Telephone delivery of psychological interventions: Balancing protocol with patient-centred care.

Common mental health problems of anxiety and depression affect significant proportions of the global population. Within the UK, and increasingly across western countries, a key policy response has been the introduction of high volume, low intensity psychological assessment and treatment services, such as the NHS's Improving Access to Psychological Therapies (IAPT) service, the largest service delivery model yet to be implemented at a national level (England). IAPT may be delivered in face-to-face meetings or over the telephone, as well as through other media. In order to increase access and achieve wide reach with efficient use of resources, IAPT's service models utilise relatively structured and standardised protocols, whilst aiming simultaneously to deliver a tailored and personalised experience for patients. Previous research has revealed that this can be a challenging balance for front-line practitioners to strike. Here we report research into the telephone delivery of guided self-help, low intensity interventions within IAPT, examining the challenges faced in remote delivery when combining structure with personalisation during assessment and treatment sessions. We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient's story, thereby compromising the personalisation and responsiveness of the service. Our study contributes new insights to our understanding of the association between personalisation, engagement and patient experience within high volume, low-intensity psychological treatment services. Our research on the telephone delivery of IAPT is particularly timely in view of the current global Covid-19 health crisis, as a result of which face-to-face delivery of IAPT has had to be (temporarily) suspended.

Anxiety and depression in patients with haematological neoplasms in Malaysia.

BACKGROUND: It is not uncommon that anxiety and depression occur in patients with cancers, and past researches have shown that the quality of life of patients is negatively affected. This study aims to determine the prevalence of anxiety and depression of patients with haematological cancers in Malaysia and to investigate the possible association of these psychological symptoms with their quality of life. METHODS: This is a cross-sectional study where patients with haematological cancers attending two major hospitals were recruited. Anxiety and depression symptoms were assessed using the Hospital Anxiety and Depression scale (HADS). Quality of life (QoL) of these patients was measured using the European Organisation for Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ C30). An overall summary QoL score in combination with financial difficulty score and global health score were used for analysis. RESULTS: A total of 319 patients were recruited. Thirty-three percent of patients had anxiety symptoms, 23.5% had depression symptoms. In summary the overall score of QoL is significantly lower in patients with higher scores for depression and anxiety, (p<0.05). Patients who exhibit anxiety symptoms were more frequently female, still undergoing treatment whereas patients who had higher depression scores were older and had acute leukemias or myeloproliferative neoplasms. Patients who have depression are significantly associated with a higher financial difficulty score, p<0.05. CONCLUSION: The poor quality of life in patients who have anxiety and depression should raise awareness amongst the health professions treating them so that additional support can be provided.

Acceptability of telephone support as perceived by patients with cancer: A systematic review.

Telephone-based interventions can increase accessibility to healthcare and are increasingly used as a convenient method of providing support. We conducted a systematic review of published literature reporting adult patients' perceptions of the acceptability of, and satisfaction with, telephone-based interventions during or post-treatment for cancer. Systematic searches identified 4,855 articles. Forty-eight articles describing 50 studies were included in the review. Three intervention categories were identified post hoc: (1) telephone follow-up in lieu of routine hospital follow-up, (2) telephone interventions for treatment side-effect monitoring and toxicity management supplementary to usual care, and (3) supplementary psycho-educational telephone interventions. Across studies, some consistent findings emerged. Positive perceptions emphasised the convenience of telephone interventions and increased accessibility to care. Conflicting perceptions of the quality of the support received, the impact of telecare on the patient-healthcare professional relationship and the need for such interventions emerged. In conclusion, the evidence base relating to patients' perceptions of telephone-based interventions is increasing. Interpretation of findings is currently limited by methodological limitations in the primary research. The instruments chosen to assess patient satisfaction quantitatively do not always reflect the patient-centred priorities that emerge from qualitative data. Subsequent research would benefit from well-designed qualitative studies and patient-centred outcome measures to ensure that the individuality of participants' positive and negative experiences is captured.

Evaluation of a co-delivered training package for community mental health professionals on service user- and carer-involved care planning.

WHAT IS KNOWN ON THE SUBJECT?: There is consistent evidence that service users and carers feel marginalized in the process of mental health care planning. Mental health professionals have identified ongoing training needs in relation to involving service users and carers in care planning. There is limited research on the acceptability of training packages for mental health professionals which involve service users and carers as co-facilitators. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: A co-produced and co-delivered training package on service user- and carer-involved care planning was acceptable to mental health professionals. Aspects of the training that were particularly valued were the co-production model, small group discussion and the opportunity for reflective practice. The organizational context of care planning may need more consideration in future training models. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses using co-production models of delivering training to other mental health professionals can be confident that such initiatives will be warmly welcomed, acceptable and engaging. On the basis of the results reported here, we encourage mental health nurses to use co-production approaches more often. Further research will show how clinically effective this training is in improving outcomes for service users and carers. ABSTRACT: Background There is limited evidence for the acceptability of training for mental health professionals on service user- and carer-involved care planning. Aim To investigate the acceptability of a co-delivered, two-day training intervention on service user- and carer-involved care planning. Methods Community mental health professionals were invited to complete the Training Acceptability Rating Scale post-training. Responses to the quantitative items were summarized using descriptive statistics (Miles, ), and qualitative responses were coded using content analysis (Weber, ). Results Of 350 trainees, 310 completed the questionnaire. The trainees rated the training favourably (median overall TARS scores = 56/63; median 'acceptability' score = 34/36; median 'perceived impact' score = 22/27). There were six qualitative themes: the value of the co-production model; time to reflect on practice; delivery preferences; comprehensiveness of content; need to consider organizational context; and emotional response. Discussion The training was found to be acceptable and comprehensive with participants valuing the co-production model. Individual differences were apparent in terms of delivery preferences and emotional reactions. There may be a need to further address the organizational context of care planning in future training. Implications for practice Mental health nurses should use co-production models of continuing professional development training that involve service users and carers as co-facilitators.

Influence of genetic polymorphisms of cytokine genes in the outcome of HLA-matched allogeneic stem cell transplantation in a South East Asian population.

Non-HLA gene polymorphisms have been shown to be associated with the risk of graft-versus-host disease (GVHD) and outcome of allogeneic haematopoietic stem cell transplantation (AHSCT). This study aims to investigate the role of IL6, TNFα, IL10, IL2 and IL12 gene polymorphisms in the outcome of AHSCT in a South East Asian population. A total of 67 patients and 59 donors who underwent HLA-identical matched sibling AHSCT were available for analysis. There was no significant association between the different cytokine genotypes of patients with the incidence and severity of acute GVHD. Patients with IL2 166∗T allele and patients who received donor stem cells who had IL2 166∗G allele appeared to have reduced incidence of cGVHD. Patients who received donor stem cells with IL12 1188∗C allele are found to be associated with better disease free survival. These results suggest a possible role of IL2 and IL12 gene polymorphisms in the outcome of AHSCT in a South East Asian population.

Bringing meaning to user involvement in mental health care planning: a qualitative exploration of service user perspectives.

BACKGROUND: Service users wish to be involved in care planning but typically feel marginalized in this process. Qualitative explorations of the barriers and enablers of user involvement in mental health care planning are limited. QUESTION: How is user involvement in care planning conceptualized by service users and how can meaningful involvement be instilled in the care planning process? METHODS: In 2013, we conducted five focus groups (n = 27) and 23 individual interviews with current or recent adult users of secondary care mental health services (n = 27) in England. Eight users participated in both. Data were analysed using Framework Analysis. Results Ten themes emerged from the data: these themes encompassed procedural elements (connection; contribution; currency; care consolidation; and consequence), service user characteristics (capacity and confidence) and professional enablers (consultation; choice; and clarity of expression). Procedural elements were discussed most frequently in service user discourse. DISCUSSION: The process of care planning, centred on the user-clinician relationship, is key to user involvement. IMPLICATIONS FOR PRACTICE: Users describe a common model of meaningful involvement in care planning. Their requests, summarized through a 10C framework of care planning involvement, provide clear direction for improving service users satisfaction with care planning and enhancing the culture of services.

Complementary and alternative medicine use in patients with hematological cancers in Malaysia.

BACKGROUND: Complementary and alternative medicine (CAM) is often used by cancer patients, but not many studies had been published on the prevalence of CAM use in patients with hematological cancers. This study aims to determine the prevalence of CAM and type of CAM used in this group of patients in a multiracial and multicultural country. PATIENTS AND METHODS: This is a cross-sectional survey carried out in two hospitals in Malaysia. Patients with underlying hematological cancers were asked to complete the questionnaires on CAM and the Hospital Anxiety and Depression Scale. RESULTS: A total of 245 patients participated. The prevalence of CAM use was 70.2 %. The most common types of CAM used are biological-based therapies (90.2 %) and mind-body interventions (42 %). Vitamin and diet supplements (68.6 %) and folk/herb remedies (58 %) are the most common biological-based therapies used. There is no significant association of CAM use with age, gender, education level, and household income. Female patients are more likely to use more than one CAM therapies. The most common reason reported for CAM use was to boost immunity (57 %) and cure (24 %). Majority of patients (65 %) felt CAM was effective, and 60 % did not inform their physicians regarding CAM usage. CONCLUSION: In view of the high prevalence of CAM use in patients with hematological cancers, it is important that the physicians play an active role in seeking information from patients and to monitor possible drug-vitamin-herbal interactions.

Helicobacter pylori infection in chronic immune thrombocytopenic purpura patients in Malaysia.

INTRODUCTION: Helicobacter Pylori has been implicated with a possible link to immune thrombocytopenia purpura (ITP) and studies have shown contradicting results in platelet recovery after eradication of H pylori infection. OBJECTIVES: To determine the prevalence of H pylori infection in adult ITP patients in Malaysia and to examine the effect of eradication of H pylori infection in these patients. METHOD: 50 ITP adult patients from haematology clinics were recruited. A 13C urea breath test for H. pylori infection was performed in all patients. Those with H. pylori infection were treated with standard eradication regimen. Platelet counts were monitored regularly after eradication therapy to assess response. Complete response (CR) was defined as the achievement of platelet counts of >150x10(9)/L within 3 months after eradication therapy and partial response (PR) was defined as platelet count above 50x10(9)/L and/or at least doubling the baseline count. RESULT: The median age of patients recruited was 50 years. The majority of patients were female (76%). Chinese was the largest ethnic groups (56%) followed by Malays (28%) and Indians (16%). 11 of the 50 patients (22%) were found to have H. pylori infection and all but one had eradication therapy. Overall, some response was observed in 3 patients (30%) with a CR seen in 2 patients and PR in one patient. However, all these patients had a drop in their platelet counts at 6th month follow up. CONCLUSION: The prevalence of H. pylori infection is relatively low in our adult ITP patients (22%) and by eradicating the infection did not have any sustained effect in the platelet recovery.

An update on imatinib mesylate therapy in chronic myeloid leukaemia patients in a teaching hospital in Malaysia.

INTRODUCTION: The introduction of imatinib mesylate in 1998 has changed the management of chronic myeloid leukaemia. It is now the first-line therapy for newly diagnosed chronic myeloid leukaemia patients worldwide. However, its long-term survival benefit still needs to be established in clinical setting among Asian patients. METHODS: All chronic myeloid leukaemia patients in the chronic phase who were on imatinib mesylate therapy were retrospectively reviewed. Data was collected through a review of case notes, which was then processed, managed and analysed. RESULTS: A total of 44 patients were included in the study. The cumulative rates of complete haematological response, major cytogenetic response and major molecular response were 93.2%, 75.0% and 34.2%, respectively. The overall survival and event-free survival at five years were 86.0% and 84.9%, respectively. 31.8% of the patients developed anaemia, 29.5% neutropenia and 27.3% thrombocytopenia. A total of 43.2% of patients developed non-haematological side effects. Higher dosage (> 600 mg) and smaller body size (< 60 kg) were risk factors for haematological side effects. Patients with major cytogenetic response and absence of thrombocytopenia had better survival. CONCLUSION: The majority of our chronic myeloid leukaemia patients did well with imatinib therapy. The adverse effects in our patients were tolerable, and no patient had to stop treatment permanently.

'It's easier just to separate them': practice constructions in the mental health care and support of younger people with dementia and their families.

There is no standard model of specialist care for younger people with dementia (onset before the age of 65 years) and specialist service provision varies widely throughout the UK. In order to gain a clearer picture about ways in which clinical staff work with younger people with dementia, semi-structured interviews were conducted with dementia care staff working in the north-west of England. Interviews focused on exploring daily working practices and the meaning placed on clinical decision making when involving family/carers in routine practice. Content analysis generated three core themes: (1) Maintaining Separation: how clinical staff conceptualize the meaning of 'family' in the provision of dementia care services; (2) Providing Practical Help: the focus in care provision on assisting families with aspects of daily life such as finances, education and physical care; and (3) Acknowledging the Family Context: how staff understand and interact with family members in an attempt to initiate care, utilizing biographically informed practice. By understanding how staff view their role in providing younger people with dementia with effective, high-quality dementia care, it is anticipated that a more family-centred approach can be integrated into already established patterns of working that more holistically meet the needs of this group.

Quality of life after haematopoietic stem cell transplantation in a multiracial population.

Haematopoietic stem cell transplantation (HSCT) was started in Malaysia since 1993 and it has improved the survival of patients with otherwise fatal haematological diseases. This study was initiated because quality of life of these survivors is an important tool in assessing the outcome of this treatment modality. The secondary objective was to identify factors that influenced their quality of life. The European Organization of Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-30) was used to assess the quality of life of eligible patients. A total of 62 patents were recruited. The mean global health score (QoL) was 71.2. The major symptoms faced by our patients were fatigue, financial difficulty and appetite loss. Appetite loss was an independent adverse factor for lower QoL.

The development and evaluation of a complex health education intervention for adults with a diagnosis of schizophrenia.

Life expectancy in adults with schizophrenia is reduced by approximately 15 years compared with others in the population. Two thirds of premature deaths result from natural causes triggered by unhealthy lifestyles and the side-effects of antipsychotic medication. There is a need to develop and evaluate health education interventions for people with this diagnosis. In this paper we describe how with reference to the UK Medical Research Council's complex interventions framework we developed and evaluated a health education intervention designed specifically for adults with schizophrenia. The study was completed in three separate but interrelated phases: (1) theoretical work was undertaken to identify the components of effective health education interventions; (2) this information was synthesized to develop the intervention; and (3) the intervention was tested in an open exploratory trial which used mixed methods to evaluate the feasibility, acceptability and potential effect of the intervention. 45 service users were referred, 39 attended the groups and 65% attended at least half of the sessions. Participants reported significant increases in their consumption of fruit and vegetables and levels of physical activity. Results suggest that this model of health education is feasible and acceptable for this population and that it shows promise in supporting health-related behaviour changes.

Nephrotic syndrome in a patient with relapsed of chronic myeloid leukemia after peripheral blood stem cell transplantation.

Nephrotic syndrome (NS) is a well documented complication after allogeneic peripheral blood stem cell transplantation. It is usually due to autoimmune glomerulonephritis and thought to be a clinical manifestation of graft versus host disease. NS has also been reported to be associated with other hematological malignancies. We report a case of nephrotic syndrome in a patient who relapsed after allogeneic peripheral blood stem cell transplantation (PBSCT) for chronic myeloid leukemia (CML). The renal biopsy was suggestive of minimal change disease. There was no other evidence of graft versus host disease. He was treated with high dose prednisolone, with no response and finally succumbed to the underlying disease.

Adult allogeneic haematopoietic stem cell transplantation: a single centre experience in Malaysia.

We analysed the outcome of 104 patients from a single institution who underwent allogeneic haematopoietic stem cell transplantation (AHSCT) from their HLA-identical siblings between 1993 and 2006. Sixty-nine percent of patients had peripheral blood stem cell (PBSC) as the stem cell source and the remaining had bone marrow (BM). The majority of patients are Chinese (60%) followed by Malays (24%) and Indians (14%). The median time to reach white cell counts of >1 x 10(9)/L and platelet counts of >30 x 10(9)/L was 13 and 15 days, respectively in patients who had PBSC transplantation compared with 16 and 25 days in patients who had BM transplantation, (p < 0.0001 and p < 0.001). Acute graft-versus-host disease (aGVHD) of grade II to IV was observed in 34% of patients and chronic graft-versus-host disease (cGVHD) in 38% of patients. Although not statistically significant, there was a higher incidence of overall aGVHD in Indian patients (73%) compared to Chinese and Malays (57% and 56% respectively). There was no significant difference in the incidence of aGVHD and cGVHD with the source of stem cells. Overall survival (OS) and disease free survival (DFS) was 50% and 60% at five years respectively. Multivariate analysis showed that patients transplanted in standard risk and those who had limited cGVHD had a significant better OS, (p = 0.05 and p = 0.05). Patients who had cGVHD and transplanted in standard risk had a better DFS, (p = 0.002 and p < 0.001). In summary, AHSCT in standard risk patients is associated with a better outcome than those transplanted in high risk and although not statistically significant, there is a higher incidence of aGVHD in Indian patients.

Nurses making a diagnosis of dementia--a potential change in practice?

OBJECTIVES: To compare nurse initial diagnoses following domiciliary visits with subsequent formal multidisciplinary formulation based upon the full possession of investigations, neuropsychological tests and brain imaging. DESIGN: Retrospective case note study. SETTING: Home-based nurse assessments, secondary care based multidisciplinary memory clinic. PARTICIPANTS: Four hundred and four consecutive referrals over an 18-month period. RESULTS: One hundred and seventy-five patients (43.3%) were diagnosed by the multi-disciplinary team as having a dementia. Seventy-three (41.5%) were classified as Alzheimer's disease, 81 (46%) of mixed sub-type and 20 (11.4%) of vascular origin. Overall nurse-MDT diagnosis agreement was 0.88 (Kappa = 0.82). Together, two nurses were able to detect dementia with 94% accuracy (Kappa = 0.88) Sensitivity was 92% and specificity 96%. The positive and negative predictive values of their judgements were 94% and 98% respectively. Nurses were able to sub-diagnose dementia with 86% (kappa = 0.76) accuracy. Multivariate logistic regression modelling showed a MDT dementia diagnosis to be independently and significantly associated with lower scores on the KOLT and total MMSE, and with the absence of biological markers of depression. Nurse dementia diagnoses were associated with lower KOLT scores and the absence of biological depression markers, high past alcohol consumption or a history of hypercholesteraemia. CONCLUSIONS: In this study, structured initial assessment by a specialist nurse was shown to be an accurate method of determining a diagnosis of cognitive impairment, when compared with formal MDT judgement. The principal benefit of this approach was that signposting to subsequent care pathways was expedited. Arguably, such distributed responsibility affords a viable option for the future detection of early dementia.

Imatinib mesylate in the treatment of chronic myeloid leukemia: a local experience.

This study was done to assess the overall response rate of imatinib mesylate in local patients with chronic myeloid leukaemia. A total of 69 patients were recruited with male/female ratio of 7:3. Of the 69 patients; 35% were in the chronic phase, 41% were in the accelerated phase, 17% were in blast crisis and the remaining 7% were after stem cell transplantation. Complete haematological response rates of patients in chronic phase, accelerated phase and blast crisis were 95.8%, 96.4% and 41.7% respectively. Thirty-eight percent of patients achieved complete cytogenetic response and 10% achieved partial cytogenetic response. The cytogenetic response rates were 80%, 41.7% and 18.2% in chronic, accelerated and blast crisis phase respectively (p < 0.005). Twenty-six percent of patients developed anaemia, 13% had neutropenia and 12% had thrombocytopenia after starting on treatment. In addition, 14% of patients developed peripheral oedema, 13% complained of musculoskeletal pain, 12% had gastrointestinal side effects which include nausea, vomiting and diarrhoea, 9% had grade 1 hepatotoxicity, 7% developed skin rashes and one patient had an abnormal renal function test. Patients taking 600mg or higher dosage of imatinib had more gastrointestinal side effects. Patients who weighed less than 60kg had a much higher risk of developing anaemia. Anaemia was a negative predictor of cytogenetic response. Presenting high white blood cell counts and absence of cytogenetic response were also negative predictors of survival. Overall survival was 87%. This was affected by the different phases of disease (chronic phase was better than accelerated and blast crisis) (p < 0.001). In conclusion, our local CML patients did well on treatment with imatinib.

Organizing and delivering training for acute mental health services: a discussion paper.

Recent policy statements that address the quality of care provided by acute mental health services have highlighted an urgent need for specialist nurse education and training. However, examples of how to design and implement such training initiatives are sparse. Drawing on recent experience of developing an innovative training programme for acute psychiatric settings, this paper seeks to examine some of the key issues associated with current training provision for acute inpatient mental health workers. The methodological and practical concerns surrounding this type of initiative are discussed with the main aspects of programme content, service user participation, team training and organizational challenges being explored. Resulting from this work, several recommendations regarding the content, organization and delivery of future training initiatives are made.

A case of T-cell acute lymphoblastic leukemia after treatment of acute promyelocytic leukemia.

We diagnosed T-cell acute lymphoblastic leukemia (T-ALL) with multiple cytogenetic abnormalities in a 17-year-old girl a year after she had received a diagnosis of acute promyelocytic leukemia (APML). After the diagnosis of APML in June 2001, the patient was treated with idarubicin and all-trans-retinoic acid. In September 1999, her younger sister also received a diagnosis of APML and to date has remained well. T-ALL after remission of APML is very rare, and only 1 such case has been reported. Possible causes include therapy-related reasons, genetic susceptibility to leukemia, and environmental exposure.

A case of severe leptospirosis with pancytopaenia.

Pancytopaenia is a rare clinical presentation of severe leptospirosis. We would like to report a case of severe leptospirosis that progressed to pancytopaenia despite initial penicillin therapy. The patient needed a second course of antibiotic with doxycycline to improve his persistent symptoms and cytopaenia. Persistent pancytopaenia in severe leptospirosis and its management were reviewed.