Systematic assessments of need and care planning in severe mental illness: cluster randomised controlled trial

BACKGROUND

Surveys have shown high levels of unmet need in representative samples of people with severe mental illness. Introducing standardised needs assessment into the care planning process might reduce these needs and improve outcome.

AIMS

To determine whether feedback from a standardised assessment of need enhances the effectiveness of care planning and whether exposing care coordinators to feedback on some patients improves their care of other patients.

METHOD

A single-blind, cluster randomised trial involving a within-cluster individually randomised arm: patients' needs were evaluated using the Cardinal Needs Schedule and the findings were fed back to their care coordinators under the care programme approach. A total of 304 patients were recruited from 72 care coordinators and 242 patients (79.6%) were reassessed at 12 months.

RESULTS

The only significant effect of the intervention was on patient satisfaction. Patients cluster-randomised to receive feedback were more satisfied than controls, but patients individually randomised to receive feedback were not.

CONCLUSIONS

Standardised needs assessment did not substantially enhance care planning in this trial. However, giving care coordinators some experience of feedback from a standardised assessment of need could improve satisfaction.

Social exclusion in clients with comorbid mental health and substance misuse problems

BACKGROUND

The concept of comorbid mental health problems and substance misuse has gained prominence in the last two decades, due in part to the closure of large psychiatric hospitals and to the increasing prevalence of drug use in the community. This client group has a dual requirement for both medical and social care needs and is at risk for social exclusion.

METHODS

A retrospective matched case-control study to examine aspects of social exclusion between service users who have comorbid diagnoses and those with a single diagnosis. Samples were drawn from the service users of a mental health Trust in the South-East of England, from both Adult Mental Health (n = 400) and Drug and Alcohol services (n = 190). Data were collected from Care Programme Approach assessment forms and medical records. McNemar's chi(2) and odds ratios via a conditional logit regression model are used to test for differences in the social exclusion indicators.

RESULTS

There were significant differences in social exclusion between the comorbid and singly diagnosed clients of the Adult Mental Health service, but differences were less pronounced between the comorbid and singly diagnosed clients of the specialist Drug and Alcohol service.

CONCLUSIONS

Recent Government policy advocates treating comorbid clients within mainstream mental health services. Health care workers need to recognise the likelihood of high levels of social exclusion among clients with comorbid problems.

Defining dual diagnosis of mental illness and substance misuse: some methodological issues

This paper discusses methodological issues arising in the initial stages of a larger epidemiological case-control study. Practitioners from both Generic Mental Health and Substance Misuse Services (n = 170) were asked to identify which of their clients, from a time-limited caseload (n = 2341), had comorbid mental health and substance misuse problems. Although practitioners were provided with a definition of 'singly diagnosed' and 'dually diagnosed', it became apparent that these definitions were applied pragmatically, depending on the nature of the client's primary problem and the agency they were presenting to. Issues raised include the time period in which a client was considered to have a concurrent mental health problem and substance misuse, how a 'mental health problem' was defined and whether a personality disorder should be categorized as a 'mental health problem'. There was also some disagreement about whether clients who were being treated primarily by Substance Misuse Services, but were also taking prescribed antidepressants, implicitly had a 'mental health problem'. We raise these methodological issues, as they have implications for determining the prevalence of 'dual diagnosis' and the subsequent provision of services.

A fatal case of malignant hyperthermia complicated by generalized compartment syndrome and rhabdomyolysis

A healthy 21-year-old male who had previously been anaesthetized without complications underwent a laparotomy following a skiing accident. He developed severe malignant hyperthermia. The initial reaction was successfully treated with dantrolene, but during the following days the patient developed several compartment syndromes requiring fasciotomies. The patient died of hyperkalaemia in spite of continuous dialysis. We present a detailed description of the case and also discuss the role of propofol and rhabdomyolysis.

Social network and social support characteristics amongst individuals recently discharged from acute psychiatric units

This study compares the social support network of a diagnostically heterogeneous group of community mental health service users recently discharged from acute inpatient units, with that of a mental health service user comparison group with no history of hospital admission. Social data were elicited by a structured interview schedule (the Social Network Schedule). It was observed that the study group was characterized by smaller overall social networks, particularly within the primary network, but conversely the group had a greater proportion of service user peer contact. Few differences in perceived social support between groups were observed, although the study group reported fewer confidants. The implications of the study for nursing staff are discussed.

An assessment of food acceptance in children with autism or pervasive developmental disorder-not otherwise specified

Some children with autism and pervasive developmental disorder-not otherwise specified (PDD-NOS) have been reported to have atypical feeding behavior, such as sensitivity to food texture and selective preferences for particular foods. No systematic studies of feeding behavior in this population have been published. Munk and Repp (1994) developed methods for assessing feeding problems in individuals with cognitive and physical disabilities that allow categorization of individual feeding patterns based on responses to repeated presentations of food. In this study, we systematically replicated the Munk and Repp procedures with children with autism and PDD-NOS. Thirty children, ages 3 to 14 years, were exposed to 12 food items across 6 sessions. Food acceptance, food expulsion, and disruptive behavior were recorded on a trial-by-trial basis. Approximately half of the participants exhibited patterns of food acceptance, indicating selectivity by food category or food texture. Others consistently accepted or rejected items across food categories. Whether these patterns of food acceptance are atypical remains to be determined by comparison with the feeding patterns of typically developing children and other children with developmental delays.

The Arabidopsis chloroplast ribosomal protein L21 is encoded by a nuclear gene of mitochondrial origin

Many chloroplast genes of cyanobacterial origin have been transferred to the nucleus during evolution and their products are re-addressed to chloroplasts. The RPL21 gene encoding the plastid r-protein L21 has been lost in higher plant chloroplast genomes after the divergence from bryophytes. Based on phylogenetic analysis and intron conservation, we now provide evidence that in Arabidopsis a nuclear RPL21c gene of mitochondrial origin has replaced the chloroplast gene. The control of expression of this gene has been adapted to the needs of chloroplast development by the acquisition of plastid-specific regulatory promoter cis-elements.

Changes in pCO2 during air medical transport of children with closed head injuries

OBJECTIVES

Because low partial pressure of carbon dioxide (pCO2) can be associated with posttraumatic cerebral ischemia, we conducted a study to determine whether the pCO2 level in ventilated children with closed head injuries transported by a trained team to tertiary care was optimally maintained during transport and determine whether hand-bagging or mechanical ventilation resulted in more optimal pCO2 levels after transport.

METHODS

We reviewed the hospital charts and transport records of all infants and children who had sustained a head injury and were transported by a specialized pediatric transport paramedic team to a single tertiary care facility during a 12-month period. All children were intubated and ventilated either mechanically or manually. Outcome measures were final pCO2 before transport and first pCO2 on arrival in the PICU.

RESULTS

Twenty-nine children (age 0.6 to 16 years, mean 7.3, median 6) met the criteria. Fourteen patients were hand-bagged (HB), and 15 were mechanically ventilated (MV). Eleven patients (5 HB and 6 MV) started in the target pCO2 range of 35 to 40 mmHg. After transport, nine patients (all MV) had pCO2 within the target range (P < 0.01). Duration of transport (mean 63 minutes, range 15-200 minutes) did not contribute to the final pCO2 level.

CONCLUSION

MV improves management of pCO2 during interfacility transport. HB significantly increases the incidence of suboptimal pCO2 and hence the risk of suboptimal cerebral blood flow. MV appears mandatory, and monitoring CO2 in transit (end-tidal or preferably point-of-care testing) should further reduce the likelihood of secondary complications from cerebral ischemia.

Female control of sexuality: illusion or reality? Use of vaginal products in south west Uganda

This paper reports on a trial of vaginal products that were distributed and used by 131 women and 21 men in south west Uganda. It focuses specifically upon the issue of female control in heterosexual relationships and examines whether methods which are ostensibly under women's control, will in practice give women greater control of their sexual health. Participants were invited to select two from a range of vaginal products that included the female condom, contraceptive sponge, film, tablets, foam and gel, and use each for five weeks and their favourite product for a further three months. They were interviewed up to seven times over a five-month period. Although the women perceived that a major advantage of the products (with the exception of the female condom) was that they could be used secretly, less than 40% were using the products without their partner's knowledge after one week and this proportion declined over time with only 22% using the products secretly after ten weeks. In the main male partners were told as women felt it their duty to inform them. In general the women were very much more positive about the products than they were about the male condom, as were the men. A contributory factor to their popularity among women was the greater control they gave them. Even though, use of these products in practice often involved negotiation with male partners, the fact that use was contingent on women's action was empowering and increased somewhat their ability to control their sexual health.

Efficacy of a hepatitis C virus core antigen enzyme-linked immunosorbent assay for the identification of 'window-phase' blood donations

BACKGROUND AND OBJECTIVES

Recent studies have suggested that potentially infectious donations provided during the antibody-negative 'window' phase of hepatitis C virus (HCV) infection may be identified by testing for viral RNA or HCV core protein. We therefore evaluated the performance of an HCV antigen enzyme-linked immunosorbent assay (ELISA) for identification of window-phase donations and for prospective screening of blood donors.

MATERIALS AND METHODS

One-hundred and twenty-eight archived plasma donations containing HCV RNA, but lacking antibody to HCV (anti-HCV), were tested by using the HCV antigen ELISA, together with 9951 freshly collected serum and plasma specimens from blood donors.

RESULTS

HCV core antigen was detected in 94% (120/128) of window-phase plasma donations. Overall specificity in freshly collected blood donor specimens was 99.74%. Two putative window-phase donations containing HCV core protein and viral RNA were identified from paid plasma donors by prospective testing with the HCV antigen ELISA.

CONCLUSION

These results indicate that an HCV antigen ELISA can identify almost all (94%) of viraemic donations given during the seronegative window phase of infection. The performance of the HCV antigen ELISA appears to be suitable for large-scale screening of blood donations.

Detection of hepatitis C core antigen in the antibody negative 'window' phase of hepatitis C infection

BACKGROUND AND OBJECTIVES

Despite improvements in assays for anti-HCV, there remains a significant delay before the appearance of antibodies following infection, during which, circulating viral RNA is present. We have evaluated a prototype assay for the serological detection of hepatitis C virus (HCV) core antigen with specimens derived from the early phase of HCV infection.

MATERIALS AND METHODS

Serial specimens from 24 individuals undergoing HCV seroconversion were tested for the presence of anti-HCV, HCV RNA and HCV core antigen.

RESULTS

HCV antigen was detected at the same time as HCV RNA in 83% (20/24) cases. The mean time to the first detection of HCV antigen was approximately 1 day later than HCV RNA. Overall, 87% of HCV-RNA-positive specimens contained detectable HCV core antigen.

CONCLUSION

These results indicate that HCV core antigen can be identified by routine serological ELISA in specimens from the early antibody-negative phase of HCV infection. A test for HCV core antigen may be a useful test for identifying window phase blood donations from antibody negative donors infected with HCV.

Detection of hepatitis C core antigen in the antibody negative 'window' phase of hepatitis C infection

BACKGROUND AND OBJECTIVES

Despite improvements in assays for anti-HCV, there remains a significant delay before the appearance of antibodies following infection, during which, circulating viral RNA is present. We have evaluated a prototype assay for the serological detection of hepatitis C virus (HCV) core antigen with specimens derived from the early phase of HCV infection.

MATERIALS AND METHODS

Serial specimens from 24 individuals undergoing HCV seroconversion were tested for the presence of anti-HCV, HCV RNA and HCV core antigen.

RESULTS

HCV antigen was detected at the same time as HCV RNA in 83% (20/24) cases. The mean time to the first detection of HCV antigen was approximately 1 day later than HCV RNA. Overall, 87% of HCV-RNA-positive specimens contained detectable HCV core antigen.

CONCLUSION

These results indicate that HCV core antigen can be identified by routine serological ELISA in specimens from the early antibody-negative phase of HCV infection. A test for HCV core antigen may be a useful test for identifying window phase blood donations from antibody negative donors infected with HCV.

An educational intervention for front-line health professionals in the assessment and management of suicidal patients (The STORM Project)

BACKGROUND

Suicide prevention is a health priority in many countries. Improved management of suicide risk may improve suicide prevention. This study aimed to assess the feasibility of health district-wide training in the assessment and management of people at risk of suicide; and to assess the impact of training on assessment and management skills.

METHODS

Staff in three health care settings, namely primary care, accident and emergency departments and mental health services (N = 359), were offered suicide risk management training in a district-wide programme, using a flexible 'facilitator' approach. The main outcomes were the rate of attendance at training, and changes in suicide risk assessment and management skills following training.

RESULTS

It was possible to deliver training to 167 health professionals (47 % of those eligible) during a 6 month training period. This included 95 primary care staff (39%), 21 accident and emergency staff(42%) and 51 mental health staff (78%). Of these, 103 (69%) attended all training. A volunteer sample of 28 staff who underwent training showed improvements in skills in the assessment and management of suicide risk. Satisfaction with training was high. The expected costs of district-wide training, if it were able to produce a 2.5% reduction in the suicide rate, would be 99,747 pound sterling per suicide prevented and 3,391 pound sterling per life year gained.

CONCLUSIONS

Training in the assessment and management of suicide risk can be delivered to approximately half the targeted staff in primary care, accident and emergency departments and mental health services. The current training package can improve skills and is well accepted. If it were to produce a modest fall in the suicide rate, such training would be cost-effective. However, a future training programme should develop a broader training package to reach those who will not attend.

Emergency psychiatric assessments: do outcomes match priorities?

The targeting of scarce mental health resources is currently organised around three broad areas: treating severe mental illness; reducing suicide; and obviating risk to the wider community. High priority clients are those who present with either psychotic symptoms, or who are perceived to be high risk to self or others. This study examined records of emergency assessments at a mental health trust in the south-east of England over a three-month period (n = 336) to see whether clients with these characteristics are more likely than others to be offered hospital admission or treatment. It was found that clients presenting with psychosis are much more likely to be offered admission than those assessed as non-psychotic, that those assessed as a suicide risk are also significantly more likely to be offered admission, and that those assessed as presenting a risk to the public at large are no more likely to be admitted than those presenting no risk. This investigation indicates that the emergency service of the trust studied is addressing the first two target areas, but may be underperforming in the third.

An acceptability study of female-controlled methods of protection against HIV and STDs in south-western Uganda

We aimed to assess the acceptability of a variety of formulations of female-controlled methods of protection against HIV and STDs among men and women in south-western Uganda. Pilot interviews were carried out with 50 men and 55 women and 25 focus group discussions (FGDs) were held with 138 women and 42 men. The female condom, foaming tablets, sponge, foam, gel and film were demonstrated to 146 women and 35 of their male partners, who then tried out 2 of the products. They were interviewed 7 times during the course of 5 months. At the end experiences were evaluated during a second series of FGDs. Sixty-five (45%) women completed the trial. The main reasons for non-completion were related to geographical mobility. Product preference after the initial demonstration was similar to that at the end of the trial. The most popular formulations were the sponge (25% of the women), foaming tablets (23%), and the female condom (19%). The foam was of medium popularity (16%). The gel (9%) and film (7%) were least popular. Ten per cent of the women and 14% of the men reported products interfering with sexual enjoyment; 24% of the women and 67% of the men said products increased enjoyment. 'Dry sex' is not popular in this area and increased lubrication was an important determinant of acceptability. Age, level of education and location did have some effect on preference. Although secrecy was a dominant theme in the FGDs, 87% of the women had informed their partners by the end of the trial. The products were generally well received. Female control was an important issue for both sexes. Male attitudes were ambivalent because female ownership of products increased women's control. Although they have clear preferences, women appear to accept the products generally and might use a single available product just as readily if choice was limited, as long as it conforms to general cultural preferences, such as those relating to wet/dry sex.

Clinical service lines bring patients into focus

In 1996, SSM St. Joseph Hospital of Kirkwood, Mo., was in crisis mode. A radical structure change from centralized nursing to clinical service lines helped to keep the organization in the black.