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Clinical shorts

who self-harm Very few studies of specific interventions for adolescents who self-harm have shown effectiveness compared with usual care, and this trial of developmental group psychotherapy is no exception. In a randomized trial of adolescents who had engaged in at least two episodes of self-harm within the previous year, 183 participants were randomized either to routine care or to group therapy plus routine care. The study showed that the addition of the group therapy program did not improve outcomes for self-harm over routine care at one year follow-up (proportional odds ratio 0.88, 95% CI [confidence interval] 0.59–1.33, p = 0.52). There was also no evidence of cost-effectiveness in terms of involvement with the criminal justice system or use of health, housing or social services. Researchers were encouraged to find that both groups had significant improvement in all outcomes (e.g., improved mood and social functioning, and reduced suicidality and episodes of self-harm) from baseline. See BMJ 2011;342:d682 doi:10.1136 /bmj.d682.


Group therapy for adolescents who self-harm
Very few studies of specific interventions for adolescents who self-harm have shown effectiveness compared with usual care, and this trial of developmental group psychotherapy is no exception.
In a randomized trial of adolescents who had engaged in at least two episodes of self-harm within the previous year, 183 participants were randomized either to routine care or to group therapy plus routine care. The study showed that the addition of the group therapy program did not improve outcomes for self-harm over routine care at one year follow-up (proportional odds ratio 0.88, 95% CI [confidence interval] 0.59-1.33, p = 0.52). There was also no evidence of cost-effectiveness in terms of involvement with the criminal justice system or use of health, housing or social services. Researchers were encouraged to find that both groups had significant improvement in all outcomes (e.g., improved mood and social functioning, and reduced suicidality and episodes of self-harm) from baseline. See BMJ 2011;342:d682 doi:10.1136 /bmj.d682.

Tranexamic acid for bleeding in trauma
Tranexamic acid should be given as early as possible to patients with bleeding from trauma, but for those admitted to hospital late after injury, it is less effective and may even be harmful. This is the conclusion of a reanalysis of the CRASH-2 trial, a multicountry randomized controlled trial with 20 211 adult patients with, or at risk of, bleeding following trauma. Participants were randomized within eight hours after injury to receive either tranexamic acid or placebo. Researchers found that 35% of deaths (1063) were due to bleeding. Early treatment with tranexamic acid (within one hour after injury) significantly reduced risk of death caused by bleeding (198/3747 events in treatment group v. 286/3704 in placebo group), with a relative risk (RR) of 0.68, 95% CI 0.57-0.82, p < 0.0001. In contrast, treatment given after three hours after injury appeared to increase the risk of death caused by bleeding (144/3272 in treatment group v. 103/3362 in placebo group), with an RR of 1.44 [95% CI 1.12-1.84, p = 0.004]. Results for treatment between one and three hours after injury did reduce the risk of death from bleeding but less dramatically than if given less than one hour after injury. There was no effect on other causes of death. See Lancet 2011;377:1096-101.

Anal injection of dextranomer for treatment of fecal incontinence
Anal injection of a bulking agent (dextranomer in stabilized hyaluronic acid) is an effective treatment for fecal incontinence in patients for whom conservative therapy has failed. The injections expand tissue volume in the sphincter, creating a sealing mechanism.
A randomized, double-blind, shamcontrolled trial of 278 adults with at least one year of fecal incontinence showed that just over half of those (71/136) who received transanal submucosal injections of the bulking agent had a 50% or more reduction in the number of incontinence episodes compared with one-third of those (22/70) who received sham injections (odds ratio 2.36, 95% CI 1.24-4.47, p = 0.0089) at six months. Adverse effects related to treatment were generally mild and transient (pain, bleeding at the injection site, fever), but two were serious (abscesses).The researchers caution that the considerable response to placebo emphasizes the need to consider the placebo effect when assessing treatments for fecal incontinence. See Lancet 2011;377:997-1003.

Screening for prostate cancer
Yet another study, this time from Sweden, has shown that screening for prostate cancer does not reduce mortality related to prostate cancer and may lead to overdetection and overtreatment. In a 20-year follow-up of 9026 men enrolled in a randomized trial of screening for prostate cancer, researchers found that the relative risk of death from prostate cancer was 1.16 [95% CI 0.78-1.73] in the screening group. Those in the screening group (1494 men) were invited to be screened every three years from 1987 to 1996, with digital rectal examination on the first two occasions and prostate-specific antigen testing added to the last two screenings after being established as a screening method. Attendance at screenings ranged from 70% to 78%. There were 85 men (5.7%) in whom prostate cancer was diagnosed in the screening group, compared with 292 (3.9%) in the control group. All men with prostate cancer underwent the same standardized management plan. Although the percentage of localized tumours was significantly higher in the screening group (56.5% v. 26.7%, p < 0.001), survival after diagnosis of prostate cancer was similar between the two groups. See BMJ 2011;342:d1539 doi:10.1136/bmj.d1539.