Routine Outcome Monitoring in CAMHS: How Can We Enable Implementation in Practice?

BACKGROUND: Many CAMHS teams across the UK are now required to use Routine Outcome Monitoring (ROM). However, some clinicians hold negative attitudes towards ROM and various practical implementation issues have been identified. METHOD: The aim of this study was to explore clinician experiences of using ROM in the context of an 'enforced' initial implementation initiative. Twenty clinicians were surveyed at the beginning (T1) and end (T2) of the six-month period in a large UK CAMHS network adopting CYP-IAPT practice. Changes in the use of and attitudes towards ROM were investigated, as well as barriers to implementation. RESULTS: Overall, a small but significant increase in clinician use of ROM was observed from T1 to T2, but attitudes towards ROM did not change significantly. On the whole, clinicians were more positive than negative about ROM during the implementation period, but key implementation challenges included clinician concerns about the value and (mis)use of ROM data, poor technological support and additional workload demands. CONCLUSIONS: CAMHS clinicians will not necessarily become more receptive to ROM simply as a by-product of being asked to use it more. Seeking clinician feedback at the early stages of implementation can help provide a focus for improvement efforts. Ideas for future research and important limitations of the study are discussed.

ACE inhibition modifies exercise-induced pro-angiogenic and mitochondrial gene transcript expression.

Skeletal muscle responds to endurance exercise with an improvement of biochemical pathways that support substrate supply and oxygen-dependent metabolism. This is reflected by enhanced expression of associated factors after exercise and is specifically modulated by tissue perfusion and oxygenation. We hypothesized that transcript expression of pro-angiogenic factors (VEGF, tenascin-C, Angpt1, Angpt1R) and oxygen metabolism (COX4I1, COX4I2, HIF-1α) in human muscle after an endurance stimulus depends on vasoconstriction, and would be modulated through angiotensin-converting enzyme inhibition by intake of lisinopril. Fourteen non-specifically trained, male Caucasians subjects, carried out a single bout of standardized one-legged bicycle exercise. Seven of the participants consumed lisinopril in the 3 days before exercise. Biopsies were collected pre- and 3 h post-exercise from the m. vastus lateralis. COX4I1 (P = 0.03), COX4I2 (P = 0.04) mRNA and HIF-1α (P = 0.05) mRNA and protein levels (P = 0.01) showed an exercise-induced increase in the group not consuming the ACE inhibitor. Conversely, there was a specific exercise-induced increase in VEGF transcript (P = 0.04) and protein levels (P = 0.03) and a trend for increased tenascin-c transcript levels (P = 0.09) for subjects consuming lisinopril. The observations indicate that exercise-induced expression of transcripts involved in angiogenesis and mitochondrial energy metabolism are to some extent regulated via a hypoxia-related ACE-dependent mechanism.

PGC-1α transcriptional response and mitochondrial adaptation to acute exercise is maintained in skeletal muscle of sedentary elderly males.

The aim of the present study was to examine the effects of ageing and training status on (1) markers of skeletal muscle mitochondrial content and (2) the ability to activate the acute signalling pathways associated with regulating exercise-induced mitochondrial biogenesis. Muscle biopsies were obtained from the vastus lateralis muscle of young untrained (24 ± 4 years, n = 6; YU), young trained (22 ± 3 years, n = 6; YT), old untrained (65 ± 6 years, n = 6; OU) and old trained (64 ± 3 years, n = 6; OT) healthy males before and after (3 h and 3 days post-exercise) completion of high-intensity interval cycling exercise. In resting muscle, lifelong training preserved mtDNA, PGC-1α and COXIV protein content such that muscles from OT individuals were comparable to muscles from both YU and YT individuals, whereas lifelong sedentary behaviour reduced such markers of mitochondrial content. Regardless of age or training status, acute exercise induced comparable increases in p38MAPK phosphorylation immediately post-exercise, PGC-1α and COXIV mRNA expression at 3 h post-exercise and COXIV protein at 3 days post-exercise. Data demonstrate that lifelong endurance training preserves skeletal muscle PGC-1α content and that despite the mitochondrial dysfunction typically observed with sedentary ageing, muscles from sedentary elderly individuals retain the capacity to activate the acute signalling pathways associated with regulating the early processes of mitochondrial biogenesis. We consider our data to have immediate translational potential as they highlight the potential therapeutic effects of exercise to induce skeletal muscle mitochondrial biogenesis persist late in adulthood, even after a lifetime of physical inactivity.

Positional cloning of heart and soul reveals multiple roles for PKC lambda in zebrafish organogenesis.

BACKGROUND: The Par-3/Par-6/aPKC complex is a key regulator of cell polarity in a number of systems. In Drosophila, this complex acts at the zonula adherens (adherens junctions) to establish epithelial polarity and helps to orient the mitotic spindle during asymmetric neuroblast divisions. In MDCKII cells, this complex localizes to the zonula occludens (tight junctions) and appears to regulate epithelial polarity. However, the in vivo role of this complex during vertebrate embryogenesis is not known, due to the lack of relevant mutations. RESULTS: We have positionally cloned the zebrafish heart and soul (has) mutation, which affects the morphogenesis of several embryonic tissues, and show that it encodes atypical protein kinase C lambda (aPKC lambda). We find that loss of aPKC lambda affects the formation and maintenance of the zonula adherens in the polarized epithelia of the retina, neural tube, and digestive tract, leading to novel phenotypes, such as the formation of multiple lumens in the developing intestine. In addition, has mutants display defects in gut looping and endodermal organ morphogenesis that appear to be independent of the defects in epithelial polarity. Finally, we show that loss of aPKC lambda leads to defects in spindle orientation during progenitor cell divisions in the neural retina. CONCLUSIONS: Our results show that aPKC lambda is required for the formation and maintenance of the zonula adherens during early epithelial development in vertebrates and demonstrate a previously undescribed yet critical role for this protein in organ morphogenesis. Furthermore, our studies identify the first genetic locus regulating the orientation of cell division in vertebrates.

Cellular distribution of the GABAA receptor-modulating 3alpha-hydroxy, 5alpha-reduced pregnane steroids in the adult rat brain.

The 3alpha-hydroxy,5alpha-reduced pregnane steroids, allopregnanolone and allotetrahydrodeoxycorticosterone, are the most potent endogenous positive modulators of GABA(A) receptor-mediated inhibition. This study presents the first immunohistochemical examination of the cellular distribution of 3alpha-hydroxy,5alpha-reduced pregnane steroids across the brain. We found a widespread distribution in the adult rat, with dense immunolabelling in the olfactory bulb, striatum and cerebral cortex, and lower density labelling in the brainstem reticular formation. In general terms, this distribution accords with the regional concentrations of 3alpha-hydroxy,5alpha-reduced steroids determined, in other laboratories, by brain region sampling and either gas chromatography-mass fragmentography or radioimmunoassay. However, immunohistochemistry allowed for a more detailed examination of regional distribution and cellular specificity. All immunoreactivity was confined to the cell bodies and thick dendrites of neurones; no identifiable glia were labelled. In most brain areas, the location and morphology of labelled cells identified them as excitatory neurones. In addition, cell populations known to be projecting GABAergic neurones (e.g. cerebellar Purkinje cells) were immunoreactive, whereas local inhibitory neurones generally were not. The cellular distribution of 3alpha-hydroxy,5alpha-reduced steroids suggests that sensory, motor, limbic and homeostatic systems can be influenced by neurosteroids at multiple stages of processing.

Effects of exposure to Bovine viral diarrhoea virus 1 on risk of bovine respiratory disease in Australian feedlot cattle.

Viruses play a key role in the complex aetiology of bovine respiratory disease (BRD). Bovine viral diarrhoea virus 1 (BVDV-1) is widespread in Australia and has been shown to contribute to BRD occurrence. As part of a prospective longitudinal study on BRD, effects of exposure to BVDV-1 on risk of BRD in Australian feedlot cattle were investigated. A total of 35,160 animals were enrolled at induction (when animals were identified and characteristics recorded), held in feedlot pens with other cattle (cohorts) and monitored for occurrence of BRD over the first 50days following induction. Biological samples collected from all animals were tested to determine which animals were persistently infected (PI) with BVDV-1. Data obtained from the Australian National Livestock Identification System database were used to determine which groups of animals that were together at the farm of origin and at 28days prior to induction (and were enrolled in the study) contained a PI animal and hence to identify animals that had probably been exposed to a PI animal prior to induction. Multi-level Bayesian logistic regression models were fitted to estimate the effects of exposure to BVDV-1 on the risk of occurrence of BRD. Although only a total of 85 study animals (0.24%) were identified as being PI with BVDV-1, BVDV-1 was detected on quantitative polymerase chain reaction in 59% of cohorts. The PI animals were at moderately increased risk of BRD (OR 1.9; 95% credible interval 1.0-3.2). Exposure to BVDV-1 in the cohort was also associated with a moderately increased risk of BRD (OR 1.7; 95% credible interval 1.1-2.5) regardless of whether or not a PI animal was identified within the cohort. Additional analyses indicated that a single quantitative real-time PCR test is useful for distinguishing PI animals from transiently infected animals. The results of the study suggest that removal of PI animals and/or vaccination, both before feedlot entry, would reduce the impact of BVDV-1 on BRD risk in cattle in Australian feedlots. Economic assessment of these strategies under Australian conditions is required.

The significance of childhood neurosis for adult mental health: a follow-up study.

The author compared the mental health of 42 young adults who had suffered from a neurosis in childhood with that of 20 control subjects. Various aspects of functioning were clinically assessed using the Current and Past Psychopathology Scales and the Health-Sickness Rating Scale. More than 75% of the former patients were at least mildly ill at follow-up, compared with only 15% of the control group. Intergroup differences in diagnoses and symptoms are described. The findings establish the fact that neurotic children require much more effective treatment than they have traditionally received in order to attain a good prognosis for adult mental health.

School phobia and other childhood neuroses: a systematic study of the children and their families.

The authors developed reliable clinical rating scales to compare 35 children with school phobia and their families with a matched sample of children with other neuroses and their families. Twice as many school phobic children as children with other neuroses showed excessive separation anxiety, dependency, and depression. Although a mutually hostile-dependent interaction was found in most of the families of children with school phobia, the development of school phobia appeared to be dependent on defects in character development in the children as well. The authors discuss the etiological significance of the almost universal parental pathology and family malfunction for both groups of children.

CD10 positive thyroid marginal zone non-Hodgkin lymphoma.

A 72 year old woman presented with swelling of the right lobe of her thyroid gland. Fine needle aspiration and flow cytometry showed a clonal population of B cells expressing CD10 and a diagnosis of follicle centre cell lymphoma was made. Subsequent excision of the thyroid showed the typical histological features of a marginal zone non-Hodgkin lymphoma. Polymerase chain reaction showed no evidence of t (14;18). Immunohistochemistry confirmed CD10 positivity and LN1 (CDw75) expression. This is only the second report of aberrant expression of CD 10 by a marginal zone lymphoma.

Mycoplasma fermentans and HIV-associated nephropathy.

We describe a patient in whom HIV-associated nephropathy developed in association with the detection of Mycoplasma fermentans. This mycoplasma was found in renal tissue by means of a polymerase chain reaction when nephropathy was first evident, and subsequently in urine, blood and the throat. The evidence presented strengthens the causal association of this micro-organism with HIV-induced nephropathy.

Early aggressive management of cryptosporidial infection in AIDS.

We report two cases of cryptosporidiosis in patients with the acquired immunodeficiency syndrome (AIDS) which responded to early intervention with intravenous zidovudine and total parenteral nutrition (TPN).

Use of in vitro culture to isolate Babesia bovis from Theileria buffeli, Eperythrozoon wenyoni and Anaplasma spp.

On nine separate occasions, Babesia bovis microaerophilus stationary phase (MASP) cultures were initiated with blood from calves with concurrent infections of B. bovis and Theileria buffeli, Eperythrozoon wenyoni or Anaplasma spp. In each case B. bovis became established in culture and was maintained for 30-49 days. Culture material was inoculated into susceptible splenectomised calves to test for persistence of the other organisms. No haemoparasites other than B. bovis were detected in Giemsa-stained blood films of recipient calves and no antibodies to T. buffeli or Anaplasma were detected using indirect fluorescent antibody and card agglutination tests, respectively. The method provides a practical way of removing contaminants such as Theileria, Eperythrozoon and Anaplasma spp. from B. bovis isolates without the use of drugs, tick passage or repeated syringe passage in cattle.

Identification of an immunodominant 40 kDa merozoite antigen common to the Australian T and Dixie vaccine strains of Babesia bovis and the development of diagnostic tests specific for these strains.

Antigenic differences among Australian vaccine and field strains of Babesia bovis were investigated in an attempt to identify strain specific antigens. Immunoblots revealed substantial differences between the current vaccine strains, designated T and Dixie, and previous vaccine strains and field isolates collected on properties where vaccination with the T or Dixie strains had failed to provide complete protection against tick-borne challenge. A major difference was an immunodominant 40 kDa antigen (T40) present in only the T and Dixie strains. The molecular weight and immunodominant nature of this antigen suggest that it may be the equivalent of the major merozoite surface antigen (MSA-1) described by others in North American strains of B. bovis. MSA-1 was shown to be conserved in north American isolates but not in an isolate from Israel or in the Australian S and L isolates. The work presented here suggests that merozoite surface antigen diversity exists among geographically different isolates of B. bovis within Australia. Monospecific antiserum to T40 was used to develop an indirect fluorescent antibody (IFA) test specific for T and Dixie strain parasites, and a blocking enzyme-linked immunosorbent assay (ELISA) specific for antibody to the T and Dixie strains. In cases of babesiosis in recently vaccinated cattle, the IFA test will be a useful tool for determining whether clinical symptoms are due to a severe vaccine reaction or to a concurrent tick-borne infection. In a preliminary assessment of potential of the ELISA for the serological identification of vaccinated cattle using a total of 160 sera, the test clearly differentiated between animals vaccinated with the T or Dixie strains and non-vaccinated animals, and was not affected by presence of antibodies to other B. bovis strains.

Chronic pain and emotional distress in children and adolescents.

Pediatric chronic pain continues to be relatively underinvestigated and undertreated. The objective of the present cross-sectional study was to investigate the emotional distress hypothesized to be concurrently associated with the chronic pain experience in children and adolescents. One hundred and sixty children and adolescents with chronic pain and their parents completed standardized assessment instruments measuring pain intensity, depressive symptoms, state anxiety, trait anxiety, general self-esteem, and internalizing and externalizing behavior problems. Consistent with the a priori Biobehavioral Model of Pediatric Pain, higher patient-perceived pain intensity was associated with higher depressive and anxious symptoms, lower general self-esteem, and higher behavior problems. The results are discussed in regard to preventing and treating pain and suffering in children and adolescents with chronic pain.

Evaluation of an ELISA for detection of antibodies to Babesia bovis in cattle in Australia and Zimbabwe.

An enzyme-linked immunosorbent assay (ELISA) for antibodies to Babesia bovis was evaluated in comparison with the indirect fluorescent antibody test (IFAT) in Australia and Zimbabwe. Positive and negative threshold values for the ELISA were set using sera from cattle of known infection status. Sensitivity and specificity estimates for the ELISA based on 158 positive sera from cattle experimentally infected with Australian isolates of B. bovis and 318 negative sera collected from B. bovis-free herds in Australia were 100% and 99.4%, respectively. The specificity of the assay in Africa, based on 328 sera from B. bovis-free herds in Kenya and South Africa, was 99.7%. The ELISA was compared with the IFAT using sequential sera from 16 calves experiencing primary B. bovis infections, and a total of 777 field sera collected from B. bovis-endemic herds in Australia and Zimbabwe. In primary infections, the ELISA and IFAT detected antibodies at or about the same time. With sera from endemic herds, the performance of the ELISA was at least comparable with that of the IFAT. Two hundred and fourteen of 221 sera that were negative by IFAT, were negative by ELISA, and 428 of 439 sera that were clearly positive by IFAT were positive by ELISA. Of 117 sera that gave equivocal (suspect or weak positive) results in the IFAT, 20 were positive by ELISA, 7 were suspect and 90 were negative. We conclude that the ELISA will be useful for epidemiological studies on B. bovis in Australia and Zimbabwe, and probably elsewhere.

Transmission of Babesia spp by the cattle tick (Boophilus microplus) to cattle treated with injectable or pour-on formulations of ivermectin and moxidectin.

OBJECTIVE: To assess the efficacy of ivermectin and moxidectin to prevent transmission of Babesia bovis and Babesia bigemina by Boophilus microplus to cattle under conditions of relatively intense experimental challenge. DESIGN: Naive Bos taurus calves were treated with either pour-on or injectable formulations of either ivermectin or moxidectin and then exposed to larvae of B microplus infected with B bovis or larvae or adults of B microplus infected with B bigemina. One calf was used for each combination of haemoparasite, B microplus life stage, drug and application route. PROCEDURE: Groups of calves were treated with the test drugs in either pour-on or injectable formulation and then infested with B microplus larvae infected with B bovis or B bigemina. B bigemina infected adult male ticks grown on an untreated calf were later transferred to a fourth group of animals. Infections were monitored via peripheral blood smears to determine haemoparasite transmission. RESULTS: Cattle treated with either pour-on or injectable formulations of ivermectin and moxidectin became infected with B bovis after infestation with infected larvae. Similarly, larvae infected with B bigemina survived to the nymphal stage to transmit the haemoparasite to animals treated with each drug preparation. Cattle treated with pour-on formulations of ivermectin and moxidectin then infested with adult male ticks infected with B bigemina did not become infected with B bigemina whereas those treated with the injectable formulations of ivermectin and moxidectin did show a parasitaemia. CONCLUSIONS: Injectable or pour-on formulations of ivermectin and moxidectin do not prevent transmission of Babesia to cattle by B microplus. Use of these drugs can therefore not be recommended as a primary means of protecting susceptible cattle from the risk of Babesia infection.

On the efficacy of psychoanalysis.

In this study we critically review the formal research literature pertinent to the outcomes of psychoanalysis and the factors influencing these outcomes. Our inquiry was conducted from a psychoanalytic perspective. We found the research yield consistent with the accumulated body of clinically derived psychoanalytic knowledge, e.g., patients suitable for psychoanalysis derive substantial therapeutic benefit; analyzability and therapeutic benefit are relatively separate dimensions and their extent is relatively unpredictable from the perspective of initial evaluation among seemingly suitable cases. The studies all contain clinical and methodological limitations which are no more substantial than in other forms of psychotherapy research, but they have not substantially advanced psychoanalytic knowledge. This raises challenges for the further development of formal research strategies native to psychoanalysis.

Slips of the analyst.

Understanding the analyst's work and its vicissitudes has been a major focus of recent psychoanalytic writing. This study on slips of the analyst represents an attempt to advance our understanding of analytic work. The slips described support the view that slips reflect not simply contributions from instinctual life, but active work-related goals of the analyst in carrying out the analytic tasks. Countertransference is discussed as reflected in the disturbance of intentionality betrayed by the occurrence of a slip. The essential role of the analyst's understanding his or her own reactions is emphasized.

How can we study the efficacy of psychoanalysis?

Psychoanalytic efficacy has been demonstrated in general, but not in comparison with other therapies, nor with detailed study of the relationship between process and outcome. The steps necessary to accomplish such studies are outlined, along with a review of our present readiness. Crucial dimensions of such work are explored, including the use of single case studies, and ways of looking at sequences of interaction between analyst and patient as they change during various phases of treatment. Methods of using control and comparison groups and follow-up studies are described, and various promising specific strategies are proposed.