How should we evaluate research on counselling and the treatment of depression? A case study on how NICE’s draft 2018 guideline considered what counts as best evidence

Background: Health guidelines are developed to improve patient care by ensuring the most recent and “best available evidence” is used to guide treatment recommendations (NICE Guidance, 2017). NICE’s revised guideline development methodology acknowledges that evidence needed to answer one question (treatment efficacy) may be different from evidence needed to answer another (cost effectiveness, treatment acceptability to patients; NICE, 2014/2017). This review uses counselling in the treatment of depression as a case study, and interrogates the constructs of ‘best’ evidence and ‘best’ guideline methodologies. Method: The review comprises six sections: (1) the implications of diverse definitions of counselling in research; (2) research findings from meta-analyses and randomised controlled trials (RCTs); (3) limitations to trials-based evidence; (4) findings from large routine outcome datasets; (5) the inclusion of qualitative research that emphasises service-user voices; and (6) conclusions and recommendations. Results: Research from meta-analyses and RCTs reviewed in the draft 2018 NICE guideline is limited but positive in relation to the effectiveness of counselling in the treatment for depression. The weight of evidence suggests little, if any, advantage to CBT over counselling once bias and researcher allegiance are taken into account. A growing body of evidence from large NHS datasets also evidences that counselling is both effective and cost-effective when delivered in NHS settings. Conclusion: Recommendations in NICE’s own updated procedures suggest that sole reliance on RCTs and meta-analyses as best methodologies is no longer adequate. There is a need to include large standardised collected datasets from routine practice as well as the voice of patients via high-quality qualitative research

Spectroscopy of new brown dwarf members of rho Ophiuchi and an updated initial mass function

To investigate the universality hypothesis of the initial mass function in the substellar regime, the population of the rho Ophiuchi molecular cloud is analysed by including a new sample of low-mass spectroscopically confirmed members. To that end, we have conducted a large spectroscopic follow-up of young substellar candidates uncovered in our previous photometric survey. The spectral types and extinction were derived for a newly found population of substellar objects, and its masses estimated by comparison to evolutionary models. A thoroughly literature search was conducted to provide an up-to-date census of the cluster, which was then used to derive the luminosity and mass functions, as well as the ratio of brown dwarfs to stars in the cluster. These results were then compared to other young clusters. It is shown that the study of the substellar population of the rho Ophiuchi molecular cloud is hampered only by the high extinction in the cluster ruling out an apparent paucity of brown dwarfs. The discovery of 16 new members of rho Ophiuchi, 13 of them in the substellar regime, reveals the low-mass end of its population and shows the success of our photometric candidate selection with the WIRCam survey. The study of the brown dwarf population of the cluster reveals a high disk fraction of 76 (+5-8)%. Taking the characteristic peak mass of the derived mass function and the ratio of brown dwarfs to stars into account, we conclude that the mass function of rho Ophiuchi is similar to other nearby young clusters.Comment: Accepted to A&A (30 December 2011); v2 includes language editin

REACH: a mixed-methods study to investigate the measurement, prediction and improvement of retention and engagement in outpatient HIV care

BACKGROUND Antiretroviral therapy (ART) benefits individuals living with human immunodeficiency virus (HIV) through reduced morbidity and mortality, and brings public health gains through a reduction in HIV transmission. People living with human immunodeficiency virus (PLWH) need to know their HIV status and engage in HIV care in order for these individual and public health benefits to be realised. OBJECTIVE To explore, describe and understand HIV outpatient attendance in PLWH, in order to develop cost-effective interventions to optimise engagement in care. DESIGN A mixed-methods study incorporating secondary analysis of data from the UK Collaborative HIV Cohort (UK CHIC) study and primary data collection. METHODS Phase 1 – an engagement-in-care (EIC) algorithm was developed to categorise patients as in care or out of care for each month of follow-up. The algorithm was used in group-based trajectory analysis to examine patterns of attendance over time and of the association between the proportion of months in care before ART initiation and post-ART mortality and laboratory test costs. Phase 2 – a cross-sectional survey was conducted among patients attending seven London HIV clinics. Regular attenders (all appointments attended in past year), irregular attenders (one or more appointments missed in past year) and non-attenders (recent absence of ≥ 1 year) were recruited. A ‘retention risk tool’ was developed to identify those at risk of disengaging from care. Individual in-depth interviews and focus groups were conducted with PLWH. Phase 3 – key informant interviews were conducted with HIV service providers. Interventions were developed from the findings of phases 2 and 3. RESULTS Plots from group-based trajectory analysis indicated that four trajectories best fitted the data. Higher EIC is associated with reduced mortality but the association between EIC before starting ART, and post-ART mortality [relative hazard (RH) per 10% increase in EIC 0.29, 95% confidence interval (CI) 0.18 to 0.47] was attenuated after adjustment for fixed covariates and post-ART cluster of differentiation 4 counts and viral loads (RH 0.74, 95% CI 0.42 to 1.30). Small differences were found in pre-ART EIC and the costs of post-ART lab tests. The final model for the retention risk tool included age at diagnosis, having children, recreational drug use, drug/alcohol dependency, insufficient money for basic needs and use of public transport to get to the clinic. Quantitative and qualitative data showed that a range of psychological, social and economic issues were associated with disengagement from care. The negative impact of stigma on attendance was highlighted. Interventions were proposed that support a holistic approach to care including peer support, address stigma by holding clinics in alternative locations and involve training staff to encourage attendance. CONCLUSIONS The study shows the adverse health impacts of disengaging from HIV care and demonstrates the importance of the wider health and social context in managing HIV effectively. Although phase 1 analysis was based on UK data, phases 2 and 3 were limited to London. The interventions proposed are supported by the data but their cost-effectiveness requires testing. Future research is needed to evaluate the interventions, to validate our retention risk tool across populations and settings, and to fully analyse the economic costs of disengaging from HIV care

Seismic issues at the Paducah Gaseous Diffusion Plant

A seismic expert workshop was held at the Paducah Gaseous Diffusion Plant (PGDP) on March 13--15, 1989. the PGDP is operated by Martin Marietta Energy Systems, Inc. for the United States Department of Energy (DOE). During the last twenty years the design criteria for natural phenomenon hazards has steadily become more demanding at all of the DOE Oak Ridge Operations (ORO) sites. The purpose of the two-day workshop was to review the seismic vulnerability issues of the PGDP facilities. Participants to the workshop included recognized experts in the fields of seismic engineering, seismology and geosciences, and probabilistic analysis, along with engineers and other personnel from Energy Systems. A complete list of the workshop participants is included in the front of this report. 29 refs

Portsmouth Gaseous Diffusion Plant environmental report for 1989

This calendar year 1989 annual report on environmental surveillance of the US Department of Energy's (DOE) Portsmouth Gaseous Diffusion Plant (PORTS) and its environs consists of two parts: the Summary, Discussion, and Conclusions (Part 1) and the Data Presentation (Part 2). The objectives of this report are the following: report 1989 monitoring data for the installation and its environs that may have been affected by operations on the plant site, provide reasonably detailed information about the plant site and plant operations, provide detailed information on input and assumptions used in all calculations, provide trend analyses (where appropriate) to indicate increases and decreases in environmental impact, and provide general information on plant quality assurance. Routine monitoring and sampling for radiation, radioactive materials, and chemical substances on and off the DOE site are used to document compliance with appropriate standards, to identify trends, to provide information for the public, and to contribute to general environmental knowledge. The surveillance program assists in fulfilling the DOE policy of protecting the public, employees, and environment from harm that could be caused by its activities and reducing negative environmental impacts to the greatest degree practicable. Environmental-monitoring information complements data on specific releases, trends, and summaries. 26 refs

Volumetric reach comparison of possible end-effectors for the articulated transporter and manipulator system

The goal of this research was to investigate the performance of the Articulated Transporter and Manipulator System (ATMS) during various tasks relative to the choice of wrist/end-effector configuration. The approach taken was to generate computer graphics-aided three-dimensional interactive application (CATIA) system-based models of four wrist/end-effector combinations and consider the volumetric reach of each of these configurations based on the capacity of the ATMS. The results indicate that a simple, lightweight end-effector provides a greater volumetric reach. The greatest variation presented herein is {approximately}40% when comparing a 7-degree-of-freedom (DOF) dexterous arm with a simple 3-DOF arm; however, the benefit of increasing volumetric reach by only 40% by using a simple arm may be outweighed by the loss of dexterity. 10 refs., 5 figs., 3 tabs