Can mental health treatments help prevent or reduce intimate partner violence in low- and middle-income countries? A systematic review.

BACKGROUND: Epidemiological research suggests an interrelationship between mental health problems and the (re)occurrence of intimate partner violence (IPV). However, little is known about the impact of mental health treatments on IPV victimization or perpetration, especially in low- and middle-income countries (LMIC). METHODS: We conducted a systematic review to identify prospective, controlled studies of mental health treatments in LMIC. We defined 'mental health treatment' as an intervention for individuals experiencing mental ill health (including substance misuse) including a substantial psychosocial or pharmacological component. Studies had to measure a mental health and IPV outcome. We searched across multi-disciplinary databases using a structured search strategy. Screening of title/abstracts and full-text eligibility assessments were conducted by two researchers independently, data were extracted using a piloted spreadsheet, and a narrative synthesis was generated. RESULTS: We identified seven studies reported in 11 papers conducted in five middle-income countries. With the exception of blinding, studies overall showed acceptable levels of risk of bias. Four of the seven studies focused on dedicated mental health treatments in various populations, including: common mental disorders in earthquake survivors; depression in primary care; alcohol misuse in men; and alcohol misuse in female adult sex workers. The dedicated mental health treatments targeting depression or alcohol misuse consistently reduced levels of these outcomes. The two studies targeting depression also reduced short-term IPV, but no IPV benefits were identified in the two alcohol-focused studies. The other three studies evaluated integrated interventions, in which a focus on substance misuse was part of efforts to reduce HIV/AIDS and violence against particularly vulnerable women. In contrast to the dedicated mental health interventions, the integrated interventions did not consistently reduce mental ill health or alcohol misuse compared to control conditions. CONCLUSIONS: Too few studies have been conducted to judge whether mental health treatments may provide a beneficial strategy to prevent or reduce IPV in LMIC. Key future research questions include: whether promising initial evidence on the effects of depression interventions on reducing IPV hold more broadly, the required intensity of mental health components in integrated interventions, and the identification of mechanisms of IPV that are amenable to mental health intervention.

Measuring implementation in global mental health: validation of a pragmatic implementation science measure in eastern Ukraine using an experimental vignette design.

BACKGROUND: There is mounting evidence supporting the effectiveness of task-shifted mental health interventions in low- and middle-income countries (LMIC). However, there has been limited systematic scale-up or sustainability of these programs, indicating a need to study implementation. One barrier to progress is a lack of locally relevant and valid implementation measures. We adapted an existing brief dissemination and implementation (D&I) measure which includes scales for acceptability, appropriateness, feasibility and accessibility for local use and studied its validity and reliability among a sample of consumers in Ukraine. METHODS: Local qualitative data informed adaptation of the measure and development of vignettes to test the reliability and validity. Participants were veterans and internally displaced persons (IDPs) recruited as part of a separate validity study of adapted mental health instruments. We examined internal consistency reliability, test-retest reliability, and construct and criterion validity for each scale on the measure. We randomly assigned half the participants to respond to a vignette depicting existing local psychiatric services which we knew were not well regarded, while the other half was randomized to a vignette describing a potentially more well-implemented mental health service. Criterion validity was assessed by comparing scores on each scale by vignette and by overall summary ratings of the programs described in the vignettes. RESULTS: N = 169 participated in the qualitative study and N = 153 participated in the validity study. Qualitative findings suggested the addition of several items to the measure and indicated the importance of addressing professionalism/competency of providers in both the scales and the vignettes. Internal consistency reliabilities ranged from α = 0.85 for feasibility to α = 0.91 for appropriateness. Test-rest reliabilities were acceptable to good for all scales (rho: 0.61-0.79). All scales demonstrated substantial and significant differences in average scores by vignette assignment (ORs: 2.21-5.6) and overall ratings (ORs: 5.1-14.47), supporting criterion validity. CONCLUSIONS: This study represents an innovative mixed-methods approach to testing an implementation science measure in contexts outside the United States. Results support the reliability and validity of most scales for consumers in Ukraine. Challenges included large amounts of missing data due to participants' difficulties responding to questions about a hypothetical program.

The colour of paternity: extra-pair paternity in the wild Gouldian finch does not appear to be driven by genetic incompatibility between morphs.

In socially monogamous species, individuals can use extra-pair paternity and offspring sex allocation as adaptive strategies to ameliorate costs of genetic incompatibility with their partner. Previous studies on domesticated Gouldian finches (Erythrura gouldiae) demonstrated a genetic incompatibility between head colour morphs, the effects of which are more severe in female offspring. Domesticated females use differential sex allocation, and extra-pair paternity with males of compatible head colour, to reduce fitness costs associated with incompatibility in mixed-morph pairings. However, laboratory studies are an oversimplification of the complex ecological factors experienced in the wild and may only reflect the biology of a domesticated species. This study aimed to examine the patterns of parentage and sex ratio bias with respect to colour pairing combinations in a wild population of the Gouldian finch. We utilized a novel PCR assay that allowed us to genotype the morph of offspring before the morph phenotype develops and to explore bias in morph paternity and selection at the nest. Contrary to previous findings in the laboratory, we found no effect of pairing combinations on patterns of extra-pair paternity, offspring sex ratio or selection on morphs in nestlings. In the wild, the effect of morph incompatibility is likely much smaller, or absent, than was observed in the domesticated birds. Furthermore, the previously studied domesticated population is genetically differentiated from the wild population, consistent with the effects of domestication. It is possible that the domestication process fostered the emergence (or enhancement) of incompatibility between colour morphs previously demonstrated in the laboratory.

Predicting the diagnosis of autism in adults using the Autism-Spectrum Quotient (AQ) questionnaire.

BACKGROUND: Many adults with autism spectrum disorder (ASD) remain undiagnosed. Specialist assessment clinics enable the detection of these cases, but such services are often overstretched. It has been proposed that unnecessary referrals to these services could be reduced by prioritizing individuals who score highly on the Autism-Spectrum Quotient (AQ), a self-report questionnaire measure of autistic traits. However, the ability of the AQ to predict who will go on to receive a diagnosis of ASD in adults is unclear. METHOD: We studied 476 adults, seen consecutively at a national ASD diagnostic referral service for suspected ASD. We tested AQ scores as predictors of ASD diagnosis made by expert clinicians according to International Classification of Diseases (ICD)-10 criteria, informed by the Autism Diagnostic Observation Schedule-Generic (ADOS-G) and Autism Diagnostic Interview-Revised (ADI-R) assessments. RESULTS: Of the participants, 73% received a clinical diagnosis of ASD. Self-report AQ scores did not significantly predict receipt of a diagnosis. While AQ scores provided high sensitivity of 0.77 [95% confidence interval (CI) 0.72-0.82] and positive predictive value of 0.76 (95% CI 0.70-0.80), the specificity of 0.29 (95% CI 0.20-0.38) and negative predictive value of 0.36 (95% CI 0.22-0.40) were low. Thus, 64% of those who scored below the AQ cut-off were 'false negatives' who did in fact have ASD. Co-morbidity data revealed that generalized anxiety disorder may 'mimic' ASD and inflate AQ scores, leading to false positives. CONCLUSIONS: The AQ's utility for screening referrals was limited in this sample. Recommendations supporting the AQ's role in the assessment of adult ASD, e.g. UK NICE guidelines, may need to be reconsidered.

Depression symptoms across cultures: an IRT analysis of standard depression symptoms using data from eight countries.

PURPOSE: Prevalence estimates of depression vary between countries, possibly due to differential functioning of items between settings. This study compared the performance of the widely used Hopkins symptom checklist 15-item depression scale (HSCL-15) across multiple settings using item response theory analyses. Data came from adult populations in the low and middle income countries (LMIC) of Colombia, Indonesia, Kurdistan Iraq, Rwanda, Iraq, Thailand (Burmese refugees), and Uganda (N = 4732). METHODS: Item parameters based on a graded response model were compared across LMIC settings. Differential item functioning (DIF) by setting was evaluated using multiple indicators multiple causes (MIMIC) models. RESULTS: Most items performed well across settings except items related to suicidal ideation and "loss of sexual interest or pleasure," which had low discrimination parameters (suicide: a = 0.31 in Thailand to a = 2.49 in Indonesia; sexual interest: a = 0.74 in Rwanda to a = 1.26 in one region of Kurdistan). Most items showed some degree of DIF, but DIF only impacted aggregate scale-level scores in Indonesia. CONCLUSIONS: Thirteen of the 15 HSCL depression items performed well across diverse settings, with most items showing a strong relationship to the underlying trait of depression. The results support the cross-cultural applicability of most of these depression symptoms across LMIC settings. DIF impacted aggregate depression scores in one setting illustrating a possible source of measurement invariance in prevalence estimates.

Intellectual abilities in tuberous sclerosis complex: risk factors and correlates from the Tuberous Sclerosis 2000 Study.

BACKGROUND: Tuberous sclerosis complex (TSC) is associated with intellectual disability, but the risk pathways are poorly understood. METHOD: The Tuberous Sclerosis 2000 Study is a prospective longitudinal study of the natural history of TSC. One hundred and twenty-five UK children age 0-16 years with TSC and born between January 2001 and December 2006 were studied. Intelligence was assessed using standardized measures at ≥2 years of age. The age of onset of epilepsy, the type of seizure disorder, the frequency and duration of seizures, as well as the response to treatment was assessed at interview and by review of medical records. The severity of epilepsy in the early years was estimated using the E-Chess score. Genetic studies identified the mutations and the number of cortical tubers was determined from brain scans. RESULTS: TSC2 mutations were associated with significantly higher cortical tuber count than TSC1 mutations. The extent of brain involvement, as indexed by cortical tuber count, was associated with an earlier age of onset and severity of epilepsy. In turn, the severity of epilepsy was strongly associated with the degree of intellectual impairment. Structural equation modelling supported a causal pathway from genetic abnormality to cortical tuber count to epilepsy severity to intellectual outcome. Infantile spasms and status epilepticus were important contributors to seizure severity. CONCLUSIONS: The findings support the proposition that severe, early onset epilepsy may impair intellectual development in TSC and highlight the potential importance of early, prompt and effective treatment or prevention of epilepsy in tuberous sclerosis.

Insertable pulse cleaning module with a saturable absorber pair and a compensating amplifier for high-intensity ultrashort-pulse lasers.

We demonstrate the performance of an efficient insertable pulse cleaning module (IPCM) that uses a saturable absorber (SA) pair with a compensating multi-pass amplifier. IPCM consists of a first SA, a grating compressor, a second SA, a stretcher and a compensating Ti:sapphire amplifier. It is implemented with a conventional chirped pulse amplification (CPA) Ti:sapphire laser system, resulting in a double CPA system architecture, and suppresses the amplified spontaneous emission (ASE) level of the pulse pedestal by about three orders of magnitude while preserving the output pulse energy and repetition-rate of the overall laser system. The duration of recompressed cleaned pulses is comparable to that obtained without the cleaning module. The effectiveness of the cleaning module is confirmed in laser-driven proton acceleration experiments. At the 10(9) W/cm2 pedestal level, the surface structure and electrical resistivity of an insulator target (100 nm silicon nitride) are preserved prior to the arrival of the intense ultrashort pulse.

Attention and inhibition in children with ASD, ADHD and co-morbid ASD + ADHD: an event-related potential study.

BACKGROUND: Substantial overlap has been reported between attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Deficits in executive function (EF) are characteristic of both disorders but these impairments have not been compared directly across pure and co-morbid cases using event-related potentials (ERPs). METHOD: Behavioural parameters and ERPs were recorded during a flankered cued-continuous performance test (CPT-OX) administered to 8-13-year-old boys with ASD (n = 19), ADHD (n = 18), co-morbid ASD + ADHD (n = 29) and typically developing controls (TD; n = 26). Preparatory processing (contingent negative variation, CNV) and attentional orienting (Cue-P3) at cues, response execution at targets (Go-P3), inhibitory processing at non-targets (NoGo-P3) and conflict monitoring between target and non-target trials (Go-N2 v. NoGo-N2) were examined. RESULTS: Categorical diagnoses and quantitative trait measures indicated that participants with ADHD (ADHD/ASD + ADHD) made more omission errors and exhibited increased reaction-time (RT) variability and reduced amplitude of the Cue-P3 and NoGo-P3 compared to TD/ASD participants. Participants with ASD (ASD/ ASD + ADHD) demonstrated reduced N2 enhancement from Go to NoGo trials compared to TD/ADHD participants. Participants with ASD-only displayed enhanced CNV amplitude compared to ASD + ADHD and TD participants. CONCLUSIONS: Children with ADHD show deficits in attentional orienting and inhibitory control whereas children with ASD show abnormalities in conflict monitoring and response preparation. Children with co-morbid ASD + ADHD present as an additive co-occurrence with deficits of both disorders, although non-additive effects are suggested for response preparation. Measuring ERPs that index attention and inhibition is useful in disentangling cognitive markers of ASD and ADHD and elucidating the basis of co-occurring ASD + ADHD to guide clinical assessment.

Neck proprioceptors contribute to the modulation of muscle sympathetic nerve activity to the lower limbs of humans.

Several different strategies have now been used to demonstrate that the vestibular system can modulate muscle sympathetic nerve activity (MSNA) in humans and thereby contribute to the regulation of blood pressure during changes in posture. However, it remains to be determined how the brain differentiates between head-only movements that do not require changes in vasomotor tone in the lower limbs from body movements that do require vasomotor changes. We tested the hypothesis that neck movements modulate MSNA in the lower limbs of humans. MSNA was recorded in 10 supine young adult subjects, at rest, during sinusoidal stretching of neck muscles (100 cycles, 35° peak to peak at 0.37 ± 0.02 Hz) and during a ramp-and-hold (17.5° for 54 ± 9 s) static neck muscle stretch, while their heads were held fixed in space. Cross-correlation analysis revealed cyclical modulation of MSNA during sinusoidal neck muscle stretch (modulation index 45.4 ± 5.3 %), which was significantly less than the cardiac modulation of MSNA at rest (78.7 ± 4.2 %). Interestingly, cardiac modulation decreased significantly during sinusoidal neck displacement (63.0 ± 9.3 %). By contrast, there was no significant difference in MSNA activity during static ramp-and-hold displacements of the neck to the right or left compared with that with the head and neck aligned. These data suggest that dynamic, but not static, neck movements can modulate MSNA, presumably via projections of muscle spindle afferents to the vestibular nuclei, and may thus contribute to the regulation of blood pressure during orthostatic challenges.

The vestibular system does not modulate fusimotor drive to muscle spindles in contracting leg muscles of seated subjects.

We previously showed that sinusoidal galvanic vestibular stimulation (GVS) does not modulate the firing of spontaneously active muscle spindles in relaxed human leg muscles. However, given that there is little, if any, fusimotor drive to relaxed human muscles, we tested the hypothesis that vestibular modulation of muscle spindles becomes apparent during volitional contractions at levels that engage the fusimotor system. Unitary recordings were made from 28 muscle spindle afferents via tungsten microelectrodes inserted percutaneously into the common peroneal nerve of seated awake human subjects. Twenty-one of the spindle afferents were spontaneously active at rest and each increased its firing rate during a weak static contraction; seven were silent at rest and were recruited during the contraction. Sinusoidal bipolar binaural galvanic vestibular stimulation (±2 mA, 100 cycles) was applied to the mastoid processes at 0.8 Hz. This continuous stimulation produced a sustained illusion of "rocking in a boat" or "swinging in a hammock" but no entrainment of EMG. Despite these robust vestibular illusions, none of the fusimotor-driven muscle spindles exhibited phase-locked modulation of firing during sinusoidal GVS. We conclude that this dynamic vestibular input was not sufficient to modulate the firing of fusimotor neurones recruited during a voluntary steady-state contraction, arguing against a significant role of the vestibular system in adjusting the sensitivity of muscle spindles via fusimotor neurones.

Transitioning mental health & psychosocial support: from short-term emergency to sustainable post-disaster development. Humanitarian Action Summit 2011.

INTRODUCTION: The Working Group (WG) on Mental Health and Psychosocial Support participated in its second Humanitarian Action Summit in 2011. This year, the WG chose to focus on a new goal: reviewing practice related to transitioning mental health and psychosocial support programs from the emergency phase to long-term development. The Working Group's findings draw on a review of relevant literature as well as case examples. OBJECTIVES: The objective of the Working Group was to identify factors that promote or hinder the long term sustainability of emergency mental health and psychosocial interventions in crisis and conflict, and to provide recommendations for transitioning such programs from relief to development. METHODS: The Working Group (WG) conducted a review of relevant literature and collected case examples based on experiences and observations of working group members in implementing mental and psychosocial programming in the field. The WG focused on reviewing literature on mental health and psychosocial programs and interventions that were established in conflict, disaster, protracted crisis settings, or transition from acute phase to development phase. The WG utilized case examples from programs in Lebanon, the Gaza Strip, Sierra Leone, Aceh (Indonesia), Sri Lanka, and New Orleans (United States). RESULTS: The WG identified five key thematic areas that should be addressed in order to successfully transition lasting and effective mental health and psychosocial programs from emergency settings to the development phase. The five areas identified were as follows: Government and Policy, Human Resources and Training, Programming and Services, Research and Monitoring, and Finance. CONCLUSIONS: The group identified several recommendations for each thematic area, which were generated from key lessons learned by working group members through implementing mental health and psychosocial support programs in a variety of settings, some successfully sustained and some that were not.

High temporal and spatial quality petawatt-class Ti:sapphire chirped-pulse amplification laser system.

Optical parametric chirped-pulse amplification (OPCPA) operation with low gain by seeding with high-energy, clean pulses is shown to significantly improve the contrast to better than 10(-10) to 10(-11) in a high-intensity Ti:sapphire laser system that is based on chirped-pulse amplification. In addition to the high-contrast broadband, high-energy output from the final amplifier is achieved with a flat-topped spatial profile of filling factor near 77%. This is the result of pump beam spatial profile homogenization with diffractive optical elements. Final pulse energies exceed 30 J, indicating capability for reaching peak powers in excess of 500 TW.

Effects of deep and superficial experimentally induced acute pain on muscle sympathetic nerve activity in human subjects.

Human studies conducted more than half a century ago have suggested that superficial pain induces excitatory effects on the sympathetic nervous system, resulting in increases in blood pressure (BP) and heart rate (HR), whereas deep pain is believed to cause vasodepression. To date, no studies have addressed whether deep or superficial pain produces such differential effects on muscle sympathetic nerve activity (MSNA). Using microneurography we recorded spontaneous MSNA from the common peroneal nerve in 13 awake subjects. Continuous blood pressure was recorded by radial arterial tonometry. Deep pain was induced by intramuscular injection of 0.5 ml hypertonic saline (5%) into the tibialis anterior muscle, superficial pain by subcutaneous injection of 0.2 ml hypertonic saline into the overlying skin. Muscle pain, with a mean rating of 4.9 +/- 0.8 (S.E.M.) on a 0-10 visual analog scale (VAS) and lasting on average 358 +/- 32 s, caused significant increases in MSNA (43.9 +/- 10.0%), BP (5.4 +/- 1.1%) and HR (7.0 +/- 2.0%) - not the expected decreases. Skin pain, rated at 4.9 +/- 0.6 and lasting 464 +/- 54 s, also caused significant increases in MSNA (38.2 +/- 12.8%), BP (5.1 +/- 2.1%) and HR (5.6 +/- 2.0%). The high-frequency (HF) to low-frequency (LF) ratio of heart rate variability (HRV) increased from 1.54 +/- 0.25 to 2.90 +/- 0.45 for muscle pain and 2.80 +/- 0.52 for skin pain. Despite the different qualities of deep (dull and diffuse) and superficial (burning and well-localized) pain, we conclude that pain originating in muscle and skin does not exert a differential effect on muscle sympathetic nerve activity, both causing an increase in MSNA and an increase in the LF:HF ratio of HRV. Whether this holds true for longer lasting experimental pain remains to be seen.

Copy number changes of the microcephalin 1 gene (MCPH1) in patients with autism spectrum disorders.

Autism spectrum disorder (ASD) represents a set of neurodevelopmental disorders with a strong genetic aetiology. Chromosomal rearrangements have been detected in 5-10% of the patients with ASD, and recent applications of array comparative genomic hybridisation (aCGH) are identifying further candidate regions and genes. In this study, we present four patients who implicate microcephalin 1 (MCPH1) in band 8p23.1 as an ASD susceptibility gene. Patient 1 was a girl with a syndromic form of autistic disorder satisfying the Autism Diagnostic Interview-Revised (ADI-R), Autism Diagnostic Observation Schedule (ADOS) and Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Oligonucleotide aCGH (oaCGH) showed that she had a classic inv dup del(8)(qter-> p23.1::p23.1-> p21.2) containing at least three candidate genes; MCPH1 and DLGAP2 within the 6.9-Mb terminal deletion and NEF3 within the concomitant 14.1-Mb duplication. Three further patients with MCPH1 copy number changes were found using single-nucleotide polymorphism (SNP) array analysis in a cohort of 54 families with ASD patients. Our results show that ASD can be a component of the classical inv dup del(8) phenotype and identify changes in copy number of MCPH1 as a susceptibility factor for ASD in the distal short arm of chromosome 8.

Energy increase in multi-MeV ion acceleration in the interaction of a short pulse laser with a cluster-gas target.

An approach for accelerating ions, with the use of a cluster-gas target and an ultrashort pulse laser of 150-mJ energy and 40-fs duration, is presented. Ions with energy 10-20 MeV per nucleon having a small divergence (full angle) of 3.4 degrees are generated in the forward direction, corresponding to approximately tenfold increase in the ion energies compared to previous experiments using solid targets. It is inferred from a particle-in-cell simulation that the high energy ions are generated at the rear side of the target due to the formation of a strong dipole vortex structure in subcritical density plasmas.

Toward a dynamical structure of DNA: comparison of theoretical and experimental NOE intensities.

Comparisons of experimental and calculated interproton nuclear Overhauser effect (NOE) buildup curves for duplex d(CGCGAATTCGCG)2 have been made. The calculated NOEs are based on molecular dynamics simulations including counterions and water and on the single-structure canonical A, B, and crystal forms. The calculated NOE effects include consideration of the motions of individual interproton vectors and the anisotropic tumbling of the DNA. The effects due to inclusion of anisotropic tumbling are much larger than those due to the local motion, and both improve the agreement between calculated and experimental results. The predictions based on the dynamical models agree significantly better with experiment than those based on either of the canonical forms or the crystal structure.

Nitrogen, phosphorus, and bacteria tile and groundwater quality following direct injection of dewatered municipal biosolids into soil.

Application of municipal biosolids (sewage) to agricultural land is a common practice to improve soil physical quality and fertility. The chosen method of land application can have a strong impact on the extent of adjacent water contamination by nutrients and bacteria. Dewatered municipal biosolids (DMB) were applied to silt-clay loam experimental field plots in Ontario, Canada using two application methods: (i) surface spreading followed by shallow incorporation (SS) and (ii) a newly developed implement that directly injects DMB into the topsoil (DI). The objective of this study was to compare N, P, and bacteria quality of tile drainage and shallow groundwater associated with each land application technique. There were no significant differences (P > 0.05) in N, P, and bacteria tile mass loads among the application treatments for time periods <100 d postapplication, when the greatest peak loads and peak tile water concentrations were observed. Both land application treatments caused groundwater Escherichia coli contamination to at least 1.2 m depth below surface after the first postapplication rainfall event, and NO(3)-N contamination to at least 2.0 m depth below surface. The DI treatment did, however, have significantly (P < 0.05) higher tile mass loads of total Kjeldahl N (TKN), total phosphorus (TP), E. coli, Enterococci, and Clostridium perfringens relative to the SS treatment for time periods >100 d postapplication. Nevertheless, relative to tile effluent data collected <100 d postapplication (no application treatment differences), peak loads, and concentrations during this time were, overall, considerably lower for both treatments. This finding, along with no significant differences in N, P, and bacteria groundwater concentrations among the application treatments, and that the direct injection technique could potentially reduce vector attraction problems and odor, suggests that the direct injection technique should be considered a dewatered municipal biosolid land application option.

Mental health and psychosocial support in crisis and conflict: report of the Mental Health Working Group.

INTRODUCTION: The Working Group on Mental Health and Psychosocial Support was convened as part of the 2009 Harvard Humanitarian Action Summit. The Working Group chose to focus on ethical issues in mental health and psychosocial research and programming in humanitarian settings. The Working Group built on previous work and recommendations, such as the Inter-Agency Standing Committee's Guidelines on Mental Health and Psychosocial Support in Emergency Settings. OBJECTIVES: The objective of this working group was to address one of the factors contributing to the deficiency of research and the need to develop the evidence base on mental health and psychosocial support interventions during complex emergencies by proposing ethical research guidelines. Outcomes research is vital for effective program development in emergency settings, but to date, no comprehensive ethical guidelines exist for guiding such research efforts. METHODS: Working Group members conducted literature reviews which included peer-reviewed publications, agency reports, and relevant guidelines on the following topics: general ethical principles in research, cross-cultural issues, research in resource-poor countries, and specific populations such as trauma and torture survivors, refugees, minorities, children and youth, and the mentally ill. Working Group members also shared key points regarding ethical issues encountered in their own research and fieldwork. RESULTS: The group adapted a broad definition of the term "research", which encompasses needs assessments and data gathering, as well as monitoring and evaluation. The guidelines are conceptualized as applying to formal and informal processes of assessment and evaluation in which researchers as well as most service providers engage. The group reached consensus that it would be unethical not to conduct research and evaluate outcomes of mental health and psychosocial interventions in emergency settings, given that there currently is very little good evidence base for such interventions. Overarching themes and issues generated by the group for further study and articulation included: purpose and benefits of research, issues of validity, neutrality, risk, subject selection and participation, confidentiality, consent, and dissemination of results. CONCLUSIONS: The group outlined several key topics and recommendations that address ethical issues in conducting mental health and psychosocial research in humanitarian settings. The group views this set of recommendations as a living document to be further developed and refined based on input from colleagues representing different regions of the globe with an emphasis on input from colleagues from low-resource countries.

Identifying research priorities for psychosocial support programs in humanitarian settings.

BACKGROUND: Given the range and reach of psychosocial support (PSS) interventions in humanitarian settings, within the continuum of mental health and psychosocial support services, evaluation of their impact is critical. Understanding stakeholders' perspectives on which PSS interventions of unknown effectiveness warrant rigorous evaluation is essential to identify research priorities. This project aimed to facilitate a process with stakeholders to reach consensus on PSS interventions that are of high priority for further research based on existing evidence and stakeholders' opinions. METHODS: Interviews with 109 stakeholders working on PSS programming in humanitarian settings served as the foundation for two in-person regional meetings and four webinars. Nominal Group Technique (NGT) was used to develop a priority PSS program list. The top five priorities from each meeting were combined for a final online survey distributed globally. RESULTS: Seventy participants across six meetings contributed to the prioritization process. Eighty-seven individuals completed the final online survey. 'Community based PSS' was the top-ranked research priority, followed by PSS integrated into basic services, providing PSS to caregivers to improve child wellbeing, PSS-focused gender-based violence programming, and classroom-based PSS interventions. CONCLUSIONS: NGT and online surveys were effective methods to engage stakeholders in a priority setting exercise to development a research agenda. Information from this stage of the project will be combined with findings from a concurrent systematic review to form the base of a second phase of work, which will include the development and implementation of a research strategy to strengthen the evidence base for those prioritized interventions.

The UK guidelines for management and surveillance of Tuberous Sclerosis Complex.

BACKGROUND: The severity of Tuberous Sclerosis Complex (TSC) can vary among affected individuals. Complications of TSC can be life threatening, with significant impact on patients' quality of life. Management may vary dependent on treating physician, local and national policies, and funding. There are no current UK guidelines. We conducted a Delphi consensus process to reach agreed guidance for the management of patients with TSC in the UK. METHODS: We performed a literature search and reviewed the 2012/13 international guideline for TSC management. Based on these, a Delphi questionnaire was formed. We invited 86 clinicians and medical researchers to complete an online survey in two rounds. All the people surveyed were based in the UK. Clinicians were identified through the regional TSC clinics, and researchers were identified through publications. In round one, 55 questions were asked. In round two, 18 questions were asked in order to obtain consensus on the outstanding points that had been contentious in round one. The data was analysed by a core committee and subcommittees, which consisted of UK experts in different aspects of TSC. The Tuberous Sclerosis Association was consulted. RESULTS: About 51 TSC experts took part in this survey. Two rounds were required to achieve consensus. The responders were neurologists, nephrologists, psychiatrist, psychologists, oncologists, general paediatricians, dermatologist, urologists, radiologists, clinical geneticists, neurosurgeons, respiratory and neurodisability clinicians. CONCLUSIONS: These new UK guidelines for the management and surveillance of TSC patients provide consensus guidance for delivery of best clinical care to individuals with TSC in the UK.