Designing a Library of Lived Experience for Mental Health: integrated realist synthesis and experience-based co-design study in UK mental health services

OBJECTIVE

Living Library events involve people being trained as living 'Books', who then discuss aspects of their personal experiences in direct conversation with attendees, referred to as 'Readers'. This study sought to generate a realist programme theory and a theory-informed implementation guide for a Library of Lived Experience for Mental Health (LoLEM).

DESIGN

Integrated realist synthesis and experience-based co-design.

SETTING

Ten online workshops with participants based in the North of England.

PARTICIPANTS

Thirty-one participants with a combination of personal experience of using mental health services, caring for someone with mental health difficulties and/or working in mental health support roles.

RESULTS

Database searches identified 30 published and grey literature evidence sources which were integrated with data from 10 online co-design workshops conducted over 12 months. The analysis generated a programme theory comprising five context-mechanism-outcome (CMO) configurations. Findings highlight how establishing psychological safety is foundational to productive Living Library events (CMO 1). For Readers, direct conversations humanise others' experiences (CMO 2) and provide the opportunity to flexibly explore new ways of living (CMO 3). Through participation in a Living Library, Books may experience personal empowerment (CMO 4), while the process of self-authoring and co-editing their story (CMO 5) can contribute to personal development. This programme theory informed the co-design of an implementation guide highlighting the importance of tailoring event design and participant support to the contexts in which LoLEM events are held.

CONCLUSIONS

The LoLEM has appeal across stakeholder groups and can be applied flexibly in a range of mental health-related settings. Implementation and evaluation are required to better understand the positive and negative impacts on Books and Readers.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42022312789.

Designing a library of lived experience for mental health (LoLEM): protocol for integrating a realist synthesis and experience based codesign approach

INTRODUCTION

People with lived expertise in managing mental health challenges can be an important source of knowledge and support for other people facing similar challenges, and for carers to learn how best to help. However, opportunities for sharing lived expertise are limited. Living libraries support people with lived expertise to be 'living books', sharing their experiences in dialogue with 'readers' who can ask questions. Living libraries have been piloted worldwide in health-related contexts but without a clear model of how they work or rigorous evaluation of their impacts. We aim to develop a programme theory about how a living library could be used to improve mental health outcomes, using this theory to codesign an implementation guide that can be evaluated across different contexts.

METHODS AND ANALYSIS

We will use a novel integration of realist synthesis and experience-based codesign (EBCD) to produce a programme theory about how living libraries work and a theory and experience informed guide to establishing a library of lived experience for mental health (LoLEM). Two workstreams will run concurrently: (1) a realist synthesis of literature on living libraries, combined with stakeholder interviews, will produce several programme theories; theories will be developed collaboratively with an expert advisory group of stakeholders who have hosted or taken part in a living library and will form our initial analysis framework; a systematic search will identify literature about living libraries; data will be coded into our analysis framework, and we will use retroductive reasoning to explain living libraries' impacts across multiple contexts. Individual stakeholder interviews will help refine and test theories; (2) data from workstream 1 will inform 10 EBCD workshops with people with experience of managing mental health difficulties and health professionals to produce a LoLEM implementation guide; data from this process will also inform the theory in workstream 1.

ETHICS AND DISSEMINATION

Ethical approval was granted by Coventry and Warwick National Health Service Research Ethics Committee on 29 December 2021 (reference number 305975). The programme theory and implementation guide will be published as open access and shared widely through a knowledge exchange event, a study website, mental health provider and peer support networks, peer reviewed journals and a funders report.

PROSPERO REGISTRATION DETAILS

CRD42022312789.

P425Single procedure pace and ablate. evaluation of efficacy and safety comparing three different vascular routes

Funding Acknowledgements

No financial support for this study

Introduction

Permanent pacemaker implantation combined with AVN ablation is a well-established treatment for rate control in patients with atrial fibrillation refractory to medical therapy. At the same sitting, this has been achieved in a single procedure via the subclavian vein (SCV) for both pacemaker implantation and AVN ablation, by pacemaker implantation via the SCV with femoral access for AVN ablation or by using the femoral vein (FV) for leadless pacemaker implantation and AVN ablation with a coaxial single-puncture technique.

We evaluated all combined procedures (pacemaker implantation and AVN ablation at the same sitting) performed in a single centre over 9 years comparing clinical outcomes, complications rates and procedure times.

Statistical methods: 

Continuous variables are described as mean ± standard deviation (SD), and statistical differences between groups were evaluated by one-way ANOVA. A X2 test was used for categorical variables, with Fisher’s exact test for any field where the expected frequency was ≤5 with pvalue < 0.05 considered as statistically significant. The statistical analysis was performed using SPSS software package. 

Results

 

141 patients underwent AVN ablation at our institution as part of a ‘pace and ablate’ single procedure strategy between 14/2/11 and 10/6/19. 61 patients had a combined procedure via the SCV, 66 patients had pacemaker implanted via the SCV and AVN ablation via the FV in the same sitting and 14 patients had leadless pacemaker (Micra) implantation and AVN ablation via the FV. Our findings suggest that the fluoroscopy time as well as the total catheter laboratory time were much less in the Micra group compared to the other groups. In the conventional pacemaker groups (group 1 and 2), the fluoroscopy time was not statistically different between the two. There was a trend towards acute procedural failure, switching to another access as well as a higher complication rate in the SCV group, however this has not reached statistical significance. 

Conclusion

 

Our early data suggests that pacemaker implantation and AVN ablation with a coaxial single femoral vein puncture technique is safe and takes less fluoroscopy time as well as total laboratory time.

Procedural outcomes All (n = 141) Group 1: SCV (n = 61) Group 2: FV (n = 66) Group 3: Micra (n = 14) P-value Total cath-lab time (mins) 113.1 ± 40.4 106.2 ± 37.2 125.7 ± 42.5 86.9 ± 23.1 0.001 Total fluoroscopy time (mins) 8.8 ± 7.6 11 ± 7.8 7.7 ± 7.6 4.5 ± 3 0.0001 Acute procedural failure, n (%) 9 (6.4) 7 (11.5) 2 (3) 0 (0) **0.6 Complications, n (%) 7 (4.9) 5 (8.2) 2 (3) 0 (0) **0.62 **Fisher"s exact test applied to analysis of Micra VS Other methods

In vitro Resistance to an Inhibitor of HIV Proteinase (Ro 31-8959) Relative to Inhibitors of Reverse Transcriptase (AZT and TIBO)

Serial passage of cell-free human immunodeficiency virus type 1 (HIV-1) strain GB8 on CEM cells was carried out in the presence of increasing concentrations of the HIV proteinase inhibitor Ro 31-8959 in parallel with representative reverse transcriptase (RT) inhibitors (AZT and the TIBO compound, R82150). In all instances, a significant increase in the concentration of compound required to produce a 90% reduction of syncytium formation (IC90) was found after seven to nine passages of virus. Reduced sensitivity to Ro 31 −8959 was confirmed by p24 ELISA. Virus passaged in the presence of RT inhibitors did not show a significant change in either the ability to grow in culture supplemented with step-wise increments of inhibitor concentration or the rate of growth in the presence of compound. In contrast, virus passaged in the presence of Ro 31 −8959 required, on average, more than 2.5-times the normal passage time and often did not replicate when increases in inhibitor concentration were applied during the initial passages.

The results show that reduced sensitivity to an inhibitor of HIV proteinase, Ro 31–8959, can be generated, but it would seem to arise less readily than that found with either of the RT inhibitors studied. While this study indicates the potential for a reduction in sensitivity to proteinase inhibitors, it does not necessarily reflect the ability of mutant virus either to be selected for or to be propagated in the clinic.

Antiviral Synergy between Inhibitors of HIV Proteinase and Reverse Transcriptase

Ro 31–8959, a potent and specific inhibitor of HIV proteinases, is shown to interact synergistically in combination with nucleoside analogue inhibitors of HIV reverse transcriptase (AZT, ddC, 2′-FddC). Ninety per cent inhibition endpoints (IC90), obtained from checkerboard titrations of compound mixtures on CEM-T4 cells infected with HIV-i strain GB8, have been further analysed. Compared with concentrations needed when inhibitors are used individually, reductions of between 2- and 30-fold were observed in combination, depending on the nucleoside analogue and the ratio of concentrations employed. The results suggest that combinations of AZT or ddC with Ro 31–8959 should be considered for development as candidate antiviral treatments of patients with HIV infection.

In vitro anti-HIV and Cytotoxicological Evaluation of the Triple Combination: AZT and ddC with HIV Proteinase Inhibitor Saquinavir (Ro 31-8959)

A combination of three anti-HIV compounds (AZT, ddC and saquinavir) has been studied in vitro. In confirmation and extension of previous studies, a greater than additive effect was found against both HIV-1GB8 and HIV-1N1T, when any two compounds were combined. Synergy of action was also found against both virus strains when all three compounds were employed together. Cytotoxicological studies indicated that a high therapeutic index could be maintained for this treatment. The potential benefits of improved anti-HIV surveillance, reduced risk of the development of resistance to the treatment and reduced requirement for drugs in quantities that produce toxic side-effects support the extension of clinical trials of saquinavir to investigate this combination.

Cluster of influenza A cases in vaccinated population of adults in Virology Laboratory in Glasgow in December 2012

BACKGROUND AND AIMS

The majority of influenza infections during the 2012/2013 influenza season in Scotland have been due to influenza A H3N2. We report an outbreak of influenza A H3N2 in a vaccinated population of adults in the Regional Virology Laboratory in Glasgow. This investigation was carried out to confirm the epidemiological link between cases.

METHODS AND RESULTS

Staff with clinical symptoms of influenza-like illness were included. Samples were tested by real-time polymerase chain reaction and sequencing. Staff were interviewed to obtain information regarding symptom onset and vaccination status. Eight confirmed cases and six clinically diagnosed cases were reported, which all occurred within 4 days of a lunchtime Christmas quiz. The eight samples subtyped as H3 virus. The haemagglutinin gene in the confirmed cases was sequenced and shown to be identical. Most of the attendees had been immunised against influenza with the same vaccine batch at least 6 weeks earlier.

CONCLUSION

This outbreak appears to have been an isolated incident, which arose due to a social event that provided the ideal conditions for transmission of a respiratory disease. It may have been compounded by low-vaccine effectiveness this season. Sequence data supported the epidemiological link.

Do Patients with Critical Limb Ischaemia Undergo Multiple Amputations after Infrainguinal Bypass Surgery?

BACKGROUND

it has been suggested that an aggressive policy of bypass for limb salvage in critical ischaemia may result in patients subsequently undergoing multiple amputations. The aim of this study was to test this suggestion in the context of a dedicated Vascular Surgical Unit in a U.K. teaching hospital.

METHODS

three hundred and sixty-eight patients undergoing lower limb bypass operations for critical limb ischaemia between April 1991 and March 1999 were studied retrospectively. Their median age was 69 years (IQR 64--75) and 243 (66%) were men.

RESULTS

seventy-five operations were followed by one or more amputation (20%). Only 2% were multiple amputations. Age and sex had no effect on amputation rates, but emergency bypass operations led to a higher rate of amputation in those with critical limb ischaemia.

CONCLUSION

patients with critical limb ischaemia who undergo lower limb bypass surgery rarely have subsequent multiple amputation.

The measurement of pupil cycling time

PURPOSE

To assess the influence of pupil size on pupil cycling time (PCT), a measure which may be elongated in cases of neurological disease.

METHOD

Clinically, pupil "cycling" is produced by focusing a slit-lamp beam on the pupil margin. A rhythmic contraction and dilation of the pupil is produced, as changes in pupil size alternately prevent and allow the light beam to reach the retina. In this study, however, the light beam was controlled electronically so that cycling could be produced around different pupil sizes. Measurements of the variation of PCT with pupil size were taken from 22 young normal subjects.

RESULTS

PCT was seen to depend upon pupil size, increasing monotonically but non-linearly as size increased. The wave-form of pupil cycling is typically sawtooth, contraction being much faster than dilation. There was considerable variation amongst subjects in the range of pupil sizes where pupil cycling could be elicited.

CONCLUSIONS

The results point to the need for a standardised procedure for the measurement of cycling time, because differences in clinical conditions will themselves influence pupil size, as will other external variables such as ambient light level. The results also bring into question neurological explanations for increased PCT in those diseases where pupil size is affected, because normal subjects have PCTs well beyond the accepted limits of normality when their pupils are enlarged.

A randomized clinical trial of cryotherapy, laser vaporization, and loop electrosurgical excision for treatment of squamous intraepithelial lesions of the cervix

OBJECTIVE

To compare cryotherapy, laser vaporization, and loop electrical excision for treatment of squamous intraepithelial lesions (SILs).

METHODS

Women at least 18 years old with biopsy-proven SIL, negative pregnancy tests, negative findings on endocervical curettage, satisfactory colposcopy examinations, and congruent Papanicolaou smear and biopsy results were assigned randomly to treatment after stratification by SIL grade, endocervical gland involvement, and lesion size; they were evaluated 1, 4, 8, 12, 16, 20, and 24 months after treatment. Data were analyzed using chi2 statistics, logistic regression analysis, and the Cox proportional hazards model.

RESULTS

Of 498 patients assigned, 108 were excluded (most because of inadequate follow-up), leaving 390 (139 cryotherapy, 121 laser vaporization, 130 loop excision) for analysis. All were followed 6-37 months (mean 16). There were no statistically significant differences in complications, persistence (disease present less than 6 months after treatment), or recurrence (disease present more than 6 months after treatment). Risk of persistent disease was higher among women with large lesions (risk ratio [RR], 18.9; 95% confidence interval [CI], 3.2, 110.6). Recurrence risk was higher among women aged 30 years and older (RR, 2.1; 95% CI, 1.2, 4.3), those with human papillomavirus type 16 or 18 (RR, 2.1; 95% CI, 1.1, 4.0), and those who had had prior treatment (RR, 2.1; 95% CI, 1.1, 3.9).

CONCLUSION

The data support a high success rate with all three modalities. No significant difference in success rates was observed between the three treatments in our population. Additional attention and research should be directed toward the higher risk patients identified above.

HIV protease genotype and viral sensitivity to HIV protease inhibitors following saquinavir therapy

OBJECTIVE

To examine the relationship between HIV protease genotype and altered protease inhibitor sensitivity of isolates from patients after therapy with saquinavir (SQV) in its hard gelatin formulation.

DESIGN

Forty-one post-therapy isolates and corresponding baseline samples were obtained from 37 patients in four different clinical trials after therapy with SQV for 16-147 weeks. Post-therapy isolates were selected on the basis of preliminary sequence or drug sensitivity data.

RESULTS

Fifteen out of 17 isolates without detectable Val-48 or Met-90 mutations retained sensitivity to SQV. (The remaining isolates showed only a marginal increase in median inhibitory concentration.) In addition, three out of 15 isolates with Met-90 retained sensitivity to all other protease inhibitors tested (indinavir, ritonavir, amprenavir, nelfinavir). Of the isolates showing reduced sensitivity to SQV, six out of 22 retained sensitivity to all other protease inhibitors, whereas only four out of 22 showed broad cross-resistance to all protease inhibitors tested. The reduction in sensitivity correlated closely with the presence of Val-48 or Met-90. Subsequent accessory substitutions were also linked to reduced sensitivity. However, significant linkage was observed only between mutations at residues 48 and 82 and between those at residues 82 and 74.

CONCLUSIONS

Recruitment of Val-48/Met-90 mutations was not found to be synonymous with cross-resistance. Indeed, the majority of isolates with these mutations retained sensitivity to at least one protease inhibitor (Val-48, 86%; Met-90, 77%). The recruitment of accessory mutations may occur only after the selection of key resistance mutations. Furthermore, Met-90 was found to be a poor marker of cross-resistance in SQV-treated patients.

Ovarian intraepithelial neoplasia and ovarian cancer

Ovarian cancer accounts for only 4% of cancers in women, but it is the leading cause of death from gynecologic malignancies in the United States. In the general population, a woman's lifetime risk of ovarian cancer is 1.4% but this risk can increase substantially in women with a strong family history of the disease. The high mortality rate from ovarian cancer is due primarily to the difficulty in detecting the disease in early stages; the disease tends to be asymptomatic until it is well advanced. The primary care physician needs to be alert to the possibility of an ovarian malignancy in all women with an intact ovary or ovaries who present with abdominal or pelvic complaints. There are no current recommendations for routine screening for ovarian cancer in the general population. Even in high-risk women, there are currently no convincing data to support extensive screening, although a number of studies looking at this issue are under way. Despite this lack of conclusive evidence, a consensus panel on ovarian cancer convened by the NIH recently issued guidelines for screening high-risk women. They recommend annual rectovaginal pelvic examination, testing of CA 125 level, and transvaginal ultrasonography. Color flow Doppler analysis of the ovarian vessels is also being studied as a possible screening modality. BRCA1 gene testing may soon play a role in women with a strong family history of the disease. Given its high mortality rate, primary prevention strategies for ovarian cancer should be used whenever possible. Oral contraceptive use appears to reduce the risk of ovarian cancer. Prophylactic oophorectomy may be suggested for women at particularly high risk of the disease. Here, too, the primary care physician can play an important role in helping a patient understand the risks and benefits of these options.

Gestational trophoblastic disease

GTD occurs in fewer than 1 in 1200 pregnancies in the United States, but it is much more common in Asia and Latin America, where its incidence may be as high as 1 in 200 pregnancies. Risk factors for GTD include advanced or young maternal age, low socioeconomic status, and prior hydatidiform mole. Early diagnosis and prompt treatment are key to a favorable outcome, and thus recognition of the signs and symptoms of the disease is important for all physicians. Because these diseases have low incidences and occur after reproductive events, screening for them in the general population is not worthwhile. No chemopreventive agents have yet been studied in women at risk for GTD, but the oral contraceptive is a good candidate.

Uterine sarcoma

Sarcomas are rare tumors with unpredictable prognosis. They are treated similarly to endometrial cancers. Little is known of epidemiologic risk factors for sarcoma; similarly, little work has been performed assessing molecular alterations in sarcomas. Because of their rarity, uterine sarcomas are not suitable for screening. Chemoprevention studies might target those at risk for recurrence or a second neoplasm.

Endometrial hyperplasia and endometrial cancer

Endometrial cancer is the most frequently seen gynecologic neoplasm, but it fortunately has low mortality, which is due largely to its presentation with abnormal bleeding and its subsequent early diagnosis. The morbidity associated with therapy for early lesions is moderate. Hyperplasia with atypia should be treated as early cancers. Many molecular markers are currently under study. Markers may soon help us identify invasive lesions at higher risk of recurring and thus more suitable for adjunct therapy. Screening in the general population is not recommended, but a high-risk group that is more suitable for screening could be identified, including obese and nulliparous women, those treated with unopposed estrogen or tamoxifen, or those with family or past histories of breast or colon cancer. Development of chemoprevention with an oral contraceptive during the reproductive years is under way, and there may be a role for chemoprevention in the reversal of hyperplasias.

Clinical applications of genetic testing: implications for the family physician

Genetic testing may be applied in a variety of clinical situations, including preconception counseling, prenatal diagnosis and postnatal determination of genetic predisposition to disease. The family physician needs to become familiar with the full range of genetic testing possibilities in all phases of the human life cycle. Cystic fibrosis, Huntington's disease and cancer are three diseases for which genetic testing has become a reality, and they serve to illustrate the clinical and ethical dilemmas that arise with this type of testing.

Weak transcriptional activation is sufficient for transformation by v-Myb

The v-myb oncogene causes monoblastic leukemia in chickens and transforms avian myelomonocytic cells in vitro, v-Myb is a short-lived nuclear protein which binds to DNA in a sequence-specific manner and can activate gene expression in transient DNA transfections. Analysis of a series of v-Myb mutants has shown that the ability to activate transcription appears to be required for leukemic transformation. We have systematically investigated transcriptional activation by v-Myb and have made several new observations: (i) v-Myb is a very weak activator when compared to GAL4; (ii) very weak transcriptional activation by v-Myb is sufficient for transformation, whereas very strong transcriptional activation by a v-Myb-VP16 fusion protein is not; and (iii) v-Myb can activate transcription by two genetically distinct mechanisms, only one of which requires the presence of Myb-binding sites.

A highly conserved cysteine in the v-Myb DNA-binding domain is essential for transformation and transcriptional trans-activation

The v-Myb protein is nuclear, binds to DNA in a sequence-specific fashion, regulates the transcription of various reporter gene and transforms myelomonocytic cells. Cysteine is one of the most conserved residues during protein evolution and has been implicated in DNA binding, protein-protein interaction and redox regulation of various proteins. Therefore, we have now individually substituted each of the seven cysteines of v-Myb with a serine. All seven mutant proteins bound to DNA when they were expressed in E. coli. However, mutant C65S neither trans-activated transcription in vivo nor transformed myeloid cells, although it was transported into the nucleus. This cysteine is conserved in the Myb-related proteins of animals, plants, yeast and the cellular slime mold Dictyostelium discoideum. The C65S mutation and a nearby codon insertion mutation also abolished trans-activation by fusion proteins containing the v-Myb DNA-binding domain and the strong constitutive activation domain of herpes simplex virus (HSV) VP16. Because this domain of VP16 appears to activate transcription whenever it is bound upstream of an appropriate promoter, these results imply that C65 may be required for high-affinity DNA binding in vivo. In support of this hypothesis, we have also shown that, in contrast to wild-type v-Myb, mutant C65S is unable to block transcription from a reporter gene in which Myb binding sites overlap the initiation site.

A comparison of enprostil and ranitidine in treatment of duodenal ulcer

Enprostil is a new synthetic prostaglandin E2 with antisecretory and mucosal-protective effects. We compared it with ranitidine in the healing of duodenal ulcer and also examined the subsequent relapse rate. Three hundred thirteen patients were recruited in 15 centers in Europe, of whom 158 were treated with enprostil (E) 35 micrograms twice daily and 155 with ranitidine (R) 150 mg twice daily for up to 6 weeks, using a double-blind method. Patients in both groups were of comparable demography. Healing was significantly quicker with ranitidine. Of patients randomized to treatment, healing (intention-to-treat analysis) at 4 weeks was E 47% and R 69%, and at 6 weeks it was E 66% and R 88%. In patients who met all protocol criteria and completed treatment, healing at 4 weeks was E 58% and R 80%, and at 6 weeks it was E 81% and R 92%. Early relief of pain, both during the day and at night, was significantly quicker with ranitidine. Nausea, diarrhea, vomiting, and abdominal pain occurred more often with enprostil. There were no clinically important abnormalities in hematology or biochemistry. Relapse rates were similar. In conclusion, enprostil is not as effective as ranitidine in healing duodenal ulcers.

Simian virus 40 large T antigen oligomers: analysis of electrophoresis in the absence of detergent

Large T antigen of simian virus 40 is found as monomeric and oligomeric species in transformed cells. These can be demonstrated in cell extracts by velocity centrifugation in sucrose gradients. We analyzed them further in a transformed human line cell (SV80) and a transformed mouse line cell (SVT2). Individual fractions from sucrose gradients were subjected to polyacrylamide gel electrophoresis in the absence of detergent. T-antigen species were then detected by protein blotting and antibody overlay with polyclonal anti-D2 T antibody or monoclonal Pab419, Pab101, or Pb1700 antibody. The rapidly sedimenting species (14S and larger) of large T antigen from both cell lines reproducibly showed two major bands with estimated molecular weights of 670,000 and 850,000. A third band of 1,200,000 was more prominent in SVT2 cells than in SV80 cells. In SV80 cells the slowly sedimenting species of large T antigen (5S to 11S) contained two reproducible bands. A band with a molecular weight of 95,000 was the predominant one in all fractions between 5S and 11S. A relatively minor band with a molecular weight of 230,000 was found in fractions between 9S and 11S. The low-molecular-weight forms were seen in SVT2 cells only when a prominent peak at 5S to 7S was present, that is, when extracts were stored before analysis. In fresh extracts, the low-molecular-weight bands and slowly sedimenting forms were absent.