Healthcare contacts with self-harm during COVID-19: An e-cohort whole-population-based study using individual-level linked routine electronic health records in Wales, UK, 2016-March 2021

INTRODUCTION

Reduced rates of help seeking by those who self-harmed during the COVID-19 pandemic have been reported.

OBJECTIVES

To understand changes in healthcare service contacts for self-harm during the COVID-19 pandemic across primary, emergency and secondary care.

METHODS

This retrospective cohort study used routine electronic healthcare data for Wales, United Kingdom, from 2016 to March 14, 2021. Population-based data from primary care, emergency departments and hospital admissions were linked at individual-level. All Welsh residents aged ≥10 years over the study period were included in the study. Primary, emergency and secondary care contacts with self-harm at any time between 2016 and March 14, 2021 were identified. Outcomes were counts, incidence, prevalence and proportion of self-harm contacts relative to all contacts in each and all settings, as well as the proportion of people contacting one or more settings with self-harm. Weekly trends were modelled using generalised estimated equations, with differences between 2020 (to March 2021) and comparison years 2016-2018 (to March 2017-2019) quantified using difference in differences, from which mean rate of odds ratios (μROR) across years was reported.

RESULTS

The study included 3,552,210 individuals over the study period. Self-harm contacts reduced across services in March and December 2020 compared to previous years. Primary care contacts with self-harm reduced disproportionately compared to non-self-harm contacts (μROR = 0.7, p<0.05), while their proportion increased in emergency departments during April 2020 (μROR = 1.3, p<0.05 in 2/3 comparison years) and hospital admissions during April-May 2020 (μROR = 1.2, p<0.05 in 2/3 comparison years). Despite this, those who self-harmed in April 2020 were more likely to be seen in primary care than other settings compared to previous years (μROR = 1.2, p<0.05). A lower proportion of those with self-harm contacts in emergency departments were subsequently admitted to hospital in December 2020 compared to previous years (μROR = 0.5, p<0.05).

CONCLUSIONS

These findings suggest that those who self-harmed during the COVID-19 pandemic may have been less likely to seek help, and those who did so faced more stringent criteria for admission. Communications encouraging those who self-harm to seek help during pandemics may be beneficial. However, this needs to be supported by maintained provision of mental health services.

A vegetation classification and description of white-winged flufftail (Sarothrura ayresi) habitat at selected high-altitude peatlands in South Africa

The white-winged flufftail is listed as critically endangered, and limited knowledge about the species' ecology has been identified as a limiting factor to effectively conserving the bird. Little is known about the vegetation inhabited by the white-winged flufftail, which hampers the identification and management of its habitat. This study presents a fine-scale classification and description of the vegetation of wetland sites where the bird is known to be present. A plant phytosociological study was conducted to describe the plant communities and vegetation structure of the habitat. Three sites were selected at Verloren Valei Nature Reserve and two at Middelpunt Wetland, Mpumalanga, South Africa, shortly after the white-winged flufftail breeding season. A total of 60 sample plots were placed within the study sites, where all plant species present were recorded and identified. Other aspects such as plant height, water depth and anthropogenic influences were also documented. A modified TWINSPAN analysis resulted in the identification of three sub-communities that can be grouped into one major community. The Cyperaceae, Asteraceae and Poaceae families dominate the vegetation, with the sedges Carex austro-africana and Cyperus denudatus being dominant, and the grasses Leersia hexandra and Arundinella nepalensis co-dominant. The broad habitat structure consisted of medium to tall herbaceous plants (0.5-0.7 m) with shallow slow-flowing water.

Suicide following acute admissions for physical illnesses across England and Wales

BACKGROUND

The study aim was to establish and quantify suicide risk following acute admissions for all major physical illnesses, for confirmatory purposes, from two independent information sources from different countries.

METHODS

Record linkage of inpatient and death certificate data for 11 004 389 acute admissions for physical illnesses in England and 713 496 in Wales. The main outcome measure was standardised mortality ratios (SMRs) for suicide at 1 year following discharge from hospital.

RESULTS

There were 1781 suicides within 1 year of discharge in England (SMR = 1.7; 95% = 1.6-1.8) and 131 in Wales (SMR = 2.0; 1.7-2.3). Of 48 major physical illnesses that were associated with at least eight suicides in either country, there was high consistent suicide mortality (significant SMR >3) in both countries for constipation (SMR = 4.1 in England, 7.5 in Wales), gastritis (4.4 and 4.9) and upper gastrointestinal bleeding (3.4 and 4.5). There was high suicide mortality in one country for alcoholic liver disease, other liver disease and chronic pancreatitis; for epilepsy and Parkinson's disease; for diabetes, hypoglycaemia and hypo-osmolality & hyponatraemia; and for pneumonia, back pain and urinary tract infections.

CONCLUSIONS

There is little or no increased suicide mortality following acute admissions for most physical illnesses. Much of the increased suicide mortality relates to gastrointestinal disorders that are often alcohol related or specific chronic conditions, which may be linked to side effects from certain therapeutic medications. Acute hospital admissions for physical illnesses may therefore provide an opportunity for targeted suicide prevention among people with certain conditions, particularly alcohol related disorders.

Autism awareness in children and young people: surveys of two populations

BACKGROUND

Increasingly, pupils on the autism spectrum are educated in inclusive mainstream classrooms. However, they often experience social isolation and bullying, and raising the awareness of autism in peers has been suggested as a remedy.

METHODS

In order to assess autism awareness in peers, autism-related questions were included in two large-scale surveys: the Kids Life and Times survey for 11-year olds and the Young Life and Times survey for 16-year olds; a total of n = 3353 children and young people completed the surveys.

RESULTS

Autism awareness was higher for the teenagers (80%) than for the younger children (50%). Many of the children knew someone with autism (50%) and generally reported positive and supportive attitudes. Self-reported prevalence of autism was 3.1% for teenagers and 2.7% for the younger children. Peers recognised bullying as a problem and were willing to help.

CONCLUSIONS

Children and young people have good levels of awareness and knowledge about autism and reported positive attitudes towards peers with autism and are willing to help those who are bullied. A higher than expected number of children and young people self-reported being on the autism spectrum. These findings bode well for peer-mediated support strategies for inclusive education.

Recent trends in primary-care antidepressant prescribing to children and young people: an e-cohort study

BACKGROUND

Concerns relating to increased use of psychotropic medication contrast with those of under-treatment and under-recognition of common mental disorders in children and young people (CYP) across developed countries. Little is known about the indications recorded for antidepressant prescribing in primary care in CYP.

METHOD

This was an electronic cohort study of routinely collected primary-care data from a population of 1.9 million, Wales, UK. Poisson regression was undertaken to model adjusted counts of recorded depression symptoms, diagnoses and antidepressant prescriptions. Associated indications were explored.

RESULTS

3 58 383 registered patients aged 6-18 years between 1 January 2003 and 31 December 2013 provided a total of 19 20 338 person-years of follow-up. The adjusted incidence of antidepressant prescribing increased significantly [incidence rate ratio (IRR) for 2013 = 1.28], mainly in older adolescents. The majority of new antidepressant prescriptions were for citalopram. Recorded depression diagnoses showed a steady decline (IRR = 0.72) while depression symptoms (IRR = 2.41) increased. Just over half of new antidepressant prescriptions were associated with depression (diagnosis or symptoms). Other antidepressant prescribing, largely unlicensed, was associated with diagnoses such as anxiety and pain.

CONCLUSION

Antidepressant prescribing is increasing in CYP while recorded depression diagnoses decline. Unlicensed citalopram prescribing occurs outside current guidelines, despite its known toxicity in overdose. Unlicensed antidepressant prescribing is associated with a wide range of diagnoses, and while accepted practice, is often not supported by safety and efficacy studies. New strategies to implement current guidance for the management of depression in CYP are required.

Recent trends in the incidence of anxiety and prescription of anxiolytics and hypnotics in children and young people: An e-cohort study

BACKGROUND

Little is known regarding the recognition of anxiety in children and young people (CYP) in primary care. This study examined trends in the presentation, recognition and recording of anxiety and of anxiolytic and hypnotic prescriptions for CYP in primary care.

METHOD

A population-based retrospective electronic cohort of individuals aged 6-18 years between 2003 and 2011 within the Secure Anonymised Information Linkage (SAIL) Databank primary care database was created. Incidence rates were calculated using person years at risk (PYAR) as a denominator accounting for deprivation, age and gender.

RESULTS

We identified a cohort of 311,343 registered individuals providing a total of 1,546,489 person years of follow up. The incidence of anxiety symptoms more than tripled over the study period (Incidence Rate Ratio (IRR)=3.55, 95% CI 2.65-4.77) whilst that of diagnosis has remained stable. Anxiolytic/hypnotic prescriptions for the cohort as a whole did not change significantly over time; however there was a significant increase in anxiolytic prescriptions for the 15-18 year age group (IRR 1.62, 95% CI 1.30-2.02).

LIMITATIONS

There was a lack of reliable information regarding other interventions available or received at a primary, secondary or tertiary level such as psychological treatments.

CONCLUSIONS

There appears to be a preference over time for the recording of general symptoms over diagnosis for anxiety in CYP. The increase in anxiolytic prescriptions for 15-18 year olds is discrepant with current prescribing guidelines. Specific guidance is required for the assessment and management of CYP presenting with anxiety to primary care, particularly older adolescents.

Suicide Information Database-Cymru: a protocol for a population-based, routinely collected data linkage study to explore risks and patterns of healthcare contact prior to suicide to identify opportunities for intervention

INTRODUCTION

Prevention of suicide is a global public health challenge extending beyond mental health services. Linking routinely collected health and social care system data records for the same individual across different services and over time has enormous potential in suicide research. Most previous research linking suicide mortality data with routinely collected electronic health records involves only one or two domains of healthcare provision such as psychiatric inpatient care. This protocol paper describes the development of a population-based, routinely collected data linkage study: the Suicide Information Database Cymru (SID-Cymru). SID-Cymru aims to contribute to the information available on people who complete suicide.

METHODS AND ANALYSIS

SID-Cymru will facilitate a series of electronic case-control studies based in the Secure Anonymised Information Linkage (SAIL) Databank. We have identified 2664 cases of suicide in Wales between 2003 and 2011 from routinely collected mortality data using International Classification of Diseases, Tenth Revision, codes X60-X84 (intentional self-harm) and Y10-Y34 (undetermined intent). Each case will be matched by age and sex to at least five controls. Records will be collated and linked from routinely collected health and social data in Wales for each individual. Conditional logistic regression will be applied to produce crude and confounder (including general practice, socioeconomic status) adjusted ORs.

ETHICS AND DISSEMINATION

The SAIL Databank has the required ethical permissions in place to analyse anonymised data. Ethical approval has been granted by the Information Governance Review Panel (IGRP). Findings will be disseminated through peer-reviewed publications, consultations with stakeholders and national/international conference presentations. The improved understanding of the prior health, nature of previous contacts with services and wider social circumstances of those who complete suicide will assist in prevention policy, service organisation and delivery. SID-Cymru is funded through the National Institute for Social Care and Health Research, Welsh Government (RFS-12-25).

A pilot behavioural and biological surveillance survey for HIV and other bloodborne infections among Aboriginal people in Regina, Saskatchewan

BACKGROUND

Aboriginal people in Canada are disproportionately affected by HIV and other blood-borne infections. A-Track is a national public health surveillance system designed to monitor HIV and related infections, behaviours and socio-demographic factors among Aboriginal populations in Canada. The pilot survey for the A-Track surveillance system, the first of its kind in Canada, was conducted in Regina, Saskatchewan and implemented via a community and public health partnership.

OBJECTIVE

To assess the prevalence of HIV, hepatitis C, syphilis and associated risk behaviours and socio-demographic factors among Aboriginal people in Regina, Saskatchewan. This focus of the pilot survey was to provide this surveillance information for public health action and to determine whether this type of public health surveillance activity could be conducted in an urban setting across Canada.

METHODS

Survey participants were self-identified Aboriginal people (First Nations, Inuit or Métis) or those who claimed Aboriginal ancestry and between the ages of 16 and 60 years. These individuals were also asked to provide a blood sample for HIV, hepatitis C and syphilis antibody testing. Descriptive analyses were performed with sex-based comparisons.

RESULTS

There were 1064 people who participated in the survey. Their average age was 33 years and 51% were male. The majority of participants (93%) lived in urban Regina at the time of the survey. Just over half (53.2%) of all participants had been removed from their families during childhood; 29.9% had lived in a residential or boarding school during childhood; and 57.7% had lived at some point in a correctional facility. Among the 1,045 participants who provided a blood sample of sufficient quantity for testing, 5.2% were HIV seropositive and 55.8% of these were aware of their HIV status. The lifetime exposure to hepatitis C was 41.6%, with significantly higher proportions of males than females testing positive for hepatitis C exposure. Syphilis seroprevalence was very low (<1%). Almost three-quarters (71.5%) of participants reported being tested for HIV at least once in their lifetime and among those ever tested, 67.6% had been tested during the 12 months prior to the interview.

CONCLUSION

Aboriginal people are disproportionately affected by the HIV/AIDS epidemic in Canada. The findings from the A-Track pilot survey can be used to inform and evaluate prevention and treatment services for HIV and other related infections among Aboriginal people. Lessons learned from the pilot survey could also be used to guide the possible implementation of A-Track in other urban and/or reserve locations in Canada.

Effect of neighbourhood deprivation and social cohesion on mental health inequality: a multilevel population-based longitudinal study

BACKGROUND

The common mental disorders (CMDs) of anxiety and depression are the most common form of poor mental health in the general population. Evidence from the small number of previous cohort studies on the role of neighbourhood factors in mental health is inconclusive. We tested the hypothesis that high levels of neighbourhood social cohesion modify an adverse association between change in individual mental health and neighbourhood deprivation.

METHOD

We carried out a longitudinal multilevel analysis using data from the Caerphilly Health and Social Needs Cohort Study with a 7-year follow-up (n = 4426; age range 18-74 years at baseline). Neighbourhood deprivation and neighbourhood social cohesion were assessed at baseline and change in mental health between follow-up and baseline was assessed using the five-item Mental Health Inventory (MHI-5).

RESULTS

Residence in the most deprived neighbourhoods was negatively associated with change in mental health, after adjusting for baseline individual socio-economic risk factors and transitions in life events. This negative effect was significantly reduced in high social cohesion neighbourhoods. The predicted change in mental health score was calculated for the 10th and 90th centiles of the household low-income distribution. The difference between them was -2.8 in the low social cohesion group and 1.1 in the high cohesion group. The difference between the groups was 3.9 [95% confidence interval (CI) 0.2-7.6].

CONCLUSIONS

The public health burden of poor mental health and mental health inequality could potentially be reduced by strengthening social cohesion in deprived neighbourhoods. This offers a mechanism to address the adverse effect of neighbourhood deprivation on population mental health.

High-risk occupations for suicide

BACKGROUND

High occupational suicide rates are often linked to easy occupational access to a method of suicide. This study aimed to compare suicide rates across all occupations in Britain, how they have changed over the past 30 years, and how they may vary by occupational socio-economic group. Method We used national occupational mortality statistics, census-based occupational populations and death inquiry files (for the years 1979-1980, 1982-1983 and 2001-2005). The main outcome measures were suicide rates per 100 000 population, percentage changes over time in suicide rates, standardized mortality ratios (SMRs) and proportional mortality ratios (PMRs).

RESULTS

Several occupations with the highest suicide rates (per 100 000 population) during 1979-1980 and 1982-1983, including veterinarians (ranked first), pharmacists (fourth), dentists (sixth), doctors (tenth) and farmers (thirteenth), have easy occupational access to a method of suicide (pharmaceuticals or guns). By 2001-2005, there had been large significant reductions in suicide rates for each of these occupations, so that none ranked in the top 30 occupations. Occupations with significant increases over time in suicide rates were all manual occupations whereas occupations with suicide rates that decreased were mainly professional or non-manual. Variation in suicide rates that was explained by socio-economic group almost doubled over time from 11.4% in 1979-1980 and 1982-1983 to 20.7% in 2001-2005.

CONCLUSIONS

Socio-economic forces now seem to be a major determinant of high occupational suicide rates in Britain. As the increases in suicide rates among manual occupations occurred during a period of economic prosperity, carefully targeted suicide prevention initiatives could be beneficial.

Health-related quality of life and children's happiness with their childcare

BACKGROUND

Almost without exception, research into the range and quality of childcare provision, and its correlates with children's development, comes from the perspective of adults. Parents, childcare workers, teachers and the general public have all been asked for their views on childcare. In contrast, there is a dearth of information on attitudes to childcare provision and its correlates from the perspective of the children themselves.

METHODS

A total of 3657 Primary 7 children, who are 10 or 11 years of age, completed the KIDSCREEN-27 health-related quality of life (HRQoL) measure along with questions on their childcare provision as part of an online survey carried out in schools.

RESULTS

Most children receiving childcare from people other than their parents were completely happy with their care. Childcare was related to poorer HRQoL for girls on four of the five KIDSCREEN domains, although the effect sizes were small. For both boys and girls, there were statistically significant, although modest, correlations between happiness with childcare and scores on all five domains of the KIDSCREEN-27.

CONCLUSIONS

Overall, the findings suggest that most children are happy with their care and that any differences between the HRQoL of those who are cared for by their parents and those who are not are small to moderate.

A population-based study of prostate cancer chemotherapy

The use of chemotherapy in the treatment of prostate cancer is a relatively recent development, with no published data on the patterns of care in the UK. We carried out a population-based study to assess variation in the use of prostate cancer chemotherapy over time in a UK cancer network.

A diagnostic system using broad categories with clinically relevant specifiers: lessons for ICD-11

A diagnostic system for ICD-11 is proposed which commences with broad reorganization and simplification of the current categories and the use of clinically relevant specifiers. Such changes have implications for the positioning of diagnostic groups and lead to a range of possibilities for improving terminology and the juxtaposition of individual conditions. The development of ICD-11 provides the fi rst opportunity in almost two decades to improve the validity and reliability of the international classification system. Widespread change in broad categories and criteria cannot be justified by research that has emerged since the last revision. It would also be disruptive to clinical practice and might devalue past research work. However, the case for reorganization of the categories is stronger and has recently been made by an eminent international group of researchers (Andrews et al., 2009). A simpler, interlinked diagnostic system is proposed here which is likely to have fewer categories than its predecessor. There are major advantages of such a system for clinical practice and research and it could also produce much needed simplification for primary care (Gask et al., 2008) and the developing world (Wig, 1990; Kohn et al., 2004).

Impact of risperidone long acting injection on resource utilization in psychiatric secondary care

Risperidone long acting injection (RLAI) is the only long acting atypical antipsychotic available in the UK. Its impact on NHS resource use has not been widely studied. This review of medical records was conducted to quantify the impact of RLAI on NHS psychiatric secondary care resource use, primarily in terms of episodes of inpatient hospital care 12 months before and 12 months after RLAI initiation. Data on number of hospitalizations and hospital bed days were collected retrospectively, from patient notes and hospital databases in four acute psychiatric units in the UK for all individuals with a diagnosis of schizophrenia or schizoaffective disorder who were prescribed RLAI more than 12 months previously. Data were collected on 100 individuals (58 male) with a mean age 40.8 years (range 19-70). The median duration of illness before RLAI initiation was 12 years (range six months to 43 years). There were 62 admissions in the 12 months pre-RLAI, falling to 22 admissions in the 12 months post-RLAI. Number of admissions, we argue, offer a more reliable indicator of the impact of treatment than total hospital bed days in this type of study. In this study there were 40 fewer admissions in the 12 months after RLAI was initiated compared with the previous 12 months. This is important as readmission is a good proxy measure of relapse, and adherence to medication is known to be a key factor in relapse prevention.

Direct transition to long-acting risperidone--analysis of long-term efficacy

This report presents data from the extension phase of a 6-month trial that evaluated the efficacy of risperidone long-acting injectable (RLAI) in stable psychotic patients requiring a treatment change. Patients continued to receive RLAI every 2 weeks for a maximum of 12 months from study entry. Symptoms were assessed using the PANSS after 1, 3, 6, 9 and 12 months of treatment (or treatment endpoint). Remission of severity criteria were defined as < or =3 points in all PANSS items suggested by the Remission in Schizophrenia Working Group.715 patients (63% male) entered the extension phase and 508 completed the 12-month study. The mean PANSS total score at Day 0 was 74.9+/-22.7. This was significantly reduced after 1 month (67.7 +/-22.3, p< or =0.001), with continued improvements over the 12 months of the study until treatment endpoint (59.7+/-21.9). Significant improvements from Day 0 to endpoint were also seen in the scores for all PANSS subscales and symptom factors. The proportion of patients who met the PANSS severity criteria for remission increased from 29% at Day 0 to 60% at endpoint, and the proportion of patients who met these criteria for < or = 6 months increased from 24% at Month 6 to 45% at endpoint. Treatment with RLAI for up to 12 months provided significant and sustained improvements in symptom control in patients with schizophrenia. These improvements may help patients to achieve and remain in remission.

Schizophrenia and weight management: a systematic review of interventions to control weight

OBJECTIVE

Weight gain is a frequent side effect of antipsychotic medication which has serious implications for a patient's health and well being. This study systematically reviews the literature on the effectiveness of interventions designed to control weight gain in schizophrenia.

METHOD

A systematic search strategy was conducted of major databases in addition to citation searches. Study quality was rated.

RESULTS

Sixteen studies met the inclusion criteria. Five of eight pharmacological intervention studies reported small reductions in weight (<5% baseline body weight). All behavioural (including diet and/or exercise) interventions reported small reductions in, or maintenance of, weight.

CONCLUSION

Weight loss may be difficult but it is not impossible. Given the inconsistent results, the widespread use of pharmacological interventions cannot be recommended. Both dietary and exercise counselling set within a behavioural modification programme is necessary for sustained weight control.

Heated socks maintain toe temperature but not always skin blood flow as mean skin temperature falls

INTRODUCTION

This study was conducted to examine whether toe skin blood flow (Q(toe)) could be maintained in subjects exposed to cold air by warming the foot using a heated sock.

METHODS

Four male subjects were exposed to air at 4 degrees C. They wore aramid shirt and trousers, a coverall made from metalized spun bonded polyethylene ("space blanket" fabric), arctic mittens, a 4-ply aramid balaclava, and loose fitting padded boot liners. The subjects rested recumbent on a couch with a pair of heated socks turned on for 120 min and with socks turned off for a further 60 min. Q(toe) was measured using laser Doppler flowmetry.

RSULTS

Although the heated socks maintained the skin temperature of the feet above 37 degrees C, Q(toe) was not maintained in two of the four male subjects for the 120 min that the socks were turned on.

DISCUSSION

Heated socks cannot be relied on to maintain Q(toe) or to prevent non-freezing cold injuries during prolonged exposure to cold conditions.

Immunological responses of Eurasian badgers (Meles meles) vaccinated with Mycobacterium bovis BCG (bacillus calmette guerin)

Wildlife species, such as the badger (Meles meles), may act as maintenance hosts for Mycobacterium bovis and contribute to the spread and persistence of tuberculosis in associated cattle populations. Targeted vaccination of badgers against tuberculosis is an option that, if successfully employed, could directly facilitate the advancement of bovine tuberculosis eradication in affected areas. In this study, the immunological responses of a group of badgers vaccinated subcutaneously with low doses of Mycobacterium bovis bacillus calmette guerin (BCG) were measured in vitro and compared with non-vaccinated control animals over a period of 42 weeks. Peripheral blood mononuclear cells (PBMC) from badgers which had received repeated booster injections of BCG proliferated in response to culture with PPD-bovine (purified protein derivative of tuberculin). The proliferation was significantly greater than that seen in the non-vaccinated control group. In contrast, the proliferative response of PBMC from vaccinated badgers to PPD-avian declined relative to the control group. These results demonstrate that repeated vaccination of badgers with M. bovis BCG induced a population of T-lymphocytes responsive to specific antigens in PPD-bovine. Throughout the course of the study, the sera from all animals were tested (BrockTest) by an enzyme-linked immunosorbent assay (ELISA) system for the presence of antibodies to MPB83, a serodominant antigen whose expression is high in M. bovis, but very low in BCG (Pasteur). No animals at any stage showed seroconversion to the antigen, consistent with the tuberculosis-free status of the badgers under study.

Stress in farmers

This study aims to document the nature and extent of occupational stress in farming. A postal survey of farmers in the South West of England, was undertaken and results indicate high levels of occupational stress in farming families. 35% of respondents scored positively on the General Health Questionnaire (GHQ) with female respondents showing significantly higher scores than males. A significant proportion of respondents also showed elevated levels of anxiety and depression as measured by the Hospital Anxiety and Depression Scale (HAD). Indices of psychological distress were correlated with ill health and family problems though the most common sources of perceived stress were coping with new legislation, the amount of paper work and media criticism. People who reported a greater number of stressors scored higher on all 3 measure of psychological distress.

The burden of personality disorder: a district-based survey

Patients with a clinical diagnosis of personality disorder (PD) often suffer prolonged distress. They are a considerable burden on psychiatric services and they are experienced as difficult to manage by their keyworkers. This paper describes the creation of a community-based case register of patients suffering from PD. It explores the relationship between psychological distress, personality dysfunction, service utilisation and keyworker stress. Mental Health workers were asked to identify those patients on their caseload whose primary problem was PD. This list provided the basis for the case register. Patients completed the revised Personality Diagnostic Questionnaire IV (PDQ 4); the General Health Questionnaire (GHQ); and the Beck Depression Inventory - 21 item (BDI). A brief, semi-structured interview was conducted by Community Psychiatric Nurses to estimate service utilisation and keyworker stress. The mean GHQ was 14.58; the mean BDI score was 28.22. The mean number of PDs per patient was 4.5. One quarter of patients (21/80) had been admitted at least once to a psychiatric ward in the previous year and 17% (13/80) had presented to casualty at least once in the previous two months. 57% of the patients had weekly or more contacts with a helping agency. The number of PD diagnoses per patient as measured by the PDQ 4 was not found to be predictive of stress experienced by CPNs, whereas high BDI and GHQ scores were strongly correlated. Similarly, the number of admissions to a psychiatric ward was associated with high BDI and GHQ scores but not with number of PDs per patient. It is feasible to establish a case register of all patients in the district with PD. There are high levels of depression and distress amongst patients with PD being treated as outpatients. Service utilisation and keyworker stress are not predicted by number of PDs per patient but are strongly associated with distress as measured by the GHQ and BDI. The implications of these findings are discussed.

Psychological distress among cancer patients and informed consent

This study examines the relationships between satisfaction with information provided, understanding of consent procedures, and levels of anxiety/depression in a sample of patients undergoing radiotherapy for cancer. One hundred patients completed a 13-item self-report questionnaire and the Hospital Anxiety and Depression Scale (HADS). Twenty-two percent of patients could not recall signing a consent form and, for those who did recall, the level of understanding for what they had consented to was patchy. One fourth of patients could not recall being told of the side-effects from radiotherapy and were unable to list even common side-effects, such as tiredness, skin irritation, and sickness. No patient had been told about the low risk of second malignancy. Twenty-eight percent of patients were unhappy with the amount of information offered to them. Thirty percent of patients reached caseness for adjustment disorder +/- anxiety/depression. Thirteen percent of patients reached caseness for major depression. There was a significant correlation between patients who scored highly on the HADS and dissatisfaction with the information provided. Clinical implications and possible mechanisms of these findings are discussed.

Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care

OBJECTIVES

To examine the effect of patients' causal attributions of common somatic symptoms on recognition by general practitioners of cases of depression and anxiety and to test the hypothesis that normalising attributions make recognition less likely.

DESIGN

Cross sectional survey.

SETTING

One general practice of eight doctors in Bristol.

SUBJECTS

305 general practice attenders.

MAIN OUTCOME MEASURE

The rate of detection by general practitioners of cases of depression and anxiety as defined by the general health questionnaire.

RESULTS

Consecutive attenders completed the general health questionnaire and the symptom interpretation questionnaire, which scores style of symptom attribution along the dimensions of psychologising, somatising, and normalising. General practitioners detected depression or anxiety in 56 (36%; 95% confidence interval 28% to 44%) of the 157 patients who scored highly on the general health questionnaire. Subjects with a normalising attributional style were less likely to be detected as cases; doctors did not make any psychological diagnosis in 46 (85%; 73% to 93%) of 54 patients who had high questionnaire and high normalising scores. Those with a psychologising style were more likely to be detected; doctors did not detect 21 (38%; 25% to 52%) of 55 patients who had high questionnaire and high psychologising scores. The somatisation scale was not associated with low detection rates. This pattern of results persisted after adjustment for age, sex, general health questionnaire score, and general practitioner.

CONCLUSIONS

Normalising attributions minimise symptoms and are non-pathological in character. The normalising attributional style is predominant in general practice attenders and is an important cause of low rates of detection of depression and anxiety.

Long-term outcome of a phase II study of BM transplants, partially depleted ex-vivo of CD5-positive and CD8-positive T-lymphocytes in unrelated and related donor 1 antigen mismatched recipients

BACKGROUND

Mismatched family donor and unrelated donor BM transplants are associated with a high risk of acute GvHD. White T-cell depletion is the best method to reduce risk of acute GvHD, there was a reluctance to use T-cell depletion in the mismatched setting because of increased risk of rejection and relapse. Partial T-cell depletion, by the panning of CDS and CD8 positive T cells may reduce complications related to GvHD without compromising outcomes.

METHOD

In a long-term follow-up of a Phase II study of partial T-cell depletion by panning for BM transplant, 32 recipients received transplants from a single-Ag (HLA A, B, or DR) mismatched family donor; or an HLA serologically-matched unrelated donor. Patients were studied for engraftment, GHD, relapse and survival.

RESULTS

30 (94%) of the patients marrow engrafted. The cumulative risk of Grade 2-4 acute GvHD was 62 - 9%; of Grade 3-4 GvHD, 11 - 6%. The 4-year cumulative risk of relapse was 18 - 8% and actuarial survival was 44 - 9%.

DISCUSSION

Partial T-cell depletion had a low rate of severe acute GvHD without compromising engrafment or relapse risk.

Osteopontin stimulates a subpopulation of quiescent human prostate epithelial cells with high proliferative potential to divide in vitro

BACKGROUND

Osteopontin (OPN) is a secreted extracellular matrix (ECM) protein found in bone, as well as associated with epithelial cells. The main objective of these studies was to test in vitro the hypothesis that interaction with OPN stimulates proliferation of a quiescent subpopulation of prostate epithelial cells with high proliferative potential.

METHODS

To simulate conditions that restrict proliferation and inhibit terminal differentiation of basal cells in vivo, control cultures grew on substrate coated with collagen (CO) or fibronectin (FN), in medium containing low levels of growth factors.

RESULTS

Under growth-restricting conditions, most prostate epithelial cells with high proliferative potential, seeded in control secondary cultures, were quiescent within the time frame of the studies, as indicated by the small number of large colonies in these cultures. Growing prostate epithelial cells (PR) under the same growth-restricting conditions, but on substrate coated with OPN instead of CO or FN, stimulated proliferation of a subpopulation of single cells with high proliferative ability as indicated by: 1) dose-dependent increase in the percentage of single cells incorporating bromodeoxyuridine, i.e., proliferating PR; and 2) subsequent dose-dependent increase in the percentage of large colonies. The OPN effect was not merely due to preferential attachment to OPN, because PR attachment to OPN, CO, or FN was identical. PR attachment to OPN was inhibited in the presence of GRGDTP or an antibody against the integrin subunit alphav, but not in the presence of an RGES peptide or a nonspecific IgG.

CONCLUSIONS

Integrin-mediated OPN/PR interaction stimulates proliferation of a quiescent subpopulation of prostate epithelial cells with high proliferative potential, possibly stem cells.

Dissimilar spine and femoral Z-scores in premenopausal women

The purpose of this study was to determine if differences exist in premenopausal women between z-scores for lumbar spine and proximal femoral bone mineral densities (BMD). Participants were 237 women ranging in age from 20 to 45 years. BMDs of the lumbar spine and proximal femur (femoral neck, Ward's area, and trochanter) were assessed using dual-energy X-ray absorptiometry (Lunar DPX). Mean (+/-SD) age, height, and weight of the participants were 29.4 +/- 6.9 years, 164.4 +/- 6.1 cm, and 64.9 +/- 12.1 kg, respectively. Lumbar spine BMD and BMD at the femoral neck, Ward's area, and trochanter were significantly correlated with large SEEs (r = 0.59-0. 65; SEE = 0.09-0.11). No positive correlation with age and BMD at any site was seen in this population but a significant negative correlation with age was seen in the proximal femur beginning at age 30. Twenty to 24% of the 20-29-year-olds exhibited a difference in z-scores of greater than 1 between the spine and sites in the proximal femur. This percentage increased to 32-46% in the 30-45-year-olds but the nature of the observed differences changed. The differences in spine and proximal femoral z-scores that are seen in the older age group appear to be the result of the earlier onset of bone loss in the proximal femur rather than an initial difference in peak bone mass which has been maintained.

Evidence for altered proliferative ability of progenitors of urothelial cells in interstitial cystitis

Secondary cultures of basal urothelial cells isolated from patients with stress incontinence (7 patients), neurogenic bladder (2 patients), interstitial cystitis (IC) (27 patients), bladder rupture (1 patient) and bacterial cystitis (3 patients) grew under growth restricting conditions. All groups displayed reproducible colony size distribution, reflecting the proliferative potential distribution in the population of progenitor cells seeded. The percentage of large colonies (> 6 cells/colony), progeny of basal cells with high proliferative potential, was low in cultures from control patients with stress incontinence, neurogenic bladder or bladder rupture. Exposure of cultures from control patients with stress incontinence to lipoteichoic acid from Streptococcus faecalis, in vitro, increased the percentage of large colonies to levels statistically indistinguishable from those in untreated IC cultures. This supported the possibility that exposure of progenitors of urothelial cells to infection in vivo may cause the persistent increase in the percentage of large colonies in 80% of the IC patients tested. Given these findings, it was not surprising that the percentage of large colonies was also high in cultures from patients with acute bacterial cystitis. In conclusion, the present findings support the theoretical model for the etiology of IC we proposed based on our studies in normal urothelial cells (Elgavish et al., Journal of Cellular Physiology 169: 42-51, 52-65, 66-77, 1996): (1) The proliferative ability of a subpopulation of progenitors of urothelial cells is increased in IC; and (2) This change may be the result of recurrent exposure of progenitors of urothelial cells to injury due, possibly but not exclusively, to infection and chronic inflammation. We propose to use this change as a diagnostic tool for IC.

Epidemiological health study of a town exposed to chemicals

The purpose of this survey was to assess the health status of community residents exposed to a 16-day release of Catacarb from a nearby refinery and to document the prevalence rates of symptoms and illnesses of this town. The health status of the exposed residents was compared to that of unexposed residents of a demographically similar control town. An epidemiologic study design was used and questionnaires were mailed to all households in both towns. Response rate was 43%. Household cluster effects, gender, education, and race were controlled in the analysis. Questionnaire health data reveal increased reporting of symptoms in the exposed, specifically headaches, respiratory, visual, gastrointestinal, and dermatologic with odds ratios ranging between 1.3 and 3. Exposure relationships with increased symptoms and worsening of illnesses was found.

A subpopulation of human urothelial cells is stimulated to proliferate by treatment in vitro with lipoteichoic acid, a cell wall component of Streptococcus faecalis

Urinary tract infection with gram-positive bacteria is common. Avenues for ingress of bacteria into the bladder include luminal and suburothelial infection. Terminally differentiated superficial urothelial cells lining the lumen of the bladder are often shed in response to infection. In contrast, infection-induced altered function of progenitors of urothelial cells residing in the basal layer of the urothelium is likely to have long lasting effects on the structure and function of the urothelium. The main objective of the present studies was to investigate in vitro the possibility that exposure to lipoteichoic acid, a cell wall component of the gram-positive Streptococcus faecalis (LT-2), stimulates basal urothelial cells to proliferate. To simulate conditions that restrict proliferation and inhibit terminal differentiation of urothelial cells in the basal layer, secondary cultures of urothelial cells (UT) were grown on collagen or fibronectin coated substrate in medium containing low levels of Ca2+ (0.2 mM) and growth factors (0.005% bovine pituitary extract [BPE]). Under these conditions, UT cultures displayed a highly reproducible colony size distribution, possibly due to the fact that colonies were progeny of basal cells with various proliferative potentials, retained in vitro. In cultures grown under growth-restricting conditions the majority of progenitors appeared to be quiescent, just like stem cells in the basal layer of the urothelium. Thus, the population of large colonies (more than six cells/colony), was small when a steady state of growth was achieved, 3-7 days after seeding. Growth factors (0.005-0.5% BPE) caused a dose-dependent increase in this population of large colonies. Moreover, treatment of UT grown under growth-restricting conditions (0.005% BPE) with LT-2 increased steady-state levels of the population of large colonies to levels obtained in cultures growing under optimal conditions with respect to growth factors. These results indicated that the subpopulation of progenitors, quiescent under normal conditions, could be stimulated to proliferate. Two lines of evidence were consistent with the possibility that treatment with LT-2 stimulated proliferation of the subpopulation of progenitors and that large colonies were the progeny of this subpopulation of single cells: (1) treatment with LT-2 increased the percentage of single cells that incorporated bromodeoxyuridine (i.e., proliferated) in a time-dependent manner. (2) An increase in the percentage of large colonies was found following LT-2-triggered proliferation of single cells. We propose that, under normal conditions, cells produced in response to LT-2-triggered proliferation of stem cells are removed from the system due to an increased rate of differentiation followed by apoptosis. Recurrent infection and inflammation may not allow these processes to proceed effectively, resulting in chronic injury to the bladder. Moreover, under conditions in which stem cells accumulate mutations that incapacitate their progeny to undergo apoptosis, LT-triggered proliferation could be a contributing factor to tumorigenesis.

Nitric oxide mediates the action of lipoteichoic acid on the function of human urothelial cells

Gram-positive bacteria are recognized pathogens in urinary tract infections. Lipoteichoic acids, major components of the cell wall of gram-positive bacteria, are important virulence attributes, but their mechanism of action is not well understood. We have postulated that infection-induced altered function of progenitors of urothelial cells (UT) residing in the basal layer is likely to have long-lasting effects on the architecture and function of the urothelium. Our earlier in vitro studies in UT of basal type, grown under growth restricting conditions, have shown that 1) treatment with lipoteichoic acid from Streptococcus faecalis (LT-2) stimulates a subpopulation of progenitors of urothelial cells to proliferate, and 2) resulting large colonies differentiated at an increased rate under conditions simulating those in the basal layer of the urothelium. The hypothesis underlying the present studies was that nitric oxide (NO) mediated LT-2 action on these functions of UT. Immunocytochemical studies using an antibody against inducible nitric oxide synthase (iNOS) confirmed expression of iNOS in LT-2-treated UT. Our hypothesis was tested by treating UT grown under growth restricting conditions (0.005% bovine pituitary extract) with LT-2 (25 micrograms/ml), in the presence or absence of inhibitors of NOS (1 mM NG-nitro-L-arginine methyl ester [L-NAME]; 1 microM dexamethasone [DEXA]) or 25 microM hemoglobin, a potent inactivator of NO. Treatment with LT-2 in the presence of these agents prevented the following effects of LT-2 alone: 1) the stimulatory effect on proliferation of single cells, as well as within the resulting large colonies; 2) the subsequent differentiation of large colonies resulting from this proliferative activity, as indicated by distribution of beta 1 subunit-containing integrins to cell-cell contacts; 3) the inhibitory effect on the subsequent ability of LT-2-treated UT to attach to extracellular matrix proteins. These studies suggest that induction of NOS by LT-2, initially aimed at restricting the replication of infectious agents, may have potential cost of damage to the host bladder by interfering with urothelial differentiation.