Abstract P3-14-12: Phase 0 study evaluating COX2 inhibition on circulating PGE2 levels from obese subjects

Introduction: Obesity is associated with poor breast cancer outcomes in postmenopausal women in response to aromatase inhibitor therapy. Our prior studies have shown an association between reduced recurrence rate and use of cyclooxygenase-2 (COX-2) inhibiting non-steroidal anti-inflammatory drugs (NSAIDs) in obese breast cancer patients. The mechanism proposed was a decrease in prostaglandin E2 (PGE2) and reduced activation of the aromatase promote locally in the breast.

Methods: Postmenopausal women of varying body habitus were recruited at the CTRC in San Antonio and underwent randomized assignment to 1 of 3 arms: ASA 81mg daily, 1500mg of docosahexaenoic acid (DHA) and 2500mg eicosapentaenoic acid (EPA) given daily, or combined ASA and DHA/EPA. Sera were collected prior to and following 28 days of exposure, and cytokines including prostaglandin E2 were assessed via enzyme-linked immunosorbant assay (ELISA). Conditioned media was generated by exposing macrophages to patient sera in order to see if the patient sera induced PGE2 concentration in vitro.

Results: Thirty of the planned 120 subjects have completed assessment. No toxicity has been noted. In 71% of the patients, serum PGE2 levels decreased, but only 60% demonstrated concurrent decrease in serum PGE2 levels as well as macrophage PGE2 production, while almost all (88%) of the patients whose serum did not demonstrate a decrease in PGE2 levels also demonstrated no decrease in induced levels.

Conclusion: NSAIDs appear to effectively decrease circulating levels of PGE2 in most obese women. However, one third of the subjects did not demonstrate concurrent suppression of induced PGE2 from macrophages. These data suggest that circulating levels of PGE2 may not be reflective of local tumor microenvironment levels, and other pro-inflammatory circulating factors may be responsible for regulating local inflammatory responses. Final analysis will be completed and presented at the SABCS meeting.

Citation Format: Lengfelder L, Brenner A, Bowers L, Apte S, Galván G, Kist K, deGraffenried L. Phase 0 study evaluating COX2 inhibition on circulating PGE2 levels from obese subjects. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-14-12.

Abstract P2-05-22: Pre-clinical findings on obesity reversal and breast cancer progression: Targeting persistent inflammation

Background

Obesity is an established risk and progression factor for several intrinsic subtypes of breast cancer, including basal-like breast cancer (BLBC). Increased local and systemic levels of pro-inflammatory mediators, which typically accompany obesity, can independently influence tumor growth. Currently, it is unclear whether weight loss can reverse the enhancing effects of obesity on breast tumorigenesis. We hypothesize that chronic obesity results in epigenetic reprogramming, which may mediate residual inflammation, and lead to persistent mammary tumor growth despite moderate weight loss.

Methods

Female C57BL/6 mice (n=51) were administered a control (10% kcal from fat) or diet-induced obesity (DIO; 60% kcal from fat) regimen. After 17 weeks, DIO mice either continued on DIO diet or were switched to control diet to stimulate gradual weight loss, subsequently designated as Formerly Obese (FOb). Mice were orthotopically injected with Wnt-1 mammary tumor cells (a model of BLBC) at week 25, and monitored for an additional 9 weeks, then killed and their tumors excised, measured and stored for subsequent analysis. In an ongoing tumor study, we will randomize mice to the control or DIO regimen, switching half the DIO mice to the control diet after 15 weeks, resulting in normal weight, obese, and FOb mice. Within each of these groups, the mice will be further randomized to +/- supplementation with Sulindac, a non-steroidal anti-inflammatory drug (NSAID), starting at the time of the diet switch. After 10 weeks of +/- Sulindac supplementation, mice will receive orthotopic injections of a mesenchymal derivative of an MMTV-Wnt-1 transgenic tumor, the M-Wnt cell line, and will continue on diet and treatment until euthanization.

Results

In our initial study, body weight, adiposity, and serum levels of leptin and insulin were similar in FOb and control mice, but serum levels of IL-6 were similar in FOb and DIO mice, and significantly higher than controls. Moreover, tumor burden, the mammary gland expression of key inflammatory genes, and the prevalence of hypermethylated inflammation-related genes in DNA from mammary tissue were comparable in DIO and FOb mice and significantly higher than in control mice, and there was high concordance with DNA methylation profiles in breast DNA from obese versus normoweight women participating in the UNC Normal Breast Study.

Conclusions

Our preclinical findings suggest that modest weight loss may not be sufficient to reverse the effects of chronic obesity on epigenetic reprogramming and inflammatory signals that are associated with obesity-related mammary tumor progression. Moreover, we have identified several genes with concordant obesity-related hypermethylation in humans and mice; which were unchanged in FOb mice. Thus combining weight loss regimens with epigenetic or inflammatory modulators may be an effective strategy for breaking the obesity-breast cancer link. We are currently assessing whether combining moderate weight loss with anti-inflammatory interventions (Sulindac or omega-3 fatty acids), or reprograming metabolism with a bariatric surgical intervention, is more effective than moderate weight loss alone at offsetting the persistent enhancing effects of chronic obesity on BLBC.

Citation Format: Rossi EL, Bowers LW, Khatib SA, Doerstling SS, Hursting SD. Pre-clinical findings on obesity reversal and breast cancer progression: Targeting persistent inflammation. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-05-22.

Abstract P2-05-28: The impact of the plant lignin secoisolariciresinol diglycoside on preclinical models of estrogen receptor positive breast cancer

Background: Several preclinical studies indicate that secoisolariciresinol diglycoside (SDG), a polyphenolic plant lignin found most abundantly in flaxseeds, inhibits the progression of both estrogen receptor (ER) positive and negative mammary tumors. SDG is metabolized by gut bacteria into the biologically active metabolites enterolactone (ENL) and enterodiol (END), which are known to have anti-estrogenic activity. However, the mechanisms mediating SDG's anti-tumor effects remain poorly understood.

Methods: In a dose-determination pilot study linked to an ongoing clinical trial of SDG in women at high risk for breast cancer, 18 week old C57BL/6 mice were randomized to a control diet or SDG-supplemented diets (25 or 74 mg/kg of food) for 8 weeks prior to euthanization, and the levels of serum and tissue SDG metabolites (particularly ENL and END), metabolic hormones and inflammatory markers were measured. In an ongoing tumor study, 12-week old C57BL/6 and foxn1 nu/nu mice were randomized to the control or control plus SDG (100 mg/kg of food, a dose projected to match ENL and END metabolite levels achieved in the clinical trial) diet regimen. After 8 weeks on diet, they will receive orthotopic injections of E0771 mouse mammary tumor cells or BT-483 human breast cancer cells (both ER positive), continuing on the same diets until euthanization. Cell culture studies examining the impact of biologically relevant concentrations of ENL and END on E0771 and BT-483 cells are also in progress.

Results: In comparison to those maintained on the control diet, the higher dose SDG diet reduced estrogen and pro-inflammatory signaling in the pilot study mice, as evidenced by higher interleukin 10 and lower C-reactive protein mammary fat pad expression as well as lower circulating levels of the adipokines leptin and resistin, which have been linked to chronic inflammation. High dose SDG also decreased serum insulin and glucose levels, indicating improved metabolic function. Because serum ENL and END levels in the pilot study did not reach those achieved in the SDG clinical trial, a 100 mg/kg SDG dose was chosen for the tumor study. Cell culture studies indicate that ENL (150 nM) inhibits E0771 and BT-483 cell proliferation and ER alpha:beta expression ratio.

Conclusions: Preliminary data suggests that the anti-tumor effects of SDG's metabolites may be mediated through multiple mechanisms, including improvements in metabolic function and inflammatory signaling as well as modulation of breast cancer cell gene expression. The results of the ongoing tumor study will inform the design of additional cell culture studies aimed at further defining these mechanisms.

Citation Format: Bowers LW, Ford NA, Rossi EL, Shamsunder MG, Kimler BF, Fabian CJ, Hursting SD. The impact of the plant lignin secoisolariciresinol diglycoside on preclinical models of estrogen receptor positive breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-05-28.

Substance use and violence among psychiatric inpatients

Nursing staff on psychiatric wards often attribute patient violence and aggression to substance use. This study examined incidents of alcohol and illicit drug use among acute psychiatric inpatients and associations between substance use and violence or other forms of aggression. A sample of 522 adult psychiatric inpatients was recruited from 84 acute psychiatric wards in England. Data were collected from nursing and medical records for the first 2 weeks of admission. Only a small proportion of the sample was reported to have used or been under the influence of alcohol (5%) or drugs (3%). There was no physical violence during a shift when a patient had used alcohol or drugs. Substance using patients were also no more likely than others to behave violently at any point during the study period. However, incidents of substance use were sometimes followed by verbal aggression. Beliefs that substance using patients are likely to be violent were not supported by this study, and could impact negatively on therapeutic relationships between nurses and this patient group. Future studies are needed to examine how staff intervene and interact with intoxicated patients.

Safewards: a new model of conflict and containment on psychiatric wards

Conflict (aggression, self-harm, suicide, absconding, substance/alcohol use and medication refusal) and containment (as required medication, coerced intramuscular medication, seclusion, manual restraint, special observation, etc.) place patients and staff at risk of serious harm. The frequency of these events varies between wards, but there are few explanations as to why this is so, and a coherent model is lacking. This paper proposes a comprehensive explanatory model of these differences, and sketches the implications on methods for reducing risk and coercion in inpatient wards. This Safewards Model depicts six domains of originating factors: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. These domains give risk to flashpoints, which have the capacity to trigger conflict and/or containment. Staff interventions can modify these processes by reducing the conflict-originating factors, preventing flashpoints from arising, cutting the link between flashpoint and conflict, choosing not to use containment, and ensuring that containment use does not lead to further conflict. We describe this model systematically and in detail, and show how this can be used to devise strategies for promoting the safety of patients and staff.

Safewards: the empirical basis of the model and a critical appraisal

ACCESSIBLE SUMMARY

In the previous paper we described a model explaining differences in rates of conflict and containment between wards, grouping causal factors into six domains: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. This paper reviews and evaluates the evidence for the model from previously published research. The model is supported, but the evidence is not very strong. More research using more rigorous methods is required in order to confirm or improve this model.

ABSTRACT

In a previous paper, we described a proposed model explaining differences in rates of conflict (aggression, absconding, self-harm, etc.) and containment (seclusion, special observation, manual restraint, etc.). The Safewards Model identified six originating domains as sources of conflict and containment: the patient community, patient characteristics, the regulatory framework, the staff team, the physical environment, and outside hospital. In this paper, we assemble the evidence underpinning the inclusion of these six domains, drawing upon a wide ranging review of the literature across all conflict and containment items; our own programme of research; and reasoned thinking. There is good evidence that the six domains are important in conflict and containment generation. Specific claims about single items within those domains are more difficult to support with convincing evidence, although the weight of evidence does vary between items and between different types of conflict behaviour or containment method. The Safewards Model is supported by the evidence, but that evidence is not particularly strong. There is a dearth of rigorous outcome studies and trials in this area, and an excess of descriptive studies. The model allows the generation of a number of different interventions in order to reduce rates of conflict and containment, and properly conducted trials are now needed to test its validity.

Sexual behaviours on acute inpatient psychiatric units

The purpose of the study was to assess the types and frequency of sexual behaviours displayed by patients during the first 2 weeks of admission to acute psychiatric units and what relationship these have to other challenging patient behaviours. The method used was a survey of sexual behaviours, conflict and containment events carried out by 522 patients during the first 2 weeks of admission in 84 wards in 31 hospitals in the South East of England. Incidents of sexual behaviour were common, with 13% of patients responsible for at least one incident. Although exposure was the most frequent of these behaviours, non-consensual sexual touching, was instigated by 1 in 20 patients. There were no differences in the numbers of sexual events between single sex and mixed gender wards. Few associations were found with the demographic features of perpetrators, although all those engaging in public masturbation were male, and male patients were more likely to sexually touch another without their consent. Single sex wards do not seem to necessarily offer significant protection to potentially vulnerable victims. Perpetrators do not seem to be predictable in advance, nor was there any common set or pattern of disruptive behavioural events indicating that a sexual incident was about to occur.

Abstract P1-06-01: NSAID use attenuates breast cancer recurrence in obese women: Role of prostaglandin-aromatase interactions

Introduction: Obesity is associated with a worse breast cancer prognosis, with the most prominent effects seen in hormone responsive postmenopausal patients. It has also been linked to elevated levels of inflammation, including greater cyclooxygenase-2 (COX-2) expression and activity in adipose-infiltrating macrophages. The product of this enzyme, the pro-inflammatory eicosanoid prostaglandin E2 (PGE2), stimulates adipose tissue aromatase expression and subsequent estrogen production, which could promote breast cancer progression. Consequently, we hypothesized that non-steroidal anti-inflammatory drug (NSAID) use decreases estrogen receptor (ER) positive breast cancer recurrence in the obese population via inhibition of PGE2-mediated local aromatase expression.

Methods: Four-hundred and forty women treated for invasive, ER positive breast cancer at San Antonio area clinics were retrospectively classified according to NSAID use, body mass index category (Normal Weight (NW): 18.5-24.9 kg/m2; Overweight (OW): 25.0-29.9 kg/m2; Obese (OB): ≥30.0 kg/m2), and disease recurrence. To examine the role of obesity-induced local aromatase expression in the link between NSAID use and disease recurrence, we utilized an in vitro model of obesity in which we exposed macrophages to pooled sera samples from NW or OB postmenopausal breast cancer patients. Adipose stromal cells’ (ASC) aromatase expression was measured following exposure to conditioned media (CM) collected from these sera-exposed macrophages. ER activity and in vitro measures of cancer aggression were assessed in MCF-7 and T47D breast cancer cells cultured in CM from sera-exposed macrophage/ASC co-cultures.

Results: Within our patient population, which had an average BMI in the obese range, NSAID users had significantly lower recurrence rates (p = 0.05) and their time to disease progression was delayed by almost 28 months in comparison to nonusers. Our in vitro studies demonstrated that growth in OB macrophage CM significantly enhances ASC aromatase expression in comparison to NW (p<0.05), while macrophage treatment with celecoxib during the generation of CM neutralizes the difference between OB and NW. This was correlated with significantly greater macrophage PGE2 production following OB versus NW sera exposure (p<0.05). In addition, CM from macrophage/ASC co-cultures exposed to OB patient sera stimulates more breast cancer cell ER activity, proliferation, and S phase activity, and these differences are eliminated by the addition of an aromatase inhibitor during the generation of CM. We also plan to examine how the co-culture CM impacts breast cancer cell expression of a panel of genes related to cancer aggression.

Conclusions: Our results indicate that NSAID use can improve the recurrence rate for hormone-responsive breast cancer patients, particularly those with an elevated BMI. The in vitro model suggests that obesity-related enhancement of PGE2-induced local aromatase expression and estrogen production may be a key mechanism mediating this effect. Further studies designed to examine the clinical benefit of NSAID use in the obese breast cancer patient population are warranted.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-06-01.

Abstract P4-09-02: Omega-3 ethyl esters suppress breast cancer growth by modulating inflammatory signaling

Introduction: Inflammation has been identified as a key contributor to breast cancer development. Both clinical and preclinical studies confirm a role for inflammatory mediators such as cytokines, interleukins, embedded immune cells and prostaglandins in promoting development of breast cancer. Elevated levels/activity of cyclooxygenase-2 (COX-2) and interleukin-6 (IL-6) are correlated with a more aggressive disease. Omega-3 fatty acid (n-3) intake is correlated with an inverse risk for breast cancer development and improvement in prognostic markers. One key target of omega-3 fatty acids is the COX-2 enzyme. We hypothesize that one mechanism by which omega-3 fatty acids suppress breast cancer progression is through inhibition of inflammatory signaling.

Methods: The impact of omega-3 ethyl esters (n-3 EE), a component of some omega-3 supplements, on the viability of MCF-7 breast cancer cells grown in a pro-inflammatory environment was assessed by MTT analysis and on proliferation by cell counting. Supplementation of the growth media with IL-6 (10ng/mL) was used to simulate a pro-inflammatory environment. Changes in expression levels of key components of inflammatory pathways were assessed by Western blot analyses and quantitative PCR. Prostaglandin E2 (PGE2) levels were measured using ELISA assays.

Results: A significant suppression in IL-6-induced proliferation was observed when cells were exposed to physiological concentrations (20 uM) of n-3 EE for 96 hrs. Molecular analyses suggest that the suppression of the NF-kB/COX-2/PGE2 signaling axis was important for mediating this effect. These results are consistent with other studies using specific COX-2 inhibitors.

Conclusions: With their potent anti-inflammatory activity, n-3 EE may prove useful in reducing malignancy of breast cancer and also slow development of new breast cancers. Importantly, they appear to have none of the toxicities associated with pharmaceutical COX inhibitors (NSAIDs). Future studies are planned to incorporate nutraceutical compounds to standard therapy to improve efficacy and reduce associated side effects.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-09-02.

Improving seclusion practice: implications of a review of staff and patient views

This review explores patient and staff perceptions and improvement suggestions regarding seclusion in psychiatric inpatient settings. After an extensive literature search, 39 empirical papers were included in the review. According to the literature, patients perceived seclusion to be a distinct negative incident. Staff thought seclusion had a therapeutic effect and believed that units could not operate effectively without seclusion, but regretted that the situation was not resolved differently. Staff and patients had suggestions to improve the seclusion experience. Common themes in relation to the implications for practice are the need for better communication and more contact between patients and staff before, during and after the seclusion event.

A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression

OBJECTIVE

To combine the results of earlier comparison studies of in-patient aggression to quantitatively assess the strength of the association between patient factors and i) aggressive behaviour,ii) repetitive aggressive behaviour.

METHOD

A systematic review and meta-analysis of empirical articles and reports of comparison studies of aggression and non-aggression within adult psychiatric in-patient settings.

RESULTS

Factors that were significantly associated with in-patient aggression included being younger, male, involuntary admissions, not being married, a diagnosis of schizophrenia, a greater number of previous admissions, a history of violence, a history of self-destructive behaviour and a history of substance abuse. The only factors associated with repeated in-patient aggression were not being male, a history of violence and a history of substance abuse.

CONCLUSION

By comparing aggressive with non-aggressive patients, important differences between the two populations may be highlighted. These differences may help staff improve predictions of which patients might become aggressive and enable steps to be taken to reduce an aggressive incident occurring using actuarial judgements. However, the associations found between these actuarial factors and aggression were small. It is therefore important for staff to consider dynamic factors such as a patient's current state and the context to reduce in-patient aggression.

Inpatient verbal aggression: content, targets and patient characteristics

Verbally aggressive behaviour on psychiatric wards is more common than physical violence and can have distressing consequences for the staff and patients who are subjected to it. Previous research has tended to examine incidents of verbal aggression in little detail, instead combining different types of aggressive behaviour into a single measure. This study recruited 522 adult psychiatric inpatients from 84 acute wards. Data were collected from nursing and medical records for the first 2 weeks of admission. Incidents of verbal aggression were categorized and associations with patient characteristics examined. There were 1398 incidents of verbal aggression in total, reported for half the sample. Types of verbal aggression were, in order of prevalence: abusive language, shouting, threats, expressions of anger and racist comments. There were also a large number of entries in the notes which did not specify the form of verbal aggression. Staff members were the most frequent target of aggression. A history of violence and previous drug use were consistently associated with verbal aggression. However, there were also some notable differences in patient variables associated with specific types of verbal aggression. Future studies should consider using multidimensional measures of verbal aggression.

Differences in seclusion rates between admission wards: does patient compilation explain?

Comparison of seclusion figures between wards in Dutch psychiatric hospitals showed substantial differences in number and duration of seclusions. In the opinion of nurses and ward managers, these differences may predominantly be explained by differences in patient characteristics, as these are expected to have a large impact on these seclusion rates. Nurses assume more admissions of severely ill patients are related to higher seclusion rates. In order to test this hypothesis, we investigated differences in patient and background characteristics of 718 secluded patients over 5,097 admissions on 29 different admission wards over seven Dutch psychiatric hospitals. We performed an extreme group analysis to explore the relationship between patient and ward characteristics and the wards' number of seclusion hours per 1,000 admission hours. In a multivariate and a multilevel analysis, various characteristics turned out to be related to the number of seclusion hours per 1,000 admission hours as well as to the likelihood of a patient being secluded, confirming the nurses assumptions. The extreme group analysis showed that seclusion rates depended on both patient and ward characteristics. A multivariate and multilevel analyses revealed that differences in seclusion hours between wards could partially be explained by ward size next to patient characteristics. However, the largest deal of the difference between wards in seclusion rates could not be explained by characteristics measured in this study. We concluded ward policy and adequate staffing may, in particular on smaller wards, be key issues in reduction of seclusion.

Event sequencing of forced intramuscular medication in England

In most inpatient psychiatric care systems it is permissible in certain situations for staff to forcibly inject patients with psychotropic medication. The aim of this study is to describe what precedes and follows a coerced intramuscular injection within a nursing shift. Data were collected on the sequence of conflict (aggression, absconding, etc.) and containment (seclusion, restraint, etc.) for the first 2 weeks of 522 acute admissions on 84 wards in 31 UK hospitals. Injections were given to 9% of patients. Aggression, regular medication refusal and pro re nata (PRN) medication refusal preceded injections. The giving of coerced medication concluded most crises. Coerced medication effectively resolves crises in the short term. Staff should offer oral PRN as an alternative, unless this is unsafe. Where only verbal violence has occurred staff should try to resolve the crisis without enforcing medication. More research on the best way to respond to inpatients' medication refusal is required.

The relationship between attitudes towards different containment measures and their usage in a national sample of psychiatric inpatients

The aims of this report were to explore the relationships between patients' approval of containment measures, their levels of usage and patients' individual experience of each measure. Additionally the psychometric properties of the Attitudes to Containment Measures Questionnaire (ACMQ) were tested. A cross-sectional design was used. The ACMQ was completed by 1361 patients across 136 acute psychiatric wards from three regions in England that participated in the 'City 128' study. Staff on each ward completed the Patient-Staff Conflict Checklist - Shift Report at the end of each shift to log how often each containment measure was used. Frequency of patient reported containment correlated with rates reported by staff. Patients had separate attitudes to each containment measure rather than an attitude towards containment in general. High frequency of coerced intramuscular (IM) medication use was associated with negative attitudes to nearly all types of containment. The ACMQ has good construct validity. In wards where high levels of IM medication are used, all patients have lower approval ratings for a number of other containment measures. This suggests that IM medication has a negative impact not only on those subjected to it but also patients who witness it. Measures to reduce the negative impact of IM medication are discussed.

The antecedents of violence and aggression within psychiatric in-patient settings

OBJECTIVE

To systematically review the types and proportions of antecedents of violence and aggression within psychiatric in-patient settings.

METHOD

Empirical articles and reports with primary data pertaining to violence and aggression within adult psychiatric in-patient settings were retrieved. For each study, prospective antecedent data were extracted. The extracted antecedent data were thematically analysed, and all higher-level themes were meta-analysed using rate data.

RESULTS

Seventy-one studies met the inclusion criteria, from which 59 distinct antecedent themes were identified and organised into nine higher-level themes. The higher-level antecedent theme 'staff-patient interaction' was the most frequent type of antecedent overall, precipitating an estimated 39% of all violent/aggressive incidents. An examination of the staff-patient interaction themes revealed that limiting patients freedoms, by either placing some sort of restriction or denying a patient request, was the most frequent precursor of incidents, accounting for an estimated 25% of all antecedents. The higher-level themes 'patient behavioural cues' and 'no clear cause' also produced other large estimates and were attributed to 38% and 33% of incidents overall.

CONCLUSION

This review underscores the influence that staff have in making in-patient psychiatric wards safe and efficacious environments.

P4-02-08: Obesity-Induced Aromatase Expression in the Breast Microenvironment Promotes Estrogen Receptor Activity Independent of Circulating Estradiol Levels

Epidemiological studies indicate that obesity increases the risk of postmenopausal breast cancer by approximately 50%. In the past, researchers have hypothesized that elevated estrogen synthesis by the peripheral adipose tissue may be the principal mediator of breast tumorigenesis in this population, which primarily develops estrogen receptor alpha (ERα) positive breast cancer. However, obesity is also accompanied by an elevation in growth factor and cytokine signaling, and these pathways have been linked to tumorigenesis. In addition, certain growth factor and cytokine family members can promote aromatase expression in both the epithelial and stromal tumor compartments. Consequently, we hypothesized that obesity increases the risk of postmenopausal breast cancer via elevated aromatase expression and/or activity in the local mammary tissue.

To test our hypothesis, we investigated how ERa activity in mammary epithelial cells was influenced by adipose stromal cells (ASC) cultured under obesity-associated conditions, including high cell density and exposure to elevated levels of circulating growth factors and cytokines. For the latter condition, sera was obtained from postmenopausal women, pooled by BMI category (lean: 18.5−24.9; obese: ≥30), and applied to the ASC, which were originally derived from women undergoing reduction mammoplasty. High ASC density was achieved via the protocol previously published by Dr. Li. Preliminary data indicated that both elevated cell density and sera from obese postmenopausal women induces greater aromatase expression in ASC, indicating that multiple factors may be contributing to the increased local aromatase expression seen with obesity. We are currently exploring the signaling pathways responsible for obesity's upregulation of ASC aromatase expression and will present these results at the meeting. Intriguingly, exposure to conditioned media from both the high density and obese sera-exposed ASC enhanced ERa activity in MCF-7 mammary epithelial cells, independent from exogenous estradiol but dependent on the presence of androgens, suggesting an important role for the aromatase enzyme in this observation. To expand on this finding, we plan to investigate the effect of ASC conditioned media on different markers of cancer aggression, including proliferation and survival, and assess the degree to which these effects depend on estradiol. Through further examination of obesity's impact on signaling pathways in both the epithelial and stromal tumor compartments, we ultimately hope to identify more effective chemopreventive and therapeutic regimens for the high-risk obese postmenopausal population.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-02-08.

Methodological issues in monitoring the use of coercive measures

PURPOSE

In many European countries, initiatives have emerged to reduce the use of seclusion and restraint in psychiatric institutions. To study the effects of these initiatives at a national and international level, consensus on definitions of coercive measures, assessment methods and calculation procedures of these coercive measures are required. The aim of this article is to identify problems in defining and recording coercive measures. The study contributes to the development of consistent comparable measurements definitions and provides recommendations for meaningful data-analyses illustrating the relevance of the proposed framework.

METHODS

Relevant literature was reviewed to identify various definitions and calculation modalities used to measure coercive measures in psychiatric inpatient care. Figures on the coercive measures and epidemiological ratios were calculated in a standardized way. To illustrate how research in clinical practice on coercive measures can be conducted, data from a large multicenter study on seclusion patterns in the Netherlands were used.

RESULTS

Twelve Dutch mental health institutes serving a population of 6.57 million inhabitants provided their comprehensive coercion measure data sets. In total 37 hospitals and 227 wards containing 6812 beds were included in the study. Overall seclusion and restraint data in a sample of 31,594 admissions in 20,934 patients were analyzed. Considerable variation in ward and patient characteristics was identified in this study. The chance to be exposed to seclusion per capita inhabitants of the institute's catchment areas varied between 0.31 and 1.6 per 100.000. Between mental health institutions, the duration in seclusion hours per 1000 inpatient hours varied from less than 1 up to 18h. The number of seclusion incidents per 1000 admissions varied between 79 up to 745. The mean duration of seclusion incidents of nearly 184h may be seen as high in an international perspective.

CONCLUSION

Coercive measures can be reliably assessed in a standardized and comparable way under the condition of using clear joint definitions. Methodological consensus between researchers and mental health professionals on these definitions is necessary to allow comparisons of seclusion and restraint rates. The study contributes to the development of international standards on gathering coercion related data and the consistent calculation of relevant outcome parameters.

A narrative review of studies of refusal of psychotropic medication in acute inpatient psychiatric care

This paper offers a narrative review of the 22 studies of medication refusal in acute psychiatry. Because of varied definitions of medication refusal, diverse methodologies and few rigorous studies, it has not been possible to draw firm conclusions on the average rate of refusal of psychotropic medications in acute psychiatry. However, it is clear that medication refusal is common and leads to poor outcomes characterized by higher rates of seclusion, restraint, threats of, and actual, assaults and longer hospitalizations. There are no statistically significant differences between refusers and acceptors in gender, marital status and preadmission living arrangements. Although no firm conclusions on the influence of ethnicity, status at admission and diagnosis on refusal, the refusers are more likely to have higher number of previous hospitalizations and history of prior refusal. The review indicates that staff factors such as the use of temporary staff, lack of confidence in ward staff and ineffective ward structure are associated with higher rates of medication refusal. Comprehensive knowledge of why, and how, patients refuse medication is lacking. Research on medication refusal is still fragmented, of variable methodological quality and lacks an integrating model.

Door locking and exit security measures on acute psychiatric admission wards

Locking the exit doors of psychiatric wards is believed to reduce the risk of patients absconding. The aims of the study were to investigate both the prevalence of door locking and other exit security measures on UK admission wards, as well as whether door locking appears to be effective in keeping inpatients in. A cross-sectional survey on 136 acute psychiatric wards in the UK was conducted, in which a range of data on patients, staff, and conflict and containment events, including door locking and absconding, were collected from shift to shift during a period of 6 months. About one-third of the participating wards (30%) operated with their ward exit door permanently locked, whereas another third (34%) never locked the ward door. Univariate analyses suggested little association between exit security measures and absconding. A more robust multilevel statistical analysis, however, did indicate a reduction of about 30% of absconding rates when the ward door was locked the entire shift. Although locking the ward door does seem to reduce absconding to a certain extent, it far from completely prevents it. As it may be unrealistic to strive for a 100% absconding-proof ward, alternative measures for door locking to prevent absconding are discussed.

Potential severity of aggressive behaviour after acquired brain injury: implications for recording

Aggression is a consequence of acquired brain injury that may necessitate admission to neurobehavioural services. The 'Overt Aggression Scale - Modified for Neurorehabilitation' (OAS-MNR) is a valid, reliable means of capturing this. A criticism of observational rating scales is they do not reflect factors like intent to harm which results in recording anomalies. 'Attacks' has been proposed as a measure which achieves this within psychiatric settings. Principal goals of this study are to determine the usefulness of measuring similar concepts in neurobehavioural services and further validating both scales. A total of 1066 physical assaults were recorded in 6 weeks by 25 patients in an inpatient neurobehavioural programme using the OAS-MNR. Fifty incidents were also rated on Attacks. Convergent validity for using both measures in neurobehavioural services was found. Modifying OAS-MNR severity scores using one of two factors found to underlie Attacks produced an index that successfully discriminated incidents whose risk necessitated more intrusive intervention, which was not evident otherwise. Modifying scores that objectively reflect severity of physical assaults using measures of perceived intent should be a feature of observational recording scales such as the OAS-MNR. Ensuring robust inter-rater reliability will be essential in any development work.

The Nursing Observed Illness Intensity Scale (NOIIS)

Inpatient progress is monitored mostly via the observation conducted by nursing staff. These tend to be unstructured, vary in reliability between different staff members, and be dependent on what has been written in nursing notes. The Nursing Observed Illness Intensity Scale (NOIIS) was devised to provide a more objective measure of behavioural improvement and symptom reduction. The scale is completed by qualified nurses at the end of every shift, based on everyday nursing observation and interaction with patients, and scores are entered on a NOIIS 'temperature' chart. In this study, more than 6000 ratings were captured on 106 admissions to a psychiatric intensive care unit. Inter-rater reliability of the scale was found to be satisfactory, and validity against the Brief Psychiatric Rating Scale good. Scores were shown to relate to the social organization and treatment methods of the unit. Recovery curves differed significantly by diagnosis, with patients having schizophrenia showing the slowest improvement. From a clinical point of view, the NOIIS can be used to track progress, response to changes in treatment and readiness of the patient for discharge; aids staff deployment; and can be used for clinical audit. For research, the scale can be used in clinical trials of treatment outcomes.

Locked doors: a survey of patients, staff and visitors

ACCESSIBLE SUMMARY

• Locking of psychiatric wards doors is more frequent, but the impact is unknown. • Staff patients and visitors returned a questionnaire about the issue. • Patients did not like the door being locked as much as staff, and being on a locked ward was associated with greater rejection of the practice. • Staff working on locked wards were more positive about it than those who did not.

ABSTRACT

Locking the door of adult acute psychiatric wards has become increasingly common in the UK. There has been little investigation of its efficacy or acceptability in comparison to other containment methods. We surveyed the beliefs and attitudes of patients, staff and visitors to the practice of door locking in acute psychiatry. Wards that previously participated in a previous study were contacted and sent a questionnaire. A total of 1227 responses were obtained, with the highest number coming from staff, and the smallest from visitors. Analysis identified five factors (adverse effects, staff benefits, patient safety benefits, patient comforts and cold milieu). Patients were more negative about door locking than the staff, and more likely to express such negative judgments if they were residing in a locked ward. For staff, being on a locked ward was associated with more positive judgments about the practice. There were significant age, gender and ethnicity effects for staff only. Each group saw the issue of locked doors from their own perspective. Patients registered more anger, irritation and depression as a consequence of locked doors than staff or visitors thought they experienced. These differences were accentuated by the actual experience of the ward being locked.

Psychiatric wards: places of safety?

In recent years, the purpose and quality of provision delivered in acute inpatient psychiatric settings have been increasingly questioned. Studies from a service user perspective have reported that while some psychiatric inpatients feel safe and cared for, others feel their time in hospital is neither safe nor therapeutic. This paper explores the experiences of service users on acute inpatient psychiatric wards in England, with a particular focus on their feelings of safety and security. Interviews were conducted with 60 psychiatric inpatients in England. The majority of service users felt safe in hospital and felt supported by staff and other service users. However, anything that threatened their sense of security such as aggression, bullying, theft, racism and the use of alcohol and drugs on the ward, made some respondents feel insecure and unsafe. Psychiatric wards are still perceived by many as volatile environments, where service users feel forced to devise personal security strategies in order to protect themselves and their property. It would appear that there remains much to do before research findings and policies are implemented in ways that facilitate all service users to derive the maximum benefit from their inpatient experience.

Manual restraint of adult psychiatric inpatients: a literature review

Relatively little is known about the prevalence of manual restraint to manage violent or challenging behaviour in hospital psychiatric services or the circumstances of its use. This review identified 45 empirical studies of manual restraint of adult psychiatric inpatients, mostly from the UK. On average, up to five episodes per month of manual restraint might be expected on an average 20-bed ward. Episodes last around 10 min, with about half involving the restraint of patients on the floor, usually in the prone position. Manually restrained patients tend to be younger, male and detained under mental health legislation. Staff value restraint-related training, but its impact on nursing practice has not been evaluated. Research has tended to focus on official reports of violent incidents rather than manual restraint per se. Larger and more complex studies are needed to examine how manual restraint is used in response to different types of incident and in different service settings.

The measurement of psychotic acuity by nursing staff

Accurate evaluation of patients' psychotic state is essential to decrease psychotic symptoms and protect the patient and others. The aim of this paper is to conduct a literature review in order to access the utility, reliability and validity of current rating scales that are purported to measure psychotic acuity of inpatient population. A search of a number of electronic databases was undertaken to retrieve potential articles that focus on the measurement of acute psychosis. We identified some conceptual and theoretical problems when using a scale that is monitoring the progress of discharge and assesses the outcome of treatments. The findings revealed a difficulty in finding a commonly agreed definition of acute psychosis and a problem of obtaining frequent measures, and the frequency of measurement and fluctuation in psychosis. The most dominant scales in assessing psychosis were reviewed: the Global Assessment of Functioning Scale, the Brief Psychiatric Rating Scale and the Positive and Negative Symptom Scale. Several issues related to the scales' inter-rater reliability and construct validity remain unexplored. None of these scales addressed the conceptual and theoretical problems that we identified. A new scale that will measure acuity of symptoms in inpatient settings needs to be created.

Locked doors in acute inpatient psychiatry: a literature review

Many acute inpatient psychiatric wards in the UK are permanently locked, although this is contrary to the current Mental Health Act Code of Practice. To conduct a literature review of empirical articles concerning locked doors in acute psychiatric inpatient wards, an extensive literature search was performed in SAGE Journals Online, EBM Reviews, British Nursing Index, CINAHL, EMBASE Psychiatry, International Bibliography of the Social Sciences, Ovid MEDLINE, PsycINFO and Google, using the search terms 'open$', 'close$', '$lock$', 'door', 'ward', 'hospital', 'psychiatr', 'mental health', 'inpatient' and 'asylum'. A total of 11 empirical papers were included in the review. Both staff and patients reported advantages (e.g. preventing illegal substances from entering the ward and preventing patients from absconding and harming themselves or others) and disadvantages (e.g. making patients feel depressed, confined and creating extra work for staff) regarding locked doors. Locked wards were associated with increased patient aggression, poorer satisfaction with treatment and more severe symptoms. The limited literature available showed the urgent need for research to determine the real effects of locked doors in inpatient psychiatry.

A replication study of the City nurse intervention: reducing conflict and containment on three acute psychiatric wards

Conflict and containment on acute inpatient psychiatric wards pose a threat to patient and staff safety, and it is desirable to minimize the frequency of these events. Research has indicated that certain staff attitudes and behaviours might serve to accomplish this, namely, positive appreciation, emotional regulation and effective structure. A previous test of an intervention based on these principles, on two wards, showed a good outcome. In this study, we tested the same intervention on three further wards. Two 'City nurses' were employed to work with three acute wards, assisting with the implementation of changes according to the working model of conflict and containment generation. Evaluation was via before-and-after measures, with parallel data collected from five control wards. While simple before-and-after analysis of the two experimental wards showed significant reductions in conflict and containment, when a comparison with controls was conducted, with control for patient occupancy and clustering of results by ward, no effect of the intervention was found. The results were therefore ambiguous, and neither confirm nor contradict the efficacy of the intervention. A further intervention study may need to be conducted with a larger sample size to achieve adequate statistical power.

Nurse staffing, bed numbers and the cost of acute psychiatric inpatient care in England

The aim of this analysis was to describe the composition, variability and factors associated with nurse staffing costs in acute psychiatric inpatient care. Numbers of acute inpatient beds in England have fallen, creating an occupancy crisis. Numbers of acute inpatient nursing staff are linked to quality of care. Variance in staffing and beds has considerable resource implications, but little is known about how these costs are structured. The sample comprised survey data from 136 wards in 26 NHS Trusts, matched with nationally available data on service levels, population and outcomes. The cost of providing acute inpatient care varied fivefold between different Trusts. This variation comprised of numbers of beds/population, numbers of nurses/beds and the proportion of nurses qualified. These variations were not fully accounted for by differing levels of social deprivation. Although service provision levels in London were higher, wide variation in costs existed in every region. Associations between nursing cost per bed and performance indicators were found. As investment in acute inpatient care varies widely, we need to know much more about the relationship of inputs to outputs, so that empirically based standard service levels can be defined.

Patient ethnicity and three psychiatric intensive care units compared: the Tompkins Acute Ward Study

Psychiatric care units provide care to disturbed patients in a context of higher security and staffing levels. Although such units are numerous, few systematic comparisons have been made, and there are indications that ethnic minority groups may be over-represented. The aim of this study was to compare the rates of adverse incidents and patterns of usage of three psychiatric intensive care units. The study used a triangulation or multi-method design, bringing together data from official statistics, local audit and interviews conducted with staff. Intensive care patients were more likely to be young, male and suffering a psychotic disorder, as compared with general acute ward patients. Caribbean patients were twice as likely, and Asian patients half as likely, to receive intensive care (age, gender and diagnosis controlled). There were large differences in service levels, staffing, team functioning and adverse incidents between the three units. Various aspects of physical security were important in preventing absconds. More evaluative research is required in order to define effective service levels, and to explore the nature of the interaction between ethnicity and inpatient care provision during acute illness.

Constraints and blocks to change and improvement on acute psychiatric wards--lessons from the City Nurses project

Recent years have seen sustained criticism and inspection of acute inpatient psychiatric wards, with the publication of reports and research leading to policy developments and a variety of efforts to improve perceived deficits. The City Nurses project seeks to reduce levels of conflict and containment on acute wards through the placement of expert nurses on wards to assist with the implementation of changes according to a working model of conflict and containment generation, based on previous research. Evaluation has shown significant decreases in aggression, absconding and self-harm by patients. However, in the course of working with the wards, various constraints and blocks to change have been identified and we describe these in detail in this paper. Analysis of the fieldwork diaries of the two City Nurses identified that change was hindered by limited staffing resources, problems with the physical environment and other resources, insufficient beds and the process of bed management, hierarchical ambiguity and multidisciplinary issues, the overdemanding role of the ward manager, and pervasive anxiety about the potential for serious untoward incidents and their implications for staff. We argue that sustained positive change in acute inpatient psychiatry requires these underlying structural issues to be both acknowledged and, if possible, resolved.

An analysis of nurses' post-incident manual restraint reports

Manual restraint techniques are associated with the management of violence in psychiatric settings. Restraint effectiveness and acceptability are under scrutiny, yet the nature and frequency of who or what were involved in restraint episodes have not previously been fully described or understood. The aim of this study was to describe the nature and frequency of manual restraint-related events and their components. This study was carried out using content analyses of nurses' post-incident reports from a psychiatric unit situated within a general hospital, and from its associated medium-secure unit. Requests for restraint occurred at the rate of about once per day, and the majority related to patients' ill-directed frustration, resistance to containment and their desire to leave the ward. Only half of responses to conflicts resulted in restraint implementation. The majority of restraint activities occurred during the afternoon and night. Male patients and detained patients were more frequent participants in restraint interventions. To a lesser extent, police, ambulance, fire services, hospital security, visitors and ex-patients were also involved in restraint episodes. Injuries were rare. In conclusion, training in restraint skills, clinical audit of adverse incidents, and research into psychiatric aggression all need to take into account the association of restraint with the enforcement of detention and treatment of acutely ill patients. The coupling of restraint with medication requires examination of its safety and efficacy. Interagency training may enable the essential services involved to coordinate restraint activities more effectively.

Reflections on the process of change on acute psychiatric wards during the City Nurse Project

The intention of this paper is to discuss the process of therapeutic change on two acute psychiatric wards during a research project that aimed to reduce conflict and containment. Analysis of fieldwork notes, reflection, team discussion and supervision. The City Nurse Project successfully reduced patient aggression, self-harm and absconding. This paper reports on the reflections made over the course of the year as changes and developments to acute wards took place. Specifically discussed are the beneficial effects of an action research approach, the role of the City Nurse, support for ward managers, education and training, clinical supervision as well as difficulties and barriers to the overall process of change. At an interim stage of the project, the staff have shown a willingness to engage in efforts to change and improve two acute wards. This paper shows the potential to improve acute wards and produce positive outcomes using a working model.

Preliminary outcomes of a trial to reduce conflict and containment on acute psychiatric wards: City Nurses

Acute psychiatric wards experience high levels of conflict behaviours (violence, absconding, self-harm, rule breaking and medication refusal) by patients. These events cause stress and injury to staff and patients. Their management through containment methods (e.g. sedation, restraint, seclusion) is contentious, and nurses are ambivalent about their use. The aim of this study was to reduce conflict and containment on two acute psychiatric wards through changes in nurses' beliefs, attitudes and practices. Two 'City Nurses' were employed to work with two acute wards for 1 year, assisting with the implementation of changes according to a working model of conflict and containment generation, itself based on previous research. Evaluation was via before-and-after measures. Statistically and clinically significant decreases in conflict occurred, with falls in aggression, absconding and self-harm. Ward atmosphere improved and nurse-patient interaction rates increased. There was no significant change in containment method use. Significant reductions in aggression, absconding and self-harm can be achieved on acute psychiatric wards. However, it does not appear that containment can be reduced, even through large reductions in conflict.

Coercive manoeuvres in a psychiatric intensive care unit

Coercive manoeuvres in a psychiatric intensive care unit The practice of physical restraint techniques in the management of disturbed behaviour is a significant part of the role of mental health nurses, particularly in Psychiatric Intensive Care Units (PICUs). Debate about what constitutes good practice is intense, and the subject of recently issued guidelines by National Institute for Mental Health in England. However, the contribution of other forms of conflict management techniques has tended to be ignored. The purpose of this study was to identify, describe and categorize coercive manoeuvres used by nurses, and to examine the circumstances and appropriateness of their use. Non-participant observation of verbal and non-verbal interaction between patients and nurses during conflict situations was undertaken on one PICU. The critical incidents observed were identified, categorized and systematically recorded. Nurses used a variety of low level physical and interactional manoeuvres in order to manage patients' disturbed and resistive behaviour. These manoeuvres were seldom recorded, discussed or reviewed, although they were frequently used to manage critical conflict situations. These manoeuvres have neither been previously described nor evaluated. They may, in some cases, be useful substitutes for actual restraint, alternatively they may, in some cases, be judged undesirable. It is not known how widespread these practices are in acute psychiatry.

Real world application of an intervention to reduce absconding

Absconding by acute psychiatric inpatients is associated with risk of harm to self and others, and creates considerable emotional as well as tangible burdens for staff. Previous research has led to the development of an effective nursing intervention to reduce absconding. In this project, that intervention was encapsulated in a self-training package, and offered freely to wards across the UK who agreed to implement it and audit the results. Fifteen wards completed this distributed audit, and achieved overall a 25.5% decrease in their absconding rates, as measured by official reports. The results support the efficacy of the intervention, and indicate that significant reductions can be made in absconding rates from unlocked or partially locked acute psychiatric wards.

Issues in the measurement of violent incidents and the introduction of a new scale: the 'attacks' (attempted and actual assault scale)

OBJECTIVE

To review the strengths and weaknesses of existing violent incident measures, and introduce a new scale, the 'attacks'. The new scale provides an objective measure of incident severity and focuses on interpersonal physical violence in isolation from other behaviours.

METHOD

The new scale was piloted on six psychiatric wards in the East End of London over a period of 16 weeks. Descriptive data were obtained and validated against official violent incident records.

RESULTS

There were 40 incidents by 21 aggressive patients, most of which occurred on the psychiatric intensive care unit. Striking assaults predominated. Continuous holding of the patient by nurses occurred after 17% of incidents. Special observation was also used as a subsequent management method in more than half of the incidents.

CONCLUSION

The scale is acceptable to nurses and valid. Interesting questions are raised about the content of training for staff in the prevention and management of violent incidents.

Training in cognitive behavioural interventions on acute psychiatric inpatient wards

There has been a drive towards addressing the types of care and therapeutic interventions available to people with serious mental illness, which is reflected in the latest government mental health policy initiatives. Recent evidence strongly supports the implementation of psychological and social interventions for people with psychosis, and in particular the use of cognitive behavioural techniques. Until now, the main focus has been on people living in the community. This study examines the delivery of psychosocial interventions training to qualified psychiatric nurses and unqualified staff on seven acute psychiatric admission wards in London, UK. The approach had the strength of on-site delivery, follow-up role modelling of the interventions and clinical supervision. Despite this, in some cases the training was less successful, mainly because of staffing and leadership weaknesses. The impact of training in these methods and the implications for mental health education and practice development are discussed.

Reasons for admission and their implications for the nature of acute inpatient psychiatric nursing

The purpose of acute inpatient psychiatric care, and nurses' role within that, are in need of clarification and restatement in order to provide a framework for practice, education, research and development. Inpatient psychiatry has suffered from a paucity of research in recent years. In addition, being a complex system, involving multiple professions with differing ideologies, means that widely accepted succinct descriptions of its purpose are hard to achieve. Yet such a framework is essential to support positive attitudes to patients and for good staff-management relationships. Using an oblique strategy, this paper defines the function of acute inpatient psychiatry, and the role of psychiatric nurses, via a structured examination of the literature on reasons for admission to acute inpatient psychiatric wards. Seven such reasons were discovered and are described: dangerousness, assessment, medical treatment, severe mental disorder, self-care deficits, respite for carers, and respite for the patient. Acute inpatient psychiatric nurses are therefore: providing safety for the patient and others; collecting and communicating information about patients, giving and monitoring treatment; tolerating and managing disturbed behaviour; providing personal care; and managing an environment where patients can comfortably stay. The implications for psychiatric nursing are discussed.

Acute psychiatric ward rules: a review of the literature

This literature review forms a background element of a comparative study of two acute psychiatric wards in the East End of London. The research focused on ward rules as a means of investigating the relationship between the flexibility/inflexibility of ward nursing regimes and patient outcomes. Previous studies identified a relationship between ward rules and patient aggression. Other studies identified a link between absconding by inpatients and nurses' attitudes towards rule enforcement. However, an in-depth exploration of psychiatric ward rules from the perspective of nurses and patients has not been undertaken previously.

A trial of an anti-absconding intervention in acute psychiatric wards

Absconding from acute psychiatric wards is a significant clinical problem that can place patients and others at risk, as well as being burdensome and anxiety provoking for staff. Previous studies have not convincingly demonstrated the best way to minimize the frequency of absconding. The aim of this trial was to evaluate the impact of an intervention to reduce absconding by patients from partially locked acute psychiatric wards. Five acute psychiatric wards in one hospital were entered into a stepped, before-and-after controlled trial. Following 3 months at baseline, nursing staff on the wards were trained in the intervention and monitored in its execution for the next 3 months. Absconding and violent incidents were recorded by nursing staff through shift reports and validated against officially collected forms. Absconding reduced by 25% overall during the intervention period, a fall which was statistically significant. Three out of the five wards implemented the intervention effectively and two of these achieved decreases in their absconding. The other two wards were not able to consistently implement the intervention, and their absconding rates remained unchanged. The findings support the efficacy of the intervention in reducing absconding. Further research is now required to replicate these findings, and to confirm that any reductions are maintained over time.

Case management models and the care programme approach: how to make the CPA effective and credible

The care programme approach (CPA), a form of case management, is a key mental health policy in England. Yet after over 10 years, it remains poorly and unevenly implemented with few benefits for service users, carers or mental health staff. This paper reviews the wider literature on case management and identifies and considers the principal models that might have informed the development of the CPA. After discussing the evidence for each of the clinical, strengths, intensive and assertive case management models, the paper identifies the key components that appear to be central to effective case management across these models. These components are then considered in relation to the CPA. It is argued that the CPA has been undermined by a failure to incorporate and build on certain important features of the major models of case management. The paper concludes by suggesting the key developments required to make the CPA more effective and to underpin the policy with a unifying philosophy while endorsing it with much needed credibility among both clinicians and service users.

Manipulation: description, identification and ambiguity

The word manipulation is frequently applied to some of the difficult-to-manage behaviours of the personality-disordered patient. However, the term is rarely defined, and a review of both the clinical and research literature shows that little has been written about its definition and identification, let alone its clinical management in both in- and outpatient settings. Recent empirical work conducted with nurses in forensic settings has demonstrated the range of behaviours that professionals refer to as 'manipulative', thus clarifying the use of the term and allowing the provision of a more precise definition. The scope of manipulation in everyday life, management practice and politics is perhaps relatively small, although manipulation can occur in all areas of human activity. Social behaviour is doubly ambiguous with respect to judgements of manipulation, as such judgements involve a moral evaluation combined with the identification of deception on the basis of little or partial evidence. The implications of this social ambiguity for clinical psychiatric practice are that professionals need to guard themselves from two polar faults: seeing manipulation everywhere; or being blind to its presence. In order to achieve a cautious moderation, staff need to hold both alternatives in mind at all times.

Manipulation: searching for an understanding

Manipulative behaviour is one of the reasons why some psychiatric professionals dislike personality-disordered (PD) patients and dislike working with them. Being manipulated arouses strong negative emotions towards the manipulator and can have severe repercussions on the ability to care for or treat those suffering from personality disorders. In order for practitioners to cope with manipulative behaviour and manage their emotional responses towards it, it is necessary to find ways to understand or construe that behaviour, so that moral condemnation and rejection of the patient can be avoided. This article offers a summary of three such methods of interpreting manipulation which are to be found in the literature: manipulation as normal behaviour; manipulation as unconsciously motivated; and manipulation as cognitive distortion. These three viable schemes for the understanding of manipulation provide not just a means to enable a non-judgmental approach, they also provide ways to manage that behaviour in a therapeutic manner.

A review of research on the structure, process and outcome of liaison mental health services

Liaison mental health services (LMHS) developed originally to address the mental health needs of people with physical illnesses in general hospitals and more recently to work also with people with mental health problems presenting at non-mental health services. The purpose of the present paper was to review empirical research on the structure, process and outcome of liaison mental health services using systematic review methods. Following a comprehensive search strategy, the authors reviewed 48 papers published between 1975 and 2001. There is an extensive international literature on LMHS, much of which describes the structure and process of liaison work. Studies evaluating the outcomes of liaison mental health services are fewer, and handicapped by methodological flaws, some of which are serious enough to cast doubts on the reported results. Professionals and clients value LMHS. LMHS based in accident and emergency (A & E) departments appear to ease the burden of general A & E staff, help clients access mental health services and reduce re-admission rates of people with mental health problems. There is little evidence supporting one model of configuring LMHS over another.

Philosophy, care and treatment on the psychiatric intensive care unit: themes, trends and future practice

Psychiatric intensive care units (PICUs) were first developed in the UK in the early 1970s and have become an integral part of inpatient services. This paper reviews all aspects of PICU provision from its origins to the most recent studies of intensive care treatment and philosophy. A search of CINAHL, MEDLINE and British Nursing Index databases revealed ample research and discussion papers from the past 30 years to permit a thorough review of the available literature. This divides roughly into discussion and descriptive research on topics related to: (a) the infrastructure of PICUs, including bed numbers, staffing levels, admission criteria and aspects of the physical environment; and (b) the treatment provided to patients on the PICU, both pharmacological and psychosocial, plus a limited amount of evaluative research on the efficacy of PICU care. This paper provides a summary and overview of these issues based upon currently available literature. It concludes that there is strong evidence for wide variation in the provision and nature of PICU care, reflecting idiosyncratic and localized development of services. Moreover, there is an almost complete lack of evidence on the efficacy of PICU care for particular types of patients and problems, leaving a paucity of research upon which PICU infrastructure, policy and therapeutic approach can be based.

Safety and security policies on psychiatric acute admission wards: results from a London-wide survey

Very little research evidence is available regarding current safety and security procedures on acute psychiatric wards. This includes controversial areas such as the temporary removal of personal property, the searching of patients and visitors, the use of alarms and modern technology, and locking of entrances to regulate those entering and leaving. This is also despite widening dismay over increasing violence within a variety of hospital settings, the comparatively high risk of physical assault faced by mental health professionals and an abundance of literature and training in regards to violence management and prevention. To gain an understanding of current safety and security measures, a London-wide survey of acute admission wards was undertaken revealing a wide variety of measures and policies in operation. Over 100 NHS and private wards were sent questionnaires; there was a response rate of 70%. Results show that a significant proportion of acute admission wards are now locked at all times and a small proportion of units have 24-hour security/reception staff on-site and a low level of modern technology usage such as CCTV and electronic access systems. There is wide variation in items banned, restrictions placed on inpatients, and the searching of patients and visitors. Two independently varying emphases of ward security policies were identifiable, the first aimed at preventing harm to patients using door security, banning of item and restrictions on inpatients. The other is aimed at reducing risks to staff via searching of patients, use of security guards and sophisticated alarm systems. There is some preliminary evidence that these security policies are differentially associated with levels of absconding and violent incidents. Further research to guide practice is urgently required.