Suicide within 12 months of contact with mental health services: national clinical survey.

OBJECTIVE: To describe the clinical circumstances in which psychiatric patients commit suicide. DESIGN: National clinical survey. SETTING: England and Wales. SUBJECTS: A two year sample of people who had committed suicide, in particular those who had been in contact with mental health services in the 12 months before death. MAIN OUTCOME MEASURES: Proportion of suicides in people who had had recent contact with mental health services; proportion of suicides in inpatients; proportion of people committing suicide and timing of suicide within three months of hospital discharge; proportion receiving high priority under the care programme approach; proportion who were recently non-compliant and not attending. RESULTS: 10 040 suicides were notified to the study between April 1996 and March 1998, of whom 2370 (24%; 95% confidence interval 23% to 24%) had had contact with mental health services in the year before death. Data were obtained on 2177, a response rate of 92%. In general these subjects had broad social and clinical needs. Alcohol and drug misuse were common. 358 (16%; 15% to 18%) were psychiatric inpatients at the time of death, 21% (17% to 25%) of whom were under special observation. Difficulties in observing patients because of ward design and nursing shortages were both reported in around a quarter of inpatient suicides. 519 (24%; 22% to 26%) suicides occurred within three months of hospital discharge, the highest number occurring in the first week after discharge. 914 (43%; 40% to 44%) were in the highest priority category for community care. 488 (26% excluding people whose compliance was unknown; 24% to 28%) were non-compliant with drug treatment while 486 (28%; 26% to 30%) community patients had lost contact with services. Most people who committed suicide were thought to have been at no or low immediate risk at the final service contact. Mental health teams believed suicide could have been prevented in 423 (22%; 20% to 24%) cases. CONCLUSIONS: Several suicide prevention measures in mental health services are implied by these findings, including measures to improve compliance and prevent loss of contact with services. Inpatient facilities should remove structural difficulties in observing patients and fixtures that can be used in hanging. Prevention of suicide after discharge may require earlier follow up in the community. Better suicide prevention in psychiatric patients is likely to need measures to improve the safety of mental health services as a whole, rather than specific measures for people known to be at high risk.

Mental disorder and clinical care in people convicted of homicide: national clinical survey.

OBJECTIVES: To estimate the rate of mental disorder in those convicted of homicide and to examine the social and clinical characteristics of those with a history of contact with psychiatric services. DESIGN: National clinical survey. SETTING: England and Wales. SUBJECTS: Eighteen month sample of people convicted of homicide. MAIN OUTCOME MEASURES: Offence related and clinical information collected from psychiatric court reports on people convicted of homicide. Detailed clinical data collected on those with a history of contact with psychiatric services. RESULTS: 718 homicides were reported to the inquiry between April 1996 and November 1997. Of the 500 cases for whom psychiatric reports were retrieved, 220 (44%; 95% confidence interval 40% to 48%) had a lifetime history of mental disorder, while 71 (14%; 11% to 17%) had symptoms of mental illness at the time of the homicide. Of the total sample, 102 (14%; 12% to 17%) were confirmed to have been in contact with mental health services at some time, 58 (8%; 6% to 10%) in the year before the homicide. The commonest diagnosis was personality disorder (20 cases, 22%; 13% to 30%). Alcohol and drug misuse were also common. Only 15 subjects (18%; 10% to 26%) were receiving intensive community care, and 60 (63%; 53% to 73%) were out of contact at the time of the homicide. CONCLUSIONS: There are substantial rates of mental disorder in people convicted of homicide. Most do not have severe mental illness or a history of contact with mental health services. Inquiry findings suggest that preventing loss of contact with services and improving the clinical management of patients with both mental illness and substance misuse may reduce risk, but clinical trials are needed to examine the effectiveness of such interventions.

Problem-based learning in American medical education: an overview.

The recent trend toward problem-based learning (PBL) in American medical education amounts to one of the most significant changes since the Flexner report motivated global university affiliation. In PBL, fundamental knowledge is mastered by the solving of problems, so basic information is learned in the same context in which it will be used. Also, the PBL curriculum employs student initiative as a driving force and supports a system of student-faculty interaction in which the student assumes primary responsibility for the process. The first PBL medical curriculum in North America was established at McMaster University in Toronto in 1969. The University of New Mexico was the first to adopt a medical PBL curriculum in the United States, and Mercer University School of Medicine in Georgia was the first U.S. medical school to employ PBL as its only curricular offering. Many interpretations of the basic PBL plan are in use in North American medical schools. Common features include small-group discussions of biomedical problems, a faculty role as facilitator, and the student's relative independence from scheduled lectures. The advantages of PBL are perceived as far outweighing its disadvantages, and the authors conclude that eventually it will see wider use at all levels of education.

Problem-based learning: an assessment of its feasibility and cost.

As our knowledge of human biology becomes more complex and the medical school applicant pool declines, there is ample reason to consider an alternative to the conventional medical curriculum. Many authorities feel that a format incorporating problem-based learning (PBL) would be more appropriate and effective. The problem-based medical curriculum is one in which facts and principles are learned in the context of a clinical problem. Problem-based medical education began as a revision of the McMaster University medical curriculum in 1969 and was instituted in the United States as a problem-based experimental track at the University of New Mexico School of Medicine in 1979. The first completely integrated, totally problem-based, McMaster-type, medical curriculum in the United States began operation in 1982 with the establishment of Mercer University School of Medicine. Many years of experience at these three institutions have shown that the problem-based curriculum works well. Several medical schools throughout the world are either practicing PBL or investigating the feasibility of adopting it. A comparison of the costs (in faculty time) of problem-based and conventional pathology programs suggests that the PBL curriculum is quite feasible for schools with a class size of 60 or less and may be so for many schools and programs with classes of less than 100.

Characterisation of acid dyes in forensic fibre analysis by high-performance liquid chromatography using narrow-bore columns and diode array detection.

A gradient elution high-performance liquid chromatographic (HPLC) system with a diode array detector and a short narrow-bore (40 x 1 mm I.D.) column has been used to characterise a number of acid dyes. The resolution and reproducibility of the HPLC system have been evaluated and the detection limits for various dyes have been estimated. Comparisons are made with current methods of fibre dyestuff examination used in forensic science. The system has been applied to the analysis of dye extracted from single fibres. Using diode array detection, both chromatographic and spectral data can be produced in a single operation from casework sized samples.

Preservation of pathology specimens by silicone plastination. An innovative adjunct to pathology education.

The authors have used the process of plastination to preserve gross anatomic specimens for teaching purposes. A specimen is fixed in 10% buffered formalin and dehydrated in increasing grades of ethanol. Thereafter it is saturated with methylene chloride and then impregnated in vacuo at -20 degrees C with silicone rubber. Final steps involve drainage and exposure to a curing agent. The total time required is approximately 16 weeks. The finished plastinated specimen is dry to the touch, odorless, and nontoxic, yet it maintains its original shape and, in many cases, is reasonably close in color and consistency. It resists deterioration and can be stored at room temperature indefinitely. The authors have found plastinated specimens to be superior to those preserved in formalin for teaching anatomic pathology to undergraduate medical students.

An epoxy resin and silicone impregnation technique for the preservation of oral pathology teaching specimens.

A technique of plastination and its application to the preservation of oral pathology teaching specimens is presented. Advantages of the technique and the methodology are briefly outlined and summarized.

An improved method for the preservation of teaching specimens.

Although gross tissue specimens are a valuable aid to the teaching of pathology and anatomy, storage and handling of them is discouragingly difficult. Impregnation of biological materials with curable polymers (plastination) allows wider use of human tissue for both basic and clinical instruction. The process involves dehydration, saturation with an appropriate intermediary solvent, and infiltration with incured polymer in vacuo. The matching of each tissue with a resin with appropriate physical and optical qualities is essential for best results. The educational value of plastinated specimens is equal or superior to that of formaldehyde-preserved tissue, whereas their handling is greatly eased.

Effects of parathyroid extract on the rupture strength of intact skin of the rat.

Rats were injected with parathyroid extract (PTE) to search for possible effects on connective tissue of the skin. Rupture strength analysis of skin samples showed a significant increase in strength of skin from PTE-treated rats. The explanation for this effect is not understood at present.