A Brief Cognitive Analytic Therapy-Informed Approach for Young People That Have Self-Injured (CATCH-Y): A Case Series

BACKGROUND

Non-suicidal self-injury (NSSI) presents an increasingly prevalent problem for young people; however, there remains a scarce evidence base for effective, scalable treatments for adolescents. This study aimed to assess the feasibility and acceptability of a brief, cognitive analytic therapy (CAT)-informed intervention for young people who engage in NSSI (CATCH-Y).

METHODS

A case series design recruited 13 young people who met the inclusion and exclusion criteria to participate in the five-session intervention. Eligible participants were aged 13-17 years (M = 15.15, SD = 1.28) and had engaged in NSSI at least once in the previous 6 months. Feasibility and acceptability were measured via recruitment, retention, qualitative feedback and missing data. The secondary outcome measures of personal recovery and motivation were administered pre- and post-assessment, with measures of depressive symptoms and urges to self-injure.

RESULTS

The intervention was found to be largely feasible and acceptable with high rates of recruitment, retention and pre-/post-assessment data completeness. Measures showed preliminary support for positive change in rates of NSSI, urges to self-harm, low mood and personal recovery, although results were mixed. Completion rates for remote assessments were low.

CONCLUSIONS

The findings of this study support further evaluation of the CATCH-Y intervention on a larger scale. In-person assessments may be preferable to remote to ensure good completion rates.

Predictive factors and screening strategy for obstructive sleep apnea in patients with advanced multiple sclerosis

BACKGROUND

Obstructive sleep apnea (OSA) screening questionnaires have been evaluated in Multiple Sclerosis (MS) but not yet validated in patients with advanced disease. The aim of this study is to identify OSA predictive factors in advanced MS and to discuss screening strategies.

METHODS

Oximetry data from 125 patients were retrospectively derived from polysomnographic reports. Univariate and multivariate analysis were used to determine predictive factors for OSA. A two-level screening model was assessed combining the oxygen desaturation index (ODI) and a method of visual analysis.

RESULTS

multivariate analysis showed that among the clinical factors only age and snoring were associated with OSA. Usual predictive factors such as sleepiness, Body mass index (BMI) or sex were not significantly associated with increased Apnea Hypopnea Index (AHI). The ODI was highly predictive (p < 0.0001) and correctly identified 84.1 % of patients with moderate OSA and 93.8 % with severe OSA. The visual analysis model combined with the ODI did not outperform the properties of ODI used alone.

CONCLUSION

As the usual clinical predictors are not associated with OSA in patients with advanced MS, questionnaires developed for the general population are not appropriate in these patients. Nocturnal oximetry seems a pertinent, ambulatory and accessible method for OSA screening in this population.

Management of obstructive sleep apnea syndrome type 1 in children and adolescents - A French consensus

This document is the outcome of a group of experts brought together at the request of the French Society of Sleep Research and Medicine to provide recommendations for the management of obstructive sleep apnea syndrome type 1 (OSA1) in children. The recommendations are based on shared experience and published literature. OSA1 is suspected when several nighttime respiratory symptoms related to upper airway obstruction are identified on clinical history taking. A specialist otolaryngologist examination, including nasofibroscopy, is essential during diagnosis. A sleep study for OSA1 is not mandatory when at least two nighttime symptoms (including snoring) are noted. Therapeutic management must be individualized according to the location of the obstruction. Ear, nose, and throat (ENT) surgery is often required, as hypertrophy of the lymphoid tissues is the main cause of OSA1 in children. According to clinical findings, orthodontic treatment generally associated with specialized orofacial-myofunctional therapy might also be indicated. Whatever treatment is chosen, follow-up must be continuous and multidisciplinary, in a network of trained specialists.

[Does a short telemedicine-based CBT programme for insomnia lead to changes in dysfunctional beliefs about sleep?]

INTRODUCTION

The Morphee Sleep network runs a short group CBT programme. During the pandemic, the programme was administered by videoconference. The programme focuses on behavioral modification. The objective of our study was to evaluate whether the videoconference programme produced changes in dysfunctional beliefs about sleep and whether these changes were linked to improvements in insomnia.

METHODS

Observational study of 3×90minute sessions of group CBT by videoconference over one month delivered by experienced psychologists. The outcome measures : insomnia severity scale (ISI), dysfunctional beliefs and attitudes about sleep short version (DBAS 16), hospital anxiety and depression scale (subscales depression HADD and anxiety HADA), and epworth sleepiness scale (ESS) completed before session 1 and at the end of session 3. The effectiveness of the programme on insomnia was evaluated by the decrease in the ISI score : full response R+ (>7 points), partial response, R- (4 - 6 points) non response, NR (<3 points). The effect on dysfunctional beliefs and attitudes about sleep were measured by the decrease in the DBAS 16 with response CR (>9 points) and no response CNR (<9 points).

RESULTS

There were fifty-five participants, 64 % women with a mean age of 49.1±16.1 years. The DBAS 16 was reduced by 6.12±1.29 to 5.09±1.57 (P< 0.0001) with 67 % of participants showing a response CR. The ISI score reduced from 17.7±3.6 to 14.0±4.9 (P< 0.0001) with 49 % showing at least a partial response (R+ and R-). A significant correlation (0.327, P=0.015) between the CBT response and dysfunctional beliefs about sleep was observed with a significant reduction in the DBAS 16 between responders R+ and non-responders (R+ vs. NR 1.67±1.3 vs. 0.57±1.28 P=0.012). Seventy-nine of R+ showed improvements in the DBAS 16 vs. 69 % of R- and 61 % of non-responders NR.

CONCLUSION

A short group CBT programme by videoconference focused on behavioral modification can reduce dysfunctional beliefs about sleep.

Clinical trial management: a profession in crisis?

Clinical trial managers play a vital role in the design and conduct of clinical trials in the UK. There is a current recruitment and retention crisis for this specialist role due to a complex set of factors, most likely to have come to a head due to the COVID-19 pandemic. Academic clinical trial units and departments are struggling to recruit trial managers to vacant positions, and multiple influences are affecting the retention of this highly skilled workforce. Without tackling this issue, we face major challenges in the delivery on the Department of Health and Social Care's Future of UK Clinical Research Delivery implementation plan. This article, led by a leading network of and for UK Trial Managers, presents some of the issues and ways in which national stakeholders may be able to address this.

163 Frailty, Doesn’t That Mean Birdlike? Research Into Attitudes and Understanding of Frailty in Undergraduate and Postgraduate Trainees

Introduction

Frailty is an increasingly recognised concept, with 25–50% of over 85’s estimated to be frail1,. Previous research considered medical students’ attitudes towards older people2, yet despite the correlation between frailty and increased age3, little is known about attitudes of healthcare professionals towards frailty.

We researched attitudes towards, and understanding of, frailty in undergraduate and postgraduate trainees, with a view to guiding future educational interventions.

Method

Approval was granted by Northumbria Healthcare NHS Foundation Trust (NHCT) Research and Development department, Newcastle University’s Research Management Group and the HRA.

3 cohorts were recruited; 3rd year Newcastle University MBBS Students, 5th year Newcastle University MBBS Students and Foundation Year 2 and Core Medical Trainees working for NHCT (junior doctors). Data was collected during scheduled teaching at NHCT and individuals were invited to participate via email prior to this. Those not participating were still required to attend the teaching. Participants provided written consent.

Within each cohort, small group discussions around frailty and Comprehensive Geriatric Assessment (CGA) were prompted using open questions (e.g. “what does frailty mean to you?”), during which participants anonymously submitted phrases to an online word-cloud generator. Discussions were audio recorded and transcribed.

Transcriptions and word-clouds were analysed using Simple Content Analysis. The over-arching themes within each cohort were identified and compared with other cohorts. Interpretations were reviewed by an independent researcher to enhance rigour.

Results

Each cohort associated frailty with older age and weakness, and often used it as a byword for complexity. Frailty was described as an abstract construct composed of personal experiences rather than an objectively defined descriptor. All associated it with negative emotions.

Cohorts differed in their approach, with 3rd year students primarily focussed on defining frailty, whereas junior doctors prioritised the clinical challenges it presented.

Junior doctors demonstrated limited understanding of CGA whilst undergraduate students were almost universally ignorant of it.

Conclusions

The lack of understanding around frailty and CGA is concerning given its high prevalence. The identification of negative emotions increases this concern. To challenge this, focussed educational interventions addressing understanding and attitudes ought to be developed for tomorrow’s doctors.

References

1. Clegg et al. Lancet 2013; 381: 752–62.

2. Samra et al. Age Ageing 2017; 46: 911–9.

3. Romero-Ortuno et al. Age Ageing 2012; 41: 684–9.

A Peek Inside the Machines of Bacterial Nucleotide Excision Repair

Double stranded DNA (dsDNA), the repository of genetic information in bacteria, archaea and eukaryotes, exhibits a surprising instability in the intracellular environment; this fragility is exacerbated by exogenous agents, such as ultraviolet radiation. To protect themselves against the severe consequences of DNA damage, cells have evolved at least six distinct DNA repair pathways. Here, we review recent key findings of studies aimed at understanding one of these pathways: bacterial nucleotide excision repair (NER). This pathway operates in two modes: a global genome repair (GGR) pathway and a pathway that closely interfaces with transcription by RNA polymerase called transcription-coupled repair (TCR). Below, we discuss the architecture of key proteins in bacterial NER and recent biochemical, structural and single-molecule studies that shed light on the lesion recognition steps of both the GGR and the TCR sub-pathways. Although a great deal has been learned about both of these sub-pathways, several important questions, including damage discrimination, roles of ATP and the orchestration of protein binding and conformation switching, remain to be addressed.

[The effects of quarantine for SARS-CoV-2 on sleep: An online survey]

Objectif

Déterminer l’évolution du sommeil chez les Français pendant le confinement motivé par la pandémie du SARS-CoV-2 et définir les facteurs comportementaux associés à un sommeil détérioré.

Méthodologie

Une enquête en ligne via les réseaux sociaux pendant la période de confinement. Les questions ont ciblé les conditions de confinement, les comportements relatifs au sommeil et les éléments de l’environnement potentiellement perturbateurs du sommeil (exposition à la lumière et activités sportives).

Résultats

Au total, 1777 participants ont été inclus dont 77 % femmes, 72 % âgés de 25–54 ans. Les conditions de confinement les plus fréquentes étaient en couple avec enfants (36 %) et en maison avec jardin (51 %). Quarante-sept pour cent rapportent une diminution de la qualité du sommeil en confinement. Les facteurs associés à une détérioration du sommeil retenus par l’analyse multivariée sont une diminution de la durée du sommeil (OR 15,52 — p < 0,001), un coucher plus tardif (OR 1,72 — p < 0,001), un lever plus matinal (2,18 — p = 0,01), des horaires plus irréguliers (OR 2,29 — p < 0,001), une diminution de l’exposition à la lumière du jour (OR 1,46 — p = 0,01) et une augmentation de l’utilisation des écrans le soir (OR 1,33 — p = 0,04).

Conclusion

La mauvaise qualité subjective du sommeil en confinement est associée à une modification des comportements relatifs au sommeil et de l’exposition à la lumière (moins de lumière du jour et plus d’écran le soir). Pour optimiser le sommeil en confinement, des horaires adaptés et réguliers, une exposition de plus d’une heure/jour à la lumière du jour et l’éviction des écrans le soir sont à conseiller.

The ATPase mechanism of UvrA2 reveals the distinct roles of proximal and distal ATPase sites in nucleotide excision repair

The UvrA₂ dimer finds lesions in DNA and initiates nucleotide excision repair. Each UvrA monomer contains two essential ATPase sites: proximal (P) and distal (D). The manner whereby their activities enable UvrA₂ damage sensing and response remains to be clarified. We report three key findings from the first pre-steady state kinetic analysis of each site. Absent DNA, a P_2ATP-D_2ADP species accumulates when the low-affinity proximal sites bind ATP and enable rapid ATP hydrolysis and phosphate release by the high-affinity distal sites, and ADP release limits catalytic turnover. Native DNA stimulates ATP hydrolysis by all four sites, causing UvrA₂ to transition through a different species, P_2ADP-D_2ADP. Lesion-containing DNA changes the mechanism again, suppressing ATP hydrolysis by the proximal sites while distal sites cycle through hydrolysis and ADP release, to populate proximal ATP-bound species, P_2ATP-D_empty and P_2ATP-D_2ATP. Thus, damaged and native DNA trigger distinct ATPase site activities, which could explain why UvrA₂ forms stable complexes with UvrB on damaged DNA compared with weaker, more dynamic complexes on native DNA. Such specific coupling between the DNA substrate and the ATPase mechanism of each site provides new insights into how UvrA₂ utilizes ATP for lesion search, recognition and repair.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Spatial and temporal distribution, environmental drivers and community structure of mosquitoes in the Kaipara Harbour, New Zealand

Mosquito communities across the globe frequently comprise a mix of native and cosmopolitan species. New Zealand's mosquito communities are no exception. Here we describe the abundance, distribution and phenological patterns for a community of six mosquito taxa resident across the Kaipara Harbour region of northern New Zealand. Adult mosquitoes were sampled using baited light traps, serviced biweekly for 3½ years. Seasonal fluctuations in abundance of adults were examined for correlations with temperature and rainfall over the preceding weeks. Four endemic species comprised over 98% of the total catch, with Coquillettidia iracunda being the most abundant. Two introduced species, Aedes notoscriptus and Culex quinquefasciatus were widely distributed, but each comprised <1% of the total catch. Culiseta tonnoiri was the only species that appeared geographically restricted, occurring at one-third of the sites. Distinct temporal peaks in adult abundance were evident: Aedes antipodeus was most abundant in spring, Ae. notoscriptus and Cq. iracunda were most abundant in summer and Cx. quinquefasciatus was most abundant in autumn. Culiseta tonnoiri and Culex pervigilans were of variable abundance throughout the year. For all species examined, temporal variations in abundance were more strongly associated with temperature in the preceding weeks than with preceding rainfall. A better knowledge of the factors driving patterns of spatial and temporal abundance will allow an improved understanding of how non-native species may integrate themselves into resident mosquito communities.

Does regional audit improve practice in the management of urological cancers?

Objective:

The effect of a regional audit is underreported and uncertain. Across the North West of England we have conducted annual regional audits of urological cancer care for over 20 years.

Methods:

We reviewed the data from four complete audit cycles (prostate, testis, bladder and kidney) to ascertain the change in adherence to agreed guidelines. Adherence to guidelines was pooled across cancer types and the following domains. Preoperative investigation, planning and counselling Perioperative and intraoperative care Follow-up regimen and documentation Difference in adherence to guidelines was expressed as an absolute percentage change and statistical significance was determined using Fisher’s exact test.

Results:

Over the four complete audit cycles 3659 case notes were reviewed totalling 20,470 observations. The four separate audits generated 42 guidelines which were equally assessable between audit cycles (prostate (nine), testis (seven), bladder (18) and kidney (eight)). Overall, adherence to guidelines between the original and follow-up audit improved from 63.4% to 73.4% ( p < 0.05). Adherence improved across all cancers; however, this was not equal across all domains. Marked improvements were seen in preoperative investigation (+13%, p < 0.05), planning and counselling and follow-up and documentation (+12%, p < 0.05). A non-significant rise of 0.1% was seen in guidelines pertaining to intraoperative care ( p = 0.95).

Conclusions:

A regional audit has overseen and documented an improvement in practice in urological cancer within the region studied. Although the mechanisms leading to this are likely to be complex, we suggest that the audit process per se is likely to contribute to this improvement rather than merely document it.

Association between reported sleep need and sleepiness at the wheel: comparative study on French highways between 1996 and 2011

OBJECTIVE

To investigate the evolution over 15 years of sleep schedules, sleepiness at the wheel and driving risk among highway drivers.

METHODS

Comparative survey including questions on usual sleep schedules and before the trip, sleepiness at the wheel, the Epworth sleepiness scale, Basic Nordic Sleep Questionnaire (BNSQ) and a travel questionnaire.

RESULTS

80% of drivers stopped by the highway patrol agreed to participate in both studies with a total of 3545 drivers in 2011 and 2196 drivers in 1996 interviewed. After standardisation based on sex, age and mean annual driving distance, drivers in 2011 reported shorter sleep time on week days (p<0.0001), and week-ends (p<0.0001) and shorter optimal sleep time (p<0.0001) compared to 1996 drivers. There were more drivers sleepy at the wheel in 2011 than in 1996 (p<0.0001) and 2.5 times more drivers in 2011 than in 1996 had an Epworth sleepiness score >15 indicating severe sleepiness.

CONCLUSIONS

Even if drivers in 2011 reported good sleep hygiene prior to a highway journey, drivers have reduced their mean weekly sleep duration over 15 years and have a higher risk of sleepiness at the wheel. Sleep hygiene for automobile drivers remains an important concept to address.

Removal of the mechanoprotective influence of the cytoskeleton reveals PIEZO1 is gated by bilayer tension

Mechanosensitive ion channels are force-transducing enzymes that couple mechanical stimuli to ion flux. Understanding the gating mechanism of mechanosensitive channels is challenging because the stimulus seen by the channel reflects forces shared between the membrane, cytoskeleton and extracellular matrix. Here we examine whether the mechanosensitive channel PIEZO1 is activated by force-transmission through the bilayer. To achieve this, we generate HEK293 cell membrane blebs largely free of cytoskeleton. Using the bacterial channel MscL, we calibrate the bilayer tension demonstrating that activation of MscL in blebs is identical to that in reconstituted bilayers. Utilizing a novel PIEZO1–GFP fusion, we then show PIEZO1 is activated by bilayer tension in bleb membranes, gating at lower pressures indicative of removal of the cortical cytoskeleton and the mechanoprotection it provides. Thus, PIEZO1 channels must sense force directly transmitted through the bilayer.

PIEZO1 is a mechanosensitive ion channel, but the mechanism of force transduction is unknown. Here Cox and Bae et al. disrupt the cortical cytoskeleton in HEK293 cells to show that PIEZO1 is gated directly by membrane tension.

A positive relationship between local abundance and regional occupancy is almost inevitable (but not all positive relationships are the same)

Recent attempts to examine the role of different mechanisms in generating a positive abundance-occupancy relationship failed to properly distinguish between Brown's (1984) sampling artefact, and the form of relationship to be expected from a random distribution of individuals. Because random distributions generate a positive relationship, one can never predict that removing the influence of some or all of the mechanisms will lead to 'no relationship'. In considering how the spatial aggregation of individuals might influence the form of the abundance-occupancy relationship it is demonstrated that curvilinear and triangular relationships are expected, and that correlation coefficients and linear regression statistics are unlikely to be sensitive to the addition and removal of mechanisms. Examining distributional data with alternative indices of spatial structure may lead to a more intuitive understanding of how different mechanisms influence the form of abundance-occupancy relationships.

The changes in prostate cancer and its management in the North West of England over a 10-year period

Objectives:

Our aim was to evaluate changes in prostate cancer diagnosis and management and to examine changes in the stage and grade of newly diagnosed prostate cancer in the North West of England over a 10-year period.

Materials and methods:

Data was collected concerning the diagnosis (including stage and grade) and management of newly diagnosed prostate cancer in the North West of England. There were three time points: 2003, 2007 and 2011 including a total of 648 patients. For assessment of median time changes Spearman’s Rank correlation test was used, for the assessment of changes in Gleason grade and clinical stage Mann–Whitney U test was used, and assessment of positive margin rates was done with Fisher’s test.

Results:

Median time from management decision to surgery has reduced from 46 (2003), 34 (2007) to 27 days (2011) ( p=0.074). The proportion of patients managed with active surveillance has remained relatively constant over time (18%, 16% and 21% respectively). More minimally invasive, nerve-sparing prostatectomies are now performed, and positive margin rates have significantly reduced from 53% (2003) to 23% (2011) ( p<0.001). Gleason grade significantly increased over time ( p<0.001); Gleason 7 disease was diagnosed in 23% of patients in 2003, 32% in 2007 and 49% in 2011 ( p<0.001). There was an increase in Gleason 8 disease; 6% (2003) to 8.6% (2011), but this was not significant ( p=0.27). Increase in clinical stage was also noted over time; identification of T3 disease rose from 2% (2003 and 2007) to 5% (2011) ( p=0.045) (excluding cases with non-recorded stage).

Conclusion:

Prostate cancer management in the North West of England has evolved over the last decade, with overall improvements in management quality. We have demonstrated an increase in the presenting stage and grade of prostate cancer over a 10-year period.

An experience sampling study of worry and rumination in psychosis

BACKGROUND

Increasing research effort is being dedicated to investigating the links between emotional processes and psychosis, despite the traditional demarcation between the two. Particular focus has alighted upon two specific anxious and depressive processes, worry and rumination, given the potential for links with aspects of delusions and auditory hallucinations. This study rigorously explored the nature of these links in the context of the daily life of people currently experiencing psychosis.

METHOD

Experience sampling methodology (ESM) was used to assess the momentary links between worry and rumination on the one hand, and persecutory delusional ideation and auditory hallucinations on the other. Twenty-seven participants completed the 6-day experience sampling period, which required repeated self-reports on thought processes and experiences. Multilevel modelling was used to examine the links within the clustered data.

RESULTS

We found that antecedent worry and rumination predicted delusional and hallucinatory experience, and the distress they elicited. Using interaction terms, we have shown that the links with momentary symptom severity were moderated by participants' trait beliefs about worry/rumination, such that they were reduced when negative beliefs about worry/rumination (meta-cognitions) were high.

CONCLUSIONS

The current findings offer an ecologically valid insight into the influence of worry and rumination on the experience of psychotic symptoms, and highlight possible avenues for future intervention strategies.

A home-based intervention using augmentative and alternative communication (AAC) techniques in rural Kenya: what are the caregivers' experiences?

BACKGROUND

Caring for a child with complex communication needs associated with a developmental condition frequently adds stress to the caregiver. Furthermore, professional assistance is scarce in low-income rural settings. For such children speech is frequently unachievable. Augmentative and alternative communication provides options for supplementing or replacing speech with other techniques. The current study aimed to examine the experiences of caregivers in Kenya before and after a home-based intervention using augmentative and alternative communication techniques with children with complex communication needs.

METHODS

Caregivers were interviewed pre- and post-intervention. The interviews were digitally recorded, transcribed and translated into English. Content analysis was applied through the stages of text familiarization and topic organization. Emergent themes and their sub-themes were identified and labelled. Connections between themes were established and interpretations made. The procedure was completed by a second researcher independently. Conflicting ideas were jointly discussed until consensus was achieved.

RESULTS

Four themes emerged from the data: communication process; struggle; normality; and supernatural power. Before intervention, the caregivers acknowledged their expertise in communications with the child, while also revealing their sense of isolation, burden and pain. Normality was present as a source of comparison and also an aspirational goal. Post-intervention more positive language was used to describe the child. There was an 'opening up' of communication that recognized the child's strengths and some social support systems were re-established. The power of the supernatural was recognized before and after intervention.

CONCLUSION

Caring of a child with complex communication needs presents many challenges. A home-based intervention using augmentative and alternative communication techniques appears to have been a catalyst for some positive transformations in the caregivers' experiences, although it is not possible to attribute this change to any one aspect. The potentials of the home-based intervention would benefit from further investigation on a larger scale.

Anxiety and depression in psychosis: a systematic review of associations with positive psychotic symptoms

OBJECTIVE

This review explores the influence of anxiety and depression on the experience of positive psychotic symptoms, and investigates the possibility of a causal role for anxiety and depression in the emergence and persistence of psychosis.

METHOD

A systematic literature search was undertaken, producing a number of papers which comment on the links between anxiety and depression, and the experience of delusions and hallucinations. In addition, evidence which could contribute to our understanding of the causal role of anxiety and depression was highlighted.

RESULTS

The findings show that both anxiety and depression are associated in meaningful ways with the severity of delusions and hallucinations, the distress they elicit and their content. However, the cross-sectional nature of the majority of studies and the focus on certain symptom subtypes tempers the validity of the findings. Data from non-clinical samples, studies which track the longitudinal course of psychosis and those which examine the impact of anxiety and depression on the prognosis for people experiencing psychosis, offer some support for the possibility of an influential role for anxiety and depression.

CONCLUSION

We conclude that anxiety and depression are related to psychotic symptom severity, distress and content and are also linked with sub-clinical experiences, symptom development, prognosis and relapse. These links may imply that anxiety and depression could be targets for therapeutic intervention. The article concludes with suggestions for further research, highlighting avenues which may circumvent the limitations of the body of work as it stands.

Understanding how women's groups improve maternal and newborn health in Makwanpur, Nepal: a qualitative study

Women's groups, working through participatory learning and action, can improve maternal and newborn survival. We describe how they stimulated change in rural Nepal and the factors influencing their effectiveness. We collected data from 19 women's group members, 2 group facilitators, 16 health volunteers, 2 community leaders, 21 local men, and 23 women not attending the women's groups, through semi-structured interviews, group interviews, focus group discussions and unstructured observation of groups. Participants took photographs of their locality for discussion in focus groups using photoelicitation methods. Framework analysis procedures were used, and data fed back to respondents. When group members were compared with 11 184 women who had recently delivered, we found that they were of similar socioeconomic status, despite the context of poverty, and caste inequalities. Four mechanisms explain the women's group impact on health outcomes: the groups learned about health, developed confidence, disseminated information in their communities, and built community capacity to take action. Women's groups enable the development of a broader understanding of health problems, and build community capacity to bring health and development benefit.

Caring for children with physical disability in Kenya: potential links between caregiving and carers' physical health

BACKGROUND

The health of a carer is a key factor which can affect the well-being of the child with disabilities for whom they care. In low-income countries, many carers of children with disabilities contend with poverty, limited public services and lack assistive devices. In these situations caregiving may require more physical work than in high-income countries and so carry greater risk of physical injury or health problems. There is some evidence that poverty and limited access to health care and equipment may affect the physical health of those who care for children with disabilities. This study seeks to understand this relationship more clearly.

METHODS

A mixed methods study design was used to identify the potential physical health effects of caring for a child with moderate-severe motor impairments in Kilifi, Kenya. Qualitative data from in-depth interviews were thematically analysed and triangulated with data collected during structured physiotherapy assessment.

RESULTS

Carers commonly reported chronic spinal pain of moderate to severe intensity, which affected essential activities. However, carers differed in how they perceived their physical health to be affected by caregiving, also reporting positive benefits or denying detrimental effects. Carers focussed on support in two key areas; the provision of simple equipment and support for their children to physically access and attend school.

CONCLUSIONS

Carers of children with moderate-severe motor impairments live with their own physical health challenges. While routine assessments lead to diagnosis of simple musculoskeletal pain syndromes, the overall health status and situation of carers may be more complex. As a consequence, the role of rehabilitation therapists may need to be expanded to effectively evaluate and support carers' health needs. The provision of equipment to improve their child's mobility, respite care or transport to enable school attendance is likely to be helpful to carers and children alike.

Mood disorders, circadian rhythms, melatonin and melatonin agonists

Recent advances in the understanding of circadian rhythms have led to an interest in the treatment of major depressive disorder with chronobiotic agents. Many tissues have autonomous circadian rhythms, which are orchestrated by the master clock, situated in the suprachiasmatic nucleus (SNC). Melatonin (N-acetyl-5-hydroxytryptamine) is secreted from the pineal gland during darkness. Melatonin acts mainly on MT1 and MT2 receptors, which are present in the SNC, regulating physiological and neuroendocrine functions, including circadian entrainment, referred to as the chronobiotic effet. Circadian rhythms has been shown to be either misaligned or phase shifted or decreased in amplitude in both acute episodes and relapse of major depressive disorder (MDD) and bipolar disorder. Manipulation of circadian rhythms either using physical treatments (such as high intensity light) or behavioral therapy has shown promise in improving symptoms. Pharmacotherapy using melatonin and pure melatonin receptor agonists, while improving sleep, has not been shown to improve symptoms of depression. A novel antidepressant, agomelatine, combines 5HT2c antagonist and melatonin agonist action, and has shown promise in both acute treatment of MDD and in preventing relapse.

Caring for children with disabilities in Kilifi, Kenya: what is the carer's experience?

BACKGROUND

Carers of children with disabilities have repeatedly highlighted their feelings of discrimination, stigma and exclusion in many domains of their lives. There is little research from Africa addressing these issues. This study investigated the challenges encountered by these carers and the mechanisms of coping with these challenges while caring for children with disabilities in a poor rural setting in Kenya.

METHODS

Thirty-five in-depth interviews were conducted with 20 carers, 10 community members and 5 primary school teachers. Ten unstructured observations were also conducted in home environments to observe mechanisms used in meeting the needs of the children with disabilities. All interviews were tape-recorded, transcribed and translated from the local dialect. Note-taking was performed during all the observations. Data were stored in NVivo software for easy retrieval and management.

RESULTS

The arrival of a disabled child severely impairs the expectations of carers. Hospital staff underestimate carers' emotional distress and need for information. Fear for the future, stress, rumour-mongering and poverty are encountered by carers. As they grapple with lost expectations, carers develop positive adaptations in the form of learning new skills, looking for external support and in some cases searching for cure for the problem. For their emotional stability, carers apply spiritual interventions and sharing of experiences.

CONCLUSION

Despite the challenges faced by the carers, values and priorities in adaptation to the challenges caused by the child's disability were applied. It is recommended that these experiences are considered as they may influence programmes that address the needs of children with disabilities.

How do children perceive health to be affected by domestic water carrying? Qualitative findings from a mixed methods study in rural South Africa

BACKGROUND

Nearly 50% of South African children lack access to clean safe water and many regularly carry water loads. The health effects of carrying water have not been well researched or considered when estimating the burden of disease due to suboptimal water supply. Improved access to safe water has potential to create important health and economic benefits, by reducing childhood exposure to risk factors for injury or disease. The aim of this study was to identify which domains of health children perceive as affected by water carrying.

METHODS

Qualitative research was used within a broader mixed methods design to investigate children's perceptions about health and water carrying in Limpopo Province, South Africa. Qualitative data from eight semi-structured interviews and three 'natural group meetings', involving a sample of 30 children, were analysed using the framework approach of Ritchie and Spencer. The results were mapped to the International Classification of Functioning Disability and Health (ICF).

RESULTS

Children broadly conceptualize and describe health to include the functions they perform and activities in which they participate. They perceived water carrying as impacting upon health in various ways, for example to make life better by facilitating water usage, or to make life worse through accidents and pain. Children's accounts demonstrate that they can identify and explain complex interactions between activities, participation and health.

CONCLUSIONS

The ICF framework facilitates the communication of children's perceptions of health and of relationships between health and water carrying. The model thus derived from their views incorporates not only commonly accepted conceptualizations of health condition, body structure and physiological function, but also of functioning through activities and social participation. Children's accounts suggest a possible association between water carrying and symptoms typical of musculoskeletal disorders. However, further research into the strength of association between water carrying and musculoskeletal disorders is needed.

Effectiveness and cost-effectiveness of height-screening programmes during the primary school years: a systematic review

OBJECTIVE

To determine the effectiveness and cost-effectiveness of height screening (of children aged 4 to 11) to identify height-related conditions.

DESIGN

Systematic review and economic modelling.

SETTING AND INTERVENTION

We included published and unpublished screening studies of any design, except case reports, conducted in any setting that measured children's height as part of a population-level assessment. Studies were identified by electronic database searches, contact with experts and from bibliographies of retrieved studies.

PARTICIPANTS

Children aged between 4 and 11 years.

OUTCOME MEASURES

Diagnostic yield of height-related conditions and change in quality of life, as measured by quality-adjusted life years (QALYs), for early versus late treatment of underlying conditions.

RESULTS

Twelve studies described a height-screening programme and provided data on the diagnostic yield of newly diagnosed height-related conditions. Where reported, yield for growth-hormone deficiency (per 1000 children screened) ranged from 0.05 (1 in 20,000) to 0.62 (approximately 1 in 1500) and for Turner syndrome (per 1000 children screened) was between 0.02 (1 in 50,000) and 0.07 (approximately 1 in 14,000). As a secondary gain, children with other potentially treatable conditions were identified; diagnostic yields ranged from 0.22 to 1.84 per 1000 children screened. Three studies did not detect any new cases, but all of these studies had methodological limitations. Economic modelling suggested that height screening is associated with health improvements and is cost effective for a willingness to pay threshold of pound 30,000 per QALY.

CONCLUSIONS

This review indicates the utility and acceptable cost-effectiveness of height screening arising from increased detection of height-related disorders and secondary pick-up of other undiagnosed conditions. Further research is needed to obtain more reliable data on quality of life gains and costs associated with early interventions for height-related conditions. The exact role of height-screening programmes in improving child health remains to be determined.

A systematic review of the routine monitoring of growth in children of primary school age to identify growth-related conditions

OBJECTIVES

To clarify the role of growth monitoring in primary school children, including obesity, and to examine issues that might impact on the effectiveness and cost-effectiveness of such programmes.

DATA SOURCES

Electronic databases were searched up to July 2005. Experts in the field were also consulted.

REVIEW METHODS

Data extraction and quality assessment were performed on studies meeting the review's inclusion criteria. The performance of growth monitoring to detect disorders of stature and obesity was evaluated against National Screening Committee (NSC) criteria.

RESULTS

In the 31 studies that were included in the review, there were no controlled trials of the impact of growth monitoring and no studies of the diagnostic accuracy of different methods for growth monitoring. Analysis of the studies that presented a 'diagnostic yield' of growth monitoring suggested that one-off screening might identify between 1:545 and 1:1793 new cases of potentially treatable conditions. Economic modelling suggested that growth monitoring is associated with health improvements [incremental cost per quality-adjusted life-year (QALY) of 9500 pounds] and indicated that monitoring was cost-effective 100% of the time over the given probability distributions for a willingness to pay threshold of 30,000 pounds per QALY. Studies of obesity focused on the performance of body mass index against measures of body fat. A number of issues relating to human resources required for growth monitoring were identified, but data on attitudes to growth monitoring were extremely sparse. Preliminary findings from economic modelling suggested that primary prevention may be the most cost-effective approach to obesity management, but the model incorporated a great deal of uncertainty.

CONCLUSIONS

This review has indicated the potential utility and cost-effectiveness of growth monitoring in terms of increased detection of stature-related disorders. It has also pointed strongly to the need for further research. Growth monitoring does not currently meet all NSC criteria. However, it is questionable whether some of these criteria can be meaningfully applied to growth monitoring given that short stature is not a disease in itself, but is used as a marker for a range of pathologies and as an indicator of general health status. Identification of effective interventions for the treatment of obesity is likely to be considered a prerequisite to any move from monitoring to a screening programme designed to identify individual overweight and obese children. Similarly, further long-term studies of the predictors of obesity-related co-morbidities in adulthood are warranted. A cluster randomised trial comparing growth monitoring strategies with no growth monitoring in the general population would most reliably determine the clinical effectiveness of growth monitoring. Studies of diagnostic accuracy, alongside evidence of effective treatment strategies, could provide an alternative approach. In this context, careful consideration would need to be given to target conditions and intervention thresholds. Diagnostic accuracy studies would require long-term follow-up of both short and normal children to determine sensitivity and specificity of growth monitoring.