderators and mediators of change in depressive symptoms within RCTs.

METHODS AND ANALYSIS

In this paper, we describe the protocol for our scoping review. Following the format outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews, a research librarian will develop an operationalised search strategy, which we will apply to the MEDLINE, Embase, PsycINFO and Cumulative Index to Nursing and Allied Health Literature databases. We will search for papers from inception to 6 February 2020. A hand search for key citations will also be conducted. Investigator-raters will screen articles, first via the titles and abstracts and then through full-text reviews. We will include articles with randomised control design which assess the treatment of adolescents with major depressive disorder. We will systematically extract and synthesise prespecified data which includes: definition of depression used for participant inclusion, measures used to evaluate changes in depression, type of outcome used (continuous, binary or both), definitions of dichotomous terms to denote change in depression (eg, response, remission, recovery, etc) and reported predictors/moderators/mediators of change.

ETHICS AND DISSEMINATION

Ethics approval is not required. Findings will be presented in journal publications and at conferences.

Mobile and wearable technology for monitoring depressive symptoms in children and adolescents: A scoping review

BACKGROUND

There has been rapid growth of mobile and wearable tools that may help to overcome challenges in the diagnosis and prediction of Major Depressive Disorder in children and adolescents, tasks that rely on clinical reporting that is inherently based on retrospective recall of symptoms and associated features. This article reviews more objective ways of measuring and monitoring mood within this population.

METHODS

A scoping review of peer-reviewed studies examined published research that employs mobile and wearable tools to characterize depression in children and/or adolescents. Our search strategy included the following terms: (1) monitoring or prediction (2) depression (3) mobile apps or wearables and (4) children and youth (including adolescents), and was applied to five databases.

RESULTS

Our search produced 829 citations (2008- Feb 2019), of which 30 (journal articles, conference papers and abstracts) were included in the analysis, and 2 reviews included in our discussion. The majority of the evidence involved smartphone apps, with very few studies using actigraphy. Mobile and wearables captured a variety of data including unobtrusive passive analytics, movement and light data, plus physical and mental health data, including depressive symptom monitoring. Most studies also examined feasibility.

LIMITATIONS

This review was limited to published research in the English language. The review criteria excluded any apps that were mainly treatment focused, therefore there was not much of a focus on clinical outcomes.

CONCLUSIONS

This scoping review yielded a variety of studies with heterogeneous populations, research methods and study objectives, which limited our ability to address our research objectives cohesively. Certain mobile technologies, however, have demonstrated feasibility for tracking depression that could inform models for predicting relapse.

An appraisal of the trustworthiness of practice guidelines for depression and anxiety in children and youth

OBJECTIVE

Little is known about the trustworthiness of clinical practice guidelines (PGs) relevant to child and youth depression or anxiety. To address this gap, we used systematic review methods to identify all available relevant PGs, quality appraise them, and make recommendations regarding which PGs are trustworthy and should be used by clinicians.

METHODS

Prespecified inclusion criteria identified eligible PGs. Two independent trained reviewers applied the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Using three AGREE II domain scores (stakeholder involvement, rigor of development [clinical validity/trustworthiness], and editorial independence), PG quality was designated as (1) minimum (≥50%) and (2) high (≥70%).

RESULTS

Of 25 eligible PGs, five met minimum quality criteria (depression, n = 4; anxiety, n = 1); three out of five met high-quality criteria (depression, n = 2; anxiety, n = 1). Among the five minimum quality PGs, developers included government (n = 2), independent expert groups (n = 2), and other (n = 1). No PGs developed by specialty societies achieved minimum or high-quality ratings; eight of 25 PGs were up-to-date.

CONCLUSIONS

Trustworthy PGs are available to support clinical decisions about depression and anxiety in children and youth, but are few in number. Many existing PGs (up to 80%) may not be clinically valid. Clinicians who implement the high-quality PGs identified here can increase the number of children and youth who receive effective interventions for depression and anxiety, minimize harm, and avoid wasted resources. Clinicians, service planners, youth, and their families should encourage PG developers to increase the pool of high-quality PGs using internationally recognized PG development standards.

Sequential Instruction System (SIS))

This article describes a relatively simple conversational computer system to handle instructional texts or to perform a computer-aided testing. The system proceeds in a sequential mode with possibilities for branching forward or backward from where a sequential course is resumed.

Instructional or explanatory texts and/or multiple choice questions may be displayed. According to the answers the correctness or incorrectness of the reply is indicated. After each incorrect answer references or explanations are given. If desired, these explanatory frames can also be accessed after correct answers.

After completion of a course the score is displayed. SIS produces a log for the instructor including answers to individual questions and summary scores.

The system is written in FORTRAN. It is designed to run under O.S. on IBM 360 series computers with 2260 cathode ray tube (CRT) displays. It exists in two versions, one operating under a stand-alone attention handler for local displays, the other requiring the B.E.S.T. (Baylor Executive System for Teleprocessing) as message control program. In this case, remote CRT’s, teletypes and typewriter-type terminals may also serve as user terminals.

Though a few courses have been implemented, SIS is the basic vehicle, not the content of courses.

Towards high-quality, useful practice guidelines for child and youth mental health disorders: protocol for a systematic review and consensus exercise

INTRODUCTION

The quality of clinical practice guidelines (PGs) has not been evaluated in child and youth mental health (CYMH). To address this gap, we will: (1) conduct a systematic review (SR) to answer the question 'among eligible PGs relevant to the prevention or treatment of CYMH conditions, which PGs meet criteria for minimum and high quality?'; (2) apply nominal group methods to create recommendations for how CYMH PG quality, completeness and usefulness can be strengthened.

METHODS AND ANALYSIS

SR: Potentially eligible PGs will be identified in 12 databases using a reproducible search strategy developed by a research librarian. Trained raters will: (1) apply prespecified criteria to identify eligible PGs relevant to depression, anxiety, suicidality, bipolar disorder, behaviour disorder (attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder) and substance use disorder; (2) extract descriptive data and (3) assess PG quality using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Scores on three AGREE II domains (rigour of development, stakeholder involvement, editorial independence) will designate PGs as minimum (≥50%) or high quality (≥70%). Nominal group: Four CYMH PG knowledge user groups (clinicians, mental health service planners, youth and adult family members) will participate in structured exercises derived using nominal group methods to generate recommendations to improve PG quality, completeness and usefulness.

ETHICS AND DISSEMINATION

Ethics approval is not required. Study products will be disseminated as follows. A cross-platform website will house eligible CYMH PGs and their quality ratings. Twitter and Facebook tools will promote it to a wide variety of PG users. Data from Google Analytics, Twitonomy and Altmetrics will inform usage evaluation. Complementary educational workshops will be conducted for CYMH professionals. Print materials and journal articles will be produced.

PROSPERO REGISTRATION NUMBER

CRD42017060738.

Self-harm in Child and Adolescent Psychiatric Inpatients: A Retrospective Study

OBJECTIVE

This study presents a comprehensive report of children and adolescents who engaged in self-harm during their admission to a psychiatric inpatient unit.

METHOD

A chart review was conducted on all admissions to an acute care psychiatric inpatient unit in a Canadian children's hospital over a one-year period. Details on patients with self-harm behaviour during the admission were recorded, including: demographics, presentation to hospital, self-harm behaviour and outcome. Baseline variables for patients with and without self-harm behaviour during admission were compared.

RESULTS

Self-harm incidents were reported in 60 of 501 (12%) admissions during the one-year period of the study. Fourteen percent of patients (50 of 351) accounted for total number of 136 self-harm incidents. Half of these incidents (49%) occurred outside of the hospital setting, when patients were on passes. Using the Beck Lethality Scale (0-10), mean severity of the self-injury attempts was 0.33, and there were no serious negative outcomes.

CONCLUSION

Self-harm behaviour during inpatient psychiatric admission is a common issue among youth, despite safety strategies in place. While self-harm behaviour is one of the most common reasons for admission to psychiatric inpatient unit, our understanding of nature of these acts during the admission and contributing factors are limited. Further research is required to better understand these factors, and to develop strategies to better support these patients.

Can 'Hot Spotting' Prove to be a Useful Tool to Identify Disproportionate ED Use in the Rural General Hospital Setting?

'Hot spotting' allows the identification of areas with disproportionate use of Emergency Department (ED) services. To date, 'hot spotting' has focused on large urban centres. The aim of this study was to determine if there are geographic hotspots for ED use in the rural general hospital. ED attendances were logged between 1st July 2013 and 30th June 2014. Frequent users and super users were isolated. Addresses were cross referenced against national census data to determine number of users per 500 population in geographically distinct regions. The number of frequent users ranged from 1.00/500 population to 4.88/500 population. Four out of nineteen areas had > or equals; 4 frequent users per 500 population. There was no correlation between number of users and distance from MGH (p=0.44). 77% of frequent users presented with mixed aetiologies. Nineteen percent of frequent attenders presented via GP referral only, 13% attended via self-referral only and 88% attended via GP and self-referral routes.

Survival of Ruptured Abdominal Aortic Aneurysms in the West of Ireland: Do Prognostic Indicators of Outcome Exist?

Ruptured abdominal aortic aneurysm (RAAA) is a demanding vascular surgical problem and the cause of significant morbidity and mortality. The aim of this study was to identify prognostic factors that influence outcome. Over 6 years, 42 ruptured abdominal aortic aneurysms were operated on with a mean diameter of 7.2 cm. RAAA was defined as free intraperitoneal rupture. Data were collected retrospectively from hospital medical records. The male:female ratio was 8:1 and the mean age was 74 years (range 55–89). Fifteen were in hypovolemic shock and 27 patients were clinically stable. The perioperative mortality rate for the 15 shocked patients was 60% (9 patients) and the 1-year cumulative survival rate was 33%. The perioperative mortality rate for the 27 clinically stable patients was 40% (11 patients) and the 1-year cumulative survival rate was 56%. Survival curves were constructed for these groups to compare male versus female, age =70 versus age <70, shocked versus stable, and preoperative hemoglobin (Hb) =10 vs >10. No patient with preoperative cardiac arrest survived more than 24 hours. With VassarStats, the confidence interval for age, gender, hemodynamic status, and preoperative Hb were calculated. The standard weighted mean analysis by ANOVA gave a p value of <0.001. The overall 30-day mortality rate was 47% (20 of 42) and the 1-year mortality rate was 52% (22 of 42). Male patients over 70 years with RAAA in hypovolemic shock with low Hb have a higher 30-day mortality rate and few survive more than 1 year. The study suggests that each of these 4 parameters separately was not a strong prognostic indicator. Collectively, however, they strongly influence the prognosis of patients with RAAA. These findings strengthen the case for selective treatment for RAAA.

An unusual cause for massive inflation

Chagas disease is a rare condition but with an increasing incidence. Megacolon is a known sequelae. Surgical management remains the only disease modifying treatment option; with variable long-term success. We highlight an interesting case to emphasize attention to this rare condition as a differential diagnosis in any patient presenting with massive intestinal dilatation.

Clinical review: surgical management of locally advanced and recurrent colorectal cancer

AIM

Recurrent and locally advanced colorectal cancers frequently require en bloc resection of involved organs to achieve negative margins. The aim of this review is to evaluate the most current literature related to the surgical management of locally advanced and recurrent colorectal cancer.

METHODS

A literature review was performed on the electronic databases MEDLINE from PubMed, EMBASE and the Cochrane library for publications in the English language from January 1993 to July 2013. The MeSH search terms 'locally advanced colorectal cancer', 'recurrent colorectal cancer' and 'surgical management' were used.

RESULTS

A total of 1,470 patients with recurrent or locally advanced primary colorectal cancer were included in 22 studies. Surgical removal of the tumour with negative margins (R0) offers the best prognosis in term of survival with a 5-year survival of up to 70 %. MVR is needed in approximately 10 % with the most commonly involved organ being the bladder. The mean post-operative morbidity is 40 %, mainly relating to superficial surgical site infection, pelvic collections and delayed wound healing. Most patients will undergo radiotherapy and/or chemotherapy pre- or post-operatively. The mean 5-year overall survival for R0 resection is 50 % for recurrent and locally advanced primary tumours while survival following R1 or R2 is 12 and <5 %, respectively.

CONCLUSION

Multimodal therapy and extended surgery to achieve clear margins offers good prognosis to patients with recurrent and locally advanced colorectal cancers.

A benign psoas teratoma of the non-pelvic retroperitoneal space: A case report

This case report is of a benign retroperitoneal teratoma which was adherent to the psoas muscle of a 53-year-old female cadaver with a history of metastatic bladder cancer as a cause of death. Teratomas possess derivatives of all three germ cell layers and are usually seen either in children or in the lower pelvic region of adults. The finding of this mass deep to the inferior pole of the kidney is quite unusual. Few studies mention a possible association between metastatic cancer and teratoma growth in extrapelvic locations. The following report is a detailed account of this unusual finding and a summary of the literature on growths of this kind.

Recombinant erythropoietin (Epo)/darbepoetin (Darb) associated venous thromboembolism (VTE) in the oncology setting: Findings from the Research on Adverse Drug Events And Reports (RADAR) project

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Background: Cancer patients are at increased risk for VTE as compared to the general population, making VTE as a sADR difficult to detect in the oncology setting. In 2004, two phase III trials identified higher mortality rates among epo-treated cancer patients who were receiving chemotherapy in “off-label” settings- with these studies identifying higher VTE rates in the treatment arms. We reviewed data on epo/darb-associated VTE in the oncology setting. Methods: Data sources were meta-analyses and the FDA’s MedWatch database. Results: Since 1996, only 259 VTE reports (darb: n=30, epo: n=229) of VTE in the setting of chemotherapy and epo/darb were reported to MedWatch. Meta-analyses findings are tabulated below: Conclusions: In 2004, package inserts for Epo/Darb were revised, identifying increased risks of VTE with these agents in the oncology setting. Identification of this adverse drug reaction thirteen years after Epo received FDA approval for this indication (and had been prescribed to > 500,000 cancer patients) illustrates difficulties inherent with current pharmacovigilance efforts.

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No significant financial relationships to disclose.

Salvage of critical limb ischemia with the "trellis reserve'' of subintimal superficial femoral-popliteal artery occlusion: a new modality in managing critical limb ischemia--a case report

Subintimal angioplasty is a safe, effective, but nondurable procedure in treating long superficial femoral artery occlusions in patients with severe lower limb ischemia. The authors report a case of acute thrombosis that presented 16 weeks after subintimal angioplasty. The ;;Trellis'' percutaneous thrombolytic infusion system permitted a controlled site-specific infusion of recombinant tissue-type plasminogen activator (rtPA). The unique design of the ;;Trellis'' allowed complete aspiration of thrombus and avoiding regional and systemic thrombolytic side effects. The ;;Trellis'' system is effective in percutaneous management of thrombotic lesions; however, intimal dissection may need to be addressed.