A cluster randomised, 16-week, parallel-group multicentre trial to compare the effectiveness of a digital school-based cognitive behavioural resilience/wellbeing-building intervention targeting emotional and behavioural problems in vulnerable Year 4 primary school children in whole classes, to the usual school curriculum: a study protocol to the "CUES for Schools" trial.

BACKGROUND: Around 10% of school-aged children experience mental health difficulties. Many more are 'vulnerable': experiencing emotional and/or behavioural problems reaching clinical levels, and thus at greatest risk of future mental illness. The trial aim is to evaluate the effectiveness of the CUES for schools programme in reducing emotional and behavioural problems in vulnerable children. METHODS: The "CUES for Schools" study is a multicentre cluster randomised controlled trial in primary schools in south east England. Schools will be randomised to receive the usual school curriculum, or the CUES programme (1:1). We aim to enrol 74 schools (5550 children including 2220 vulnerable children). CUES is a whole-class teacher-facilitated interactive digital cognitive-behavioural intervention, delivered as 24 short (20-min) modules over 12 weeks, targeting emotional/behavioural regulation skills. Children self-report emotional/behavioural problems at baseline, 8, and 16 weeks, and wellbeing and cognitive vulnerability at 0 and 16 weeks. Adverse events are assessed at 8 and 16 weeks. Teachers rate classroom behaviour at baseline and 16 weeks. School senior leadership teams and individual teachers consent to involvement in the study; parents can opt their child out of CUES sessions, assessments, or research. Children can similarly opt out and assent to research participation. The primary objective of this trial is to evaluate the effectiveness of CUES for schools compared to the usual school curriculum in improving emotional/behavioural problems for vulnerable Year 4 (8-9 years old) children at 16 weeks post-randomisation, as measured using a standardised questionnaire designed for primary schools. The secondary objective is to investigate the impact of the CUES for schools programme on both vulnerable and non-vulnerable children on wellbeing and teacher-rated classroom behaviour. DISCUSSION: The study will show whether CUES for schools is more effective than the usual curriculum in reducing emotional and behavioural problems in vulnerable Year 4 children, and thus reducing the risk of mental health difficulties in later adolescent and adult life. As a digital, teacher-facilitated intervention, CUES for schools can be readily implemented, at minimal cost. If effective, CUES for schools therefore has the potential to reduce the impact of emotional/behavioural difficulties on children's learning, behaviour, and relationships and the burden of future mental health morbidity. TRIAL REGISTRATION: Trial Registration ISRCTN11445338. Registered on September 12, 2022.

Distressing psychotic-like experiences, cognitive functioning and early developmental markers in clinically referred young people aged 8-18 years.

PURPOSE: Neurocognitive difficulties and early childhood speech/motor delays are well documented amongst older adolescents and young adults considered at risk for psychosis-spectrum diagnoses. We aimed to test associations between unusual or psychotic-like experiences (PLEs), co-occurring distress/emotional symptoms, current cognitive functioning and developmental delays/difficulties in young people (aged 8-18 years) referred to Child and Adolescent Mental Health Services in South London, UK. METHODS: Study 1 examined receptive language, verbal learning and caregiver-reported speech and motor delays/difficulties in a sample of 101 clinically-referred children aged 8-14 years, comparing those reporting no PLEs (n = 19), PLEs without distress (n = 16), and PLEs with distress (n = 66). Study 2 tested associations of severity of distressing PLEs with vocabulary, perceptual reasoning, word reading and developmental delays/difficulties in a second sample of 122 adolescents aged 12-18 years with distressing PLEs. RESULTS: In Study 1, children with distressing PLEs had lower receptive language and delayed recall and higher rates of developmental delays/difficulties than the no-PLE and non-distressing PLE groups (F values: 2.3-2.8; p values: < 0.005). Receptive language (ß = 0.24, p = 0.03) and delayed recall (ß = - 0.17, p = 0.02) predicted PLE distress severity. In Study 2, the cognitive-developmental variables did not significantly predict PLE distress severity (ß values = 0.01-0.22, p values: > 0.05). CONCLUSION: Findings may be consistent with a cognitive-developmental model relating distressing PLEs in youth with difficulties in cognitive functioning. This highlights the potential utility of adjunctive cognitive strategies which target mechanisms associated with PLE distress. These could be included in cognitive-behavioural interventions offered prior to the development of an at-risk mental state in mental health, educational or public health settings.

Prevalence of non-tuberculous mycobacteria in HIV-infected patients admitted to hospital with pneumonia.

People living with the human immunodeficiency virus (PLWH) may be particularly vulnerable to the consequences of non-tuberculous mycobacteria (NTM) given their defective T cell-mediated immunity and high rates of structural lung disease. To determine the prevalence of NTM in PLWH hospitalized with pneumonia and to assess the potential predictors of NTM isolation. Secondary data analysis of a prospective cohort study (2007-2011) of early bronchoscopy in PLWH presenting with suspected pneumonia was undertaken. Subjects with any species of NTM, henceforth described as 'NTM of undetermined significance' (NTM-US), isolated from sputum or bronchoalveolar lavage fluid (BALF), were included in the analysis. Potential predictors were chosen a priori. Among 196 HIV-infected subjects hospitalized with pneumonia, 96 had respiratory samples positive for NTM-US, with 91% of all NTM-US isolated from sputum compared with BALF. The overall prevalence of NTM-US was 49% (96/196). More NTM subjects were smokers (P = 0.08), with a history of chronic obstructive pulmonary disease (P = 0.08). Among those with pathogenic NTM, 39% (34/88) would have met American Thoracic Society microbiologic criteria for NTM pulmonary disease (17% of total cohort). Respiratory cultures, predominantly sputum samples, were positive for NTM-US in 45% of HIV-infected subjects admitted to hospital for pneumonia. Further research is needed to characterize the prevalence of NTM in PLWH and help establish specific diagnostic criteria in this population. .

Understanding the relationship between schematic beliefs, bullying, and unusual experiences in 8-14 year olds.

BACKGROUND: Cognitive models of adult psychosis propose that negative schematic beliefs (NSBs) mediate the established association between victimisation and psychotic symptoms. In childhood, unusual, or psychotic-like, experiences are associated with bullying (a common form of victimisation) and NSBs. This study tests the mediating role of NSBs in the relationship between bullying and distressing unusual experiences (UEDs) in childhood. METHOD: Ninety-four 8-14 year olds referred to community Child and Adolescent Mental Health Services completed self-report assessments of UEDs, bullying, and NSBs about the self (NS) and others (NO). RESULTS: Both NS and NO were associated with bullying (NS: r=.40, P<.001; NO: r=.33, P=.002), and with UEDs (NS: r=.51, P<.001; NO: r=.43, P<.001). Both NS and NO significantly mediated the relationship between bullying and UEDs (NS: z=3.15, P=.002; NO: z=2.35, P=.019). CONCLUSIONS: Children's NSBs may mediate the adverse psychological impact of victimisation, and are appropriate treatment targets for young people with UEDs. Early educational intervention to reduce negative appraisals of the self and others may increase resilience to future adverse experiences and reduce later mental health risk.

A preliminary investigation of schematic beliefs and unusual experiences in children.

BACKGROUND: In cognitive models of adult psychosis, schematic beliefs about the self and others are important vulnerability and maintaining factors, and are therefore targets for psychological interventions. Schematic beliefs have not previously been investigated in children with distressing unusual, or psychotic-like, experiences (UEDs). The aim of this study was firstly to investigate whether a measure of schematic beliefs, originally designed for adults with psychosis, was suitable for children; and secondly, to examine the association of childhood schematic beliefs with internalising and externalising problems and with UEDs. METHOD: Sixty-seven children aged 8-14 years, with emotional and behavioural difficulties, completed measures of UEDs, internalising (depression and anxiety), and externalising (conduct and hyperactivity-inattention) problems, together with the Brief Core Schema Scales (BCSS). RESULTS: The BCSS was readily completed by participants, and scale psychometric properties were good. Children tended to view themselves and others positively. Internalising and externalising problems and UEDs were all associated with negative schematic beliefs; effect sizes were small to medium. CONCLUSIONS: Schematic beliefs in young people can be measured using the BCSS, and negative schematic beliefs are associated with childhood psychopathology and with UEDs. Schematic beliefs may therefore form a useful target in psychological interventions for young people with UEDs.

Delusional belief flexibility and informal caregiving relationships in psychosis: a potential cognitive route for the protective effect of social support.

Aims. For people with psychosis, contact with informal caregivers is an important source of social support, associated with recovery, and with better outcomes following individual cognitive therapy (CBTp). In this study, we tested whether increased flexibility in delusional thinking, an established predictor of positive outcome following CBTp, was a possible mechanism underlying this effect. Methods. 219 participants with delusions (mean age 38 years; 71% male; 75% White) were grouped according to the presence of a caregiver (37% with a caregiver) and caregiver level of expressed emotion (High/Low EE, 64% Low). Delusional belief flexibility was compared between groups, controlling for interpersonal functioning, severity of psychotic symptoms, and other hypothesised outcome predictors. Results. Participants with caregivers were nearly three times more likely than those without to show flexibility (OR = 2.7, 95% CI 1.5 to 5.0, p = 0.001), and five times more likely if the caregiving relationship was Low EE (OR = 5.0, 95% CI 2.0-13.0, p = 0.001). ORs remained consistent irrespective of controlling for interpersonal functioning and other predictors of outcome. Conclusions. This is the first evidence that having supportive caregiving relationships is associated with a specific cognitive attribute in people with psychosis, suggesting a potential cognitive mechanism by which outcomes following CBTp, and perhaps more generally, are improved by social support.

Psychological interventions for adolescent psychosis: a pilot controlled trial in routine care.

PURPOSE: Evidence for the recommendation to deliver Cognitive Behavioural Therapy (CBT) and Family Interventions (FI) to under-18s with psychosis derives from adult research, and no previous study has focused exclusively on an adolescent population. We evaluated adaptations of these therapies for adolescent inpatients with psychosis (CBTpA and FIpA), delivered as an adjunct to inpatient standard care (SC). SUBJECTS AND METHODS: Thirty adolescent inpatients with psychotic symptoms on admission were sequentially allocated to receive CBTpA+SC (n=10); FIpA+SC (n=10) or SC alone (n=10). Psychotic symptoms and functioning were measured at admission and discharge. RESULTS: Group comparisons did not reach conventional significance, but effect sizes in this pilot study showed a promising impact of CBTpA compared to SC alone, in reducing symptoms (ES: d=0.6), with smaller effect sizes for functioning (d=0.2) and for FIpA (symptoms, d=0.1 and functioning, d=0.4). There was no advantage of either additional treatment in reducing length of stay, but self-report satisfaction ratings were higher for both psychological therapies. DISCUSSION AND CONCLUSIONS: The study is the first to focus on an exclusively adolescent population, using appropriately adapted therapy protocols. Findings suggest that the interventions are feasible, acceptable and helpful for adolescents with psychosis. Larger randomised controlled trials are now needed.

Low intensity cognitive behavioural therapy for psychosis: a pilot study.

BACKGROUND AND OBJECTIVES: The dissemination and delivery of psychological therapies for people with psychosis has been limited by workforce and organisational factors. 'Low Intensity' (LI) delivery, whereby staff are trained to deliver brief, focused, manualised interventions, may be one way of improving access. In this study, we piloted a new LI intervention specifically for people with psychosis, aimed at helping people to reach a personal recovery goal, whilst targeting anxious avoidance or depression-related inactivity. Frontline mental health workers were trained to deliver the intervention. We report here on the impact of the intervention on therapeutic outcomes. METHODS: Twelve people with psychosis and either anxious avoidance or low mood, who wanted to work towards a personal goal, completed the intervention and a battery of assessments of mood, functioning and psychotic symptoms. RESULTS: Eleven out of the twelve participants achieved their personal goals. The results of a series of Friedman K related sample tests revealed significant improvements in depression, clinical distress, activity levels, negative symptoms and delusions across the three time points, and no change in hallucinations, or anxious avoidance. Staff and participant satisfaction was high. LIMITATIONS: The study is a small uncontrolled pilot study. Outcomes should therefore be interpreted with caution, pending replication. CONCLUSIONS: The new LI intervention shows preliminary evidence of effectiveness and is a feasible model of therapy delivery for people with psychosis. The results suggest that frontline mental health workers can be trained relatively easily to deliver the intervention. A larger, randomised controlled trial is warranted to determine the effectiveness of the intervention and training programme.

Patients' beliefs about the causes, persistence and control of psychotic experiences predict take-up of effective cognitive behaviour therapy for psychosis.

BACKGROUND: There is evidence that patients with schizophrenia benefit from standard cognitive behaviour therapy (CBT) only if active techniques are used ('full therapy'). By contrast, attending sessions but not proceeding beyond engagement and assessment strategies ('partial therapy'), or simply not attending sessions ('no therapy'), is not associated with better outcomes. The factors leading to full therapy are unknown. We hypothesized that patients' initial ideas about the nature and extent of their problems would predict use of CBT. A match between patients' views of their problems and the principles underlying treatment would lead to better outcomes. METHOD: Ninety-two patients with a recent relapse of psychosis completed the Illness Perception Questionnaire (IPQ) before receiving CBT. We examined whether their illness perceptions predicted the take-up of therapy. RESULTS: Patients who did not attend sessions believed their problems would not last as long as those who attended them. Those who attended sessions but did not proceed to full therapy had a lower sense of control over their problems and a more biological view of their causes. Patients who took up full therapy were more likely to attribute the cause of their problems to their personality and state of mind. The take-up of therapy was predicted neither by levels of psychiatric symptoms nor by insight. CONCLUSIONS: People with psychosis who have psychologically orientated views of their problems, including the potential to gain control over them, may be more likely to engage fully and do well with standard CBT for psychosis, irrespective of the severity of their problems.

Effective elements of cognitive behaviour therapy for psychosis: results of a novel type of subgroup analysis based on principal stratification.

BACKGROUND: Meta-analyses show that cognitive behaviour therapy for psychosis (CBT-P) improves distressing positive symptoms. However, it is a complex intervention involving a range of techniques. No previous study has assessed the delivery of the different elements of treatment and their effect on outcome. Our aim was to assess the differential effect of type of treatment delivered on the effectiveness of CBT-P, using novel statistical methodology. METHOD: The Psychological Prevention of Relapse in Psychosis (PRP) trial was a multi-centre randomized controlled trial (RCT) that compared CBT-P with treatment as usual (TAU). Therapy was manualized, and detailed evaluations of therapy delivery and client engagement were made. Follow-up assessments were made at 12 and 24 months. In a planned analysis, we applied principal stratification (involving structural equation modelling with finite mixtures) to estimate intention-to-treat (ITT) effects for subgroups of participants, defined by qualitative and quantitative differences in receipt of therapy, while maintaining the constraints of randomization. RESULTS: Consistent delivery of full therapy, including specific cognitive and behavioural techniques, was associated with clinically and statistically significant increases in months in remission, and decreases in psychotic and affective symptoms. Delivery of partial therapy involving engagement and assessment was not effective. CONCLUSIONS: Our analyses suggest that CBT-P is of significant benefit on multiple outcomes to patients able to engage in the full range of therapy procedures. The novel statistical methods illustrated in this report have general application to the evaluation of heterogeneity in the effects of treatment.

Implementing the NICE guideline for schizophrenia recommendations for psychological therapies: a qualitative analysis of the attitudes of CMHT staff.

OBJECTIVES: Despite national guidelines recommending cognitive-behavioural therapy (CBT) and family intervention (FI) in the treatment of schizophrenia, levels of implementation in routine care remain low. The present study investigates attitudinal factors amongst community mental health team (CMHT) staff affecting guideline implementation. DESIGN: CMHTs were audited to measure the capacity and delivery of CBT and FI, and semi-structured interviews were conducted with staff from the teams. Methods. Four CMHTs were audited, and five care coordinators from each team were interviewed. A purposive approach to sampling was used to represent the range of professional training of care coordinating staff. Data were analysed using thematic content analysis. RESULTS: Positive views towards guidelines were evident, although tempered by specific implementation issues. Employing simple psychological interventions and approaches as part of the care coordinating role also emerged as highly valued by staff. Severe workload, time pressure and the need for specialist staff were crucial barriers to implementation. Pessimistic views of recovery for clients with psychosis were also apparent and may affect implementation. CONCLUSIONS: Staff attitudes and knowledge are an important area of research when examining guideline implementation and require further study. Key themes that have emerged could inform future training agendas and should be considered when developing guideline implementation strategies for the updated 2009 guidelines.

The influence of schizotypy traits on prepulse inhibition in young healthy controls.

Deficits in sensorimotor gating or prepulse inhibition (PPI) have been demonstrated repeatedly in patients with schizophrenia or with schizotypal personality disorder, but not consistently in schizotypal non-psychiatric controls. The appearance of normal PPI in this group has been interpreted as reflecting a discontinuous underlying vulnerability to psychosis in high-risk groups. An alternative interpretation is that underlying vulnerability to psychosis is continuously distributed in the normal population (Claridge, 1972, 1987), and therefore that performance on information processing tasks should vary continuously with increasing levels of schizotypy in non-clinical populations. We attempted to examine further the notion of a continuous relationship between PPI and schizotypy in 44 (17 female, 27 male) healthy, non-smoking subjects controlling for menstrual phase. In this selected sample, the findings do not support a continuum model, and suggest that PPI deficits may indeed be the result of a discontinuous neurophysiological change in those with psychotic illness, rather than one continuously distributed in the normal population.

Promoting teenage sexual health: an investigation into the knowledge, activities and perceptions of gynaecology nurses.

AIM: This study was designed to investigate the teenage sexual health service provided by gynaecology nurses at Queen's Medical Centre, Nottingham, United Kingdom (UK), by assessing their knowledge, activities and perceptions in relation to teenage sexual health. BACKGROUND: Part of a gynaecology nurse's work is caring for teenagers with sexual health problems, including unwanted pregnancies and sexually transmitted infections (STIs). Given the current national focus in the UK on improving teenage sexual health, there is clearly a role for gynaecology nurses to play, but this is rarely referred to in published literature and appears to be poorly defined. METHOD: A cross sectional survey of all gynaecology nurses at Queen's Medical Centre was carried out, followed by semi-structured interviews with a small random subsample. FINDINGS: Results indicated that, although 65% of nurses had worked on the gynaecology unit for more than 5 years, there was poor knowledge, an inconsistent pattern of nursing interventions and negative perceptions of the service offered. A majority of the nurses (87%) had not received any specific training in how to nurse teenagers with sexual health problems and 65% considered that the quality of sexual health service offered to teenagers was poor. Unexpected findings included poor general knowledge of local teenage sexual health services, the emotional effect on some nurses caring for young teenagers undergoing medical terminations of pregnancy (ToP), and the complete lack of training and protocols for taking a sexual history. CONCLUSIONS: The nurses felt that the teenage sexual health service provided could be improved by better staff training, better information for teenagers and better organization. Recommendations have been made as a result of the study but the staff will need management support to ensure that changes are effective. Generalizations cannot be drawn from a study in one hospital but the results could reflect the low profile given to the teenage sexual health aspect of gynaecology nurses' work in the UK.

Regulation of cell morphology and cytochrome P450 expression in human hepatocytes by extracellular matrix and cell-cell interactions.

The influence of extracellular matrix conditions and plating density on cell cytoarchitecture and the constitutive and chemically induced expression of cytochrome P450 3A4 (CYP3A4) was examined in primary cultures of human hepatocytes. Constitutive and drug-induced microsomal CYP3A4 expression occurred equally well in human hepatocyte cultures maintained on either a complex or simple substratum (Matrigel vs collagen, type I), or in a sandwich configuration (i.e., between two layers of extracellular matrix), despite the markedly different morphological properties exhibited by each condition. However, a density-dependent decrease in both the constitutive and induced levels of CYP3A4 was observed in hepatocytes maintained on a simple collagen substratum as plating density was reduced from 100% to 25%. Marked alterations in cell shape and cytoarchitecture were noted concomitant with decreases in the expression and localization of intercellular gap junctions and E-cadherin-mediated cell adhesions. In addition, the intracellular distribution of microtubules and microfilaments was altered substantially and the expression of immunoreactive actin and beta-tubulin increased as cell density was decreased. These effects were reversed to some extent by overlaying monolayers with extracellular matrix or by co-culturing with another cell type. Efforts to maintain normal cell shape and cytoskeletal distribution in hepatocytes at low cell density with a Matrigel substratum failed to restore normal basal levels of CYP3A4 expression or responsiveness to rifampicin (RIF). Likewise, E-cadherin and Cx-32 expression was again reduced, even though the distribution and expression of cytoskeletal elements returned to normal levels. These results suggest that cell-cell contacts, but not the extracellular matrix configuration or composition, play a critical role in determining normal responsiveness to chemical modulators in human hepatocytes.

Managing post-operative nausea and vomiting.

Post-operative nausea and vomiting leads to unnecessary suffering for many surgical patients. Improved nursing management can help prevent and better treat this condition.

Post-operative nausea and vomiting: a survey of nurses' knowledge.

Many patients experience the discomfort of post-operative nausea and vomiting. This article reports on a survey to find out just how much nurses know about relieving these distressing symptoms.

Patient information on post-operative sickness.

AIM: To determine the amount of information patients received on post-operative nausea and vomiting and whether this could be improved. METHOD: A convenience sample of 140 post-operative patients was questioned. The patients were asked whether they had received any information, whether they thought information provision could be improved, whether an information leaflet would be useful and what information could be included. This led to a patient information leaflet being designed and piloted with 30 patients. A clear policy for patient education and staff training was also drawn up and a second audit was later carried out with 150 patients. RESULTS: About half the patients questioned in the first audit had not received any information, but thought that a patient information leaflet would be useful. On re-audit, 86 per cent of patients questioned had received information. Approximately half had the new patient information leaflet and only four did not receive any information. About 80 per cent of patients no longer thought it important to improve the information provision. CONCLUSION: This study showed that addressing information provision on post-operative nausea and vomiting with the use of audit led to a vast improvement in patient satisfaction with the amount of information they received.

Characterization and management of paraesophageal hernias in children after antireflux operation.

PURPOSE: The aim of this study was to determine the important factors in the development and subsequent treatment of postoperative paraesophageal hernia (PPEH). METHODS: A retrospective analysis was performed in 464 consecutive children (ages 3 days to 18 years) for PPEH after a primary antireflux operation performed at a Children's Hospital and University Hospital between 1985 and 1997. All operations included a crural repair, but the Nissen fundoplication was performed with (n = 162) and without (n = 70) plication of the esophagus to the crus at 3 points. Patients with and without PPEH were compared with respect to the type of antireflux operation, the patient's age at operation, and the preoperative and postoperative clinical courses. A preoperative corrected gastric emptying value was obtained from a radionuclide gastric emptying study in 289 patients. The treatment of PPEH also was examined. RESULTS: The incidence of PPEH in our patients was 4.5% (21 of 464). Although there was a lower incidence of PPEH in patients with crural plication compared with patients without crural plication during Nissen fundoplication (5 of 162, 3% v 7 of 70, 10%; P = .035), 2 patients with crural plication had a postoperative esophageal leak. Patients with PPEH had a significantly increased prevalence of gagging before the initial antireflux operation compared with patients without PPEH (3 of 21, 14.3% v 7 of 443, 1.6%; P = .007). A higher prevalence of slow corrected gastric emptying preoperatively also was seen in patients with PPEH compared with patients without PPEH (8 of 15, 53% v 79 of 274, 29%; P = .046). The prevalences of central nervous system disease, young age (<6 months) at initial operation, and a particular type of antireflux operation were not higher in patients with PPEH. Nine patients with a small PPEH treated by simple observation alone subsequently had resolution of symptoms. CONCLUSIONS: Patients who have gagging or slow corrected gastric emptying before an antireflux operation are at higher risk for a postoperative paraesophageal hernia. Patients with a small postoperative paraesophageal hernia can be treated nonoperatively. Crural plication of the esophagus during Nissen fundoplication reduces the occurrence of postoperative paraesophageal hernia, but also may result in significant morbidity.