Care management. Care programme approach constitutes good management.
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Case Management↗
Biomedical subjects
M Phelan
Publications and source records attributed to M Phelan.
Ethnic differences in risk of compulsory psychiatric admission among representative cases of psychosis in London.
OBJECTIVE: To compare the risk of detention under the Mental Health Act 1983 in a representative group of people with psychotic disorders from different ethnic groups. SETTING: Two defined geographical areas in south London. DESIGN: Annual period prevalent cases of psychosis were identified in 1993 in the study areas from hospital and community data. Standardised criteria were applied to case notes to establish diagnosis and detention under the act. SUBJECTS: 535 patients were identified, of whom 439 fulfilled ICD-10 criteria for psychosis. MAIN OUTCOME MEASURES: Risk of ever having been detained under the Mental Health Act 1983, risk of detention under specific sections of the act during the study year, and risk of contact with forensic services for the different ethnic groups. RESULTS: 439 patients with a psychotic illness were identified. Nearly half of the white patients had been detained under the act compared with 70% and 69% of black Caribbean and black African patients, respectively. Black Caribbean and black African patients were more likely than white patients to have been involuntarily detained (adjusted odds ratio 3.67; 95% confidence interval 2.07 to 6.50 and 2.88; 1.04 to 7.95, respectively). Rates of use of sections 2, 3 and 136 in the study year were higher for black than for white patients, and black patients were more likely than white patients to have been admitted to a psychiatric intensive care facility or prison. CONCLUSION: Independent of psychiatric diagnosis and sociodemographic differences, black African and black Caribbean patients with psychosis in south London were more likely than white patients to have ever been detained under the Mental Health Act 1983.
Africa↗
Duodenal mucosal ferritin in rheumatoid arthritis: implications for anaemia of chronic disease.
Anaemia is a common feature of rheumatoid arthritis (RA) and other chronic diseases. Among the alterations in iron metabolism contributing to this effect is a decrease in intestinal iron absorption. The mechanism for this is unknown, but might involve a 'mucosal block' process similar to that proposed in iron overload, whereby increased expression of an enterocyte storage protein binds absorbed iron and prevents its transfer to the circulation. We examined the effect of disease-modifying therapy on ferritin expression in duodenal mucosa in RA to determine whether it may play a role in the 'mucosal block' process. Endoscopic small bowel biopsies were obtained from 11 patients with active RA both before, and 6 months after, a course of either gold or methotrexate (MTX). Mucosal ferritin levels in small bowel and stomach were measured by radioimmune assay. Duodenal mucosal ferritin decreased significantly following treatment (p < 0.05). There were no changes in gastric mucosal ferritin. The fall in duodenal mucosal ferritin correlated with indices of disease activity at start of therapy, and the largest decreases were in those patients showing the best response to treatment in terms of a fall in inflammatory markers. Site-specific changes in mucosal ferritin may underlie the altered iron absorption observed in active inflammatory disease by modifying the enterocyte 'mucosal block'.
Adult↗
Hypoxia induces AP-1-regulated genes and AP-1 transcription factor binding in human endothelial and other cell types.
Hypoxia results in differential expression of specific genes in certain cell types. In endothelial cells, hypoxia activates several genes that are known to be inducible by transcription factor AP-1, including endothelin-1 and platelet-derived growth factor-B (PDGF-B). In this study we demonstrated that other AP-1-inducible genes are activated by hypoxia in these cells, including collagenase IV and c-jun, and sought to correlate the activation of genes by hypoxia with the activation of transcription factor AP-1. Depending upon the type of cell studied, hypoxic exposure resulted in the induction of AP-1 transcription factor DNA-binding activity with wide variations in levels of binding. The magnitude of activation of transcription factor AP-1 by hypoxia did not always strictly correlate with the level of induction of AP-1-inducible genes. This finding indicates a requirement for additional mechanisms of controlling transcription beyond the simple activation of AP-1 factor DNA-binding activity for the activation of AP-1-inducible genes during hypoxia. Hypoxia has been reported to lower the intracellular redox potential. The effect of redox state changes on AP-1 transcription factor activity and on the activation of AP-1-inducible genes was also studied. PDTC, a potent reducing agent, activated the AP-1 transcription factor in HeLa cells, and also resulted in increased accumulation of c-jun mRNA in these cells. In contrast to PDTC-mediated activation of the AP-1 transcription factor and the subsequent induction of the AP-1-regulated c-jun gene, hypoxic activation of AP-1 transcription factor binding to its cognate DNA sequence did not activate the c-jun gene in HeLa cells, thus documenting distinct differences in signals generated by the reducing intracellular microenvironments created by hypoxia and PDTC. These results demonstrate the induction of AP-1 transcription factor activity by hypoxic environments, but suggest that additional factors or cell-specific signals are involved in the regulation of hypoxia-induced genes.
Binding Sites↗
How to work with an interpreter.
The Audit Commission recently highlighted the need for health services to plan language services to help the problems of poor communication facing non-English speaking patients. Doctors and other health workers need to know how to work effectively when interviewing patients with an interpreter. This article describes the different options for helping non-English speaking patients; explains how interviews should be conducted with a trained interpreter, including those using sign language; and outlines the extent of interpreting services currently available in the United Kingdom, complete with a list of addresses of organisations offering interpreting services.
Communication↗
Non-linkage of a T-cell receptor gamma chain microsatellite (D7S485) to rheumatoid arthritis in multiplex families.
A highly informative microsatellite marker, D7S485, from the T-cell receptor gamma (TCRG) locus, has been used to study segregation of TCRG genes in 26 multiplex rheumatoid arthritis (RA) families. We used the sib-pair method to assess excess identity-by-descent sharing among affected members in these families and the LINKAGE package of programs was used to calculate two-point lod scores for the D7S485 marker. There was no evidence for segregation of TCRG genes with RA in affected siblings and significantly negative lod scores were obtained from linkage analyses using both autosomal dominant and recessive models of inheritance.
Adolescent↗
Sickle erythrocytes, after sickling, regulate the expression of the endothelin-1 gene and protein in human endothelial cells in culture.
The molecular defect in sickle cell disease resides in the beta globin gene, with consequent defects in erythrocytes only, suggesting that the vascular occlusion and vasomotor instability which characterize this disease are the result of interactions between abnormal sickle erythrocytes and cells of the blood vessel wall. We explored whether sickle erythrocytes may have effects on vascular tone, exclusive of adhesion events. Exposure of human endothelial cells in culture to previously sickled sickle erythrocytes resulted in a four to eight-fold transcriptional induction of the gene encoding the potent vasoconstrictor endothelin-1 (ET-1). Unsickled sickle erythrocytes or normal erythrocytes exposed to "sickling" conditions had no effect on ET-1 gene induction. Contact of the sickled erythrocytes with the endothelium was not required. Elevations in the ET-1 transcript peaked at 3 h after exposure and persisted for up to 24 h. Four to sixfold increases in the amount of ET-1 peptide was released into the medium surrounding the endothelial cells after exposure to sickled sickle erythrocytes. This is the first demonstration of the regulation of gene expression in endothelial cells as a result of interaction with sickle cells, with induction of genes encoding vasoconstrictors. Furthermore, these findings suggest that sickle erythrocytes may have the capacity to affect local vasomotor tone directly.
Anemia, Sickle Cell↗
Effectiveness of diagnosis-related groups in predicting psychiatric resource utilization in the U.K.
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Cost Savings↗
Mental health tribunals.
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Commitment of Persons with Psychiatric Disorders↗
The Camberwell Assessment of Need: the validity and reliability of an instrument to assess the needs of people with severe mental illness.
BACKGROUND: People with severe mental illness often have a complex mixture of clinical and social needs. The Camberwell Assessment of Need (CAN) is a new instrument which has been designed to provide a comprehensive assessment of these needs. There are two versions of the instrument: the clinical version has been designed to be used by staff to plan patients' care; whereas the research version is primarily a mental health service evaluation tool. The CAN has been designed to assist local authorities to fulfil their statutory obligations under the National Health Service and Community Care Act 1990 to assess needs for community services. METHOD: A draft version of the instrument was designed by the authors. Modifications were made following comments from mental health experts and a patient survey. Patients (n = 49) and staff (n = 60) were then interviewed, using the amended version, to assess the inter-rater and test-retest reliability of the instrument. RESULTS: The mean number of needs identified per patient ranged from 7.55 to 8.64. Correlations of the inter-rater and test-retest reliability of the total number of needs identified by staff were 0.99 and 0.78 respectively. The percentage of complete agreement on individual items ranged from 100-81.6% (inter-rater) and 100-58.1% (test-retest). CONCLUSIONS: The study suggests that the CAN is a valid and reliable instrument for assessing the needs of people with severe mental illness. It is easily learnt by staff from a range of professional backgrounds, and a complete assessment took, on average, around 25 minutes.
Adult↗
A method for in vivo high resolution MRI of rat spinal cord injury.
We have developed an implanted radiofrequency coil to obtain high resolution in vivo MR images at 1.9 Tesla of rat spinal cords that have been injured using a standardized weight drop technique. The signal-to-noise ratio and motion artifact suppression of these images is superior to that achieved in earlier attempts at this field strength using an external surface coil. The high quality and spatial resolution provided by this technique afford the possibility for longitudinal studies of experimental spinal cord injury before and after treatment, as well as detailed correlation of in vivo MRI contrast, histopathological findings, and functional deficit, in a controlled setting.
Animals↗
Global function scales.
There is a close relationship between impairment of global functioning and mental illness. However valid measurement of global functioning is difficult, and there is no perfect scale. The instruments reviewed in this paper illustrate a range of different approaches. Despite the inherent difficulties the measurement of functioning is a critical domain in mental health evaluative research.
Activities of Daily Living↗
Diagnosis and length of psychiatric in-patient stay.
This paper examines the link between diagnosis and length of psychiatric in-patient stay. Up to now the main method of predicting the use of in-patient services has been to use diagnosis-related groups (DRGs), primarily in the USA. Previous findings have revealed that DRGs generally predict less than 10% of variation in hospital stay. Psychiatric DRGs are considered to lack homogeneity and are too broad. Nevertheless, diagnosis, as an indicator of resource utilization, is now on the agenda in the UK and a study which examines the link between service use and diagnosis per se is called for. Altogether 5482 patients were allocated to 43 diagnostic categories (DCs). These DCs covered mental disorders, drug and alcohol-related problems, diseases of the nervous system and sense organs, and other related illnesses. Age was used in an attempt to refine the model further. Coefficients of variation were calculated for the DCs, and multivariate regression analysis was performed to gauge predictiveness. The results reveal that DCs contain extremely limited homogeneity and only predict 3% of variation in length of stay. When age group is included the results are only marginally improved, although the numbers contained in some DCs are low. Diagnosis, even when clearly defined, is a poor indicator of resource utilization.
Adolescent↗
Which patients with non-affective functional psychosis are not admitted at first psychiatric contact?
BACKGROUND: We wished to explore the sociodemographic and clinical characteristics associated with admission to hospital in patients with a non-organic non-affective psychosis. METHOD: Subjects were 484 first-contact patients with a non-affective functional psychosis from an inner-city catchment area over 20 years from the mid-1960s. Sociodemographic and clinical characteristics associated with admission to hospital were analysed. RESULTS: Around 20% of patients were not admitted, and the proportion did not change significantly over the years. Ethnicity, sex, and marital and employment status did not predict admission. Factors associated with admission included police involvement, and violence to self or others. A diagnosis of schizoaffective disorder, and persecutory delusions, auditory hallucinations, and bizarre behaviour were all more common in patients admitted to hospital. CONCLUSIONS: The study indicates biases which might arise in research based exclusively on patients admitted to hospital.
Adolescent↗
A study of deaths involving oxycodone.
Nine deaths involving oxycodone were investigated to assess the contribution of this opiate to these fatalities. All except one of the bodies were subjected to a full autopsy by specialist pathologists with a subsequent thorough toxicological examination. No significant anatomical pathology was found at autopsy. All deaths gave concentrations of oxycodone in femoral blood higher than expected following normal therapeutic use. In three cases no other drug in toxic concentrations was detected. Two cases involved the presence of a high concentration of a benzodiazepine and in a further two cases a high concentration of alcohol in addition to other drugs in therapeutic concentrations were present. One case involved methamphetamine in significant concentrations and another involved high concentrations of oxazepam in combination with pethidine. In all cases the presence of oxycodone was given as a factor contributing to the death. In only one case were there circumstances clearly indicating suicide. Our observations suggest that oxycodone is at least as toxic as other opiates and will cause deaths if misused.
Adult↗
Home treatment for acute psychiatric disorder. Innovative services merit investigation.
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Health Planning↗
Botulinum B toxin as an alternative to botulinum A toxin: a histologic study.
Histochemical effects of botulinum B toxin were studied on fibers from longissimus dorsi muscle in Albino rabbits and compared to effects produced by botulinum A toxin. Acetylcholinesterase staining, muscle fiber size analysis, and ATPase staining indicated botulinum B toxin produced a denervation gradient and field similar to that produced by botulinum A toxin. At 5 weeks postinjection with botulinum B toxin, analysis showed muscle fiber size variability, and diffuse acetylcholinesterase fiber staining comparable to botulinum A toxin at the injection site. Muscle sections taken at 4.0 cm for analysis showed statistically significant decreased fiber size variability and contraction of acetylcholinesterase staining pattern for both immunotypes. In addition, the denervation reflected by histochemical staining and fiber size analysis appeared transient and lasted for approximately 3 months for both immunotypes. These findings suggest botulinum B toxin produces pharmacologic effects on innervation of striated muscle similar to botulinum A toxin. Because immunologic tolerance has been demonstrated after therapeutic botulinum A toxin injections, further clinical studies need to be conducted with other immunotypes of toxin with no cross-reactivity to type A.
Acetylcholinesterase↗
Activation of neutrophils by soluble and insoluble immunoglobulin aggregates from synovial fluid of patients with rheumatoid arthritis.
OBJECTIVES: Previous work has shown that synovial fluid isolated from patients with active rheumatoid arthritis contains soluble (not sedimented by centrifugation at 11,600 g for two minutes) and insoluble (sedimented by centrifugation at 11,600 g for two minutes) immunoglobulin aggregates that are capable of activating reactive oxidant production by bloodstream neutrophils. The purpose of this study was to determine which of these types of immunoglobulin aggregates activated the secretion of reactive oxygen metabolites and granule enzymes from neutrophils. METHODS: Cell free synovial fluid (from patients with rheumatoid arthritis) was added to neutrophils isolated from blood of healthy controls that had been incubated in the presence and absence of granulocyte-macrophage colony stimulating factor (GM-CSF). Reactive oxidant production was measured by luminol chemiluminescence (which detects both intracellular and extracellular oxidant production) and by cytochrome c reduction (which measures superoxide secretion). RESULTS: The soluble aggregates only activated neutrophils that were previously primed, and activated a rapid and transient burst of reactive oxidant secretion. On the other hand, the insoluble aggregates activated primed and unprimed neutrophils with similar efficacy and most of the oxidants generated (especially in unprimed cells) were intracellular. The soluble aggregates, but not the insoluble aggregates, also activated the secretion of myeloperoxidase from neutrophils that had either been pretreated with cytochalasin B or primed with GM-CSF. CONCLUSION: It is thus proposed that these soluble immunoglobulin aggregates are responsible for activation of the release of tissue damaging granule enzymes and reactive oxidants from primed neutrophils within the rheumatoid joint.
Adult↗