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.

Effect of pharmacological therapies for stroke prevention on major gastrointestinal bleeding in patients with atrial fibrillation.

Various antiplatelet and anticoagulation options are available for stroke prevention in patients with atrial fibrillation (AF). Currently, it is unclear whether these agents differ in their propensity to cause major gastrointestinal bleeding (MGIB). To our knowledge, no systematic evaluation of MGIB rates from randomised controlled trials (RCTs) of pharmacological stroke prevention in patients with AF has been conducted. Two independent investigators conducted systematic literature searches in MEDLINE and CENTRAL from the earliest possible date through November 2010. To be included, RCTs had to evaluate an adult population with AF or flutter and report data on the incidence of MGIB. Peto's odds ratios (ORs) with associated 95% confidence intervals (CIs) were calculated for all possible pair-wise comparisons of pharmacological stroke prevention alternatives. A total of 16 unique trials (n = 42,983) met inclusion criteria. The reported incidence of MGIB in placebo or control arms of identified trials was as high as 1.5%. Upon pair-wise meta-analysis of different pharmacological strategies, adjusted-dose vitamin K antagonists (VKAs) were found to be associated with a higher odds of MGIB compared with placebo/control (OR 3.21, 95% CI 1.32-7.82) and aspirin (or triflusal or indobufen) (OR 1.92, 95% CI 1.08-3.41). The addition of aspirin (or triflusal) to an adjusted-dose VKA resulted in greater odds of MGIB compared with aspirin alone (OR 4.72, 95% CI 1.35-16.49) and adjusted-dose VKA alone (OR 2.66, 95% CI 1.05-6.74). While aspirin increased the odds of MBIG by 3.23-fold compared with placebo/control, this finding did not reach statistical significance. The combination of aspirin and clopidogrel increased patients' odds of MGIB compared with aspirin alone (OR 1.93, 95% CI 1.46-2.56). Dabigatran was associated with a 30% increased odds of MGIB compared with adjusted-dose VKA (OR 1.30, 95% CI 1.06-1.59); however, ximelagatran was not. Low-intensity VKA therapy, alone or in combination with aspirin, was not associated with increased odds of MGIB compared with any (active-) comparator. The MGIB is a concern for patients with AF receiving pharmacological stroke prevention. Current RCT data suggest that dabigatran and adjusted-dose VKA therapy are associated with the highest odds of MGIB. Aspirin was not found to increase patients' odds of MGIB; however, this finding may be the result of type 2 error. Dual therapy resulting from the addition of an antiplatelet agent was typically associated with further increased odds of MGIB compared with monotherapy.

Effectiveness and cost-effectiveness of admissions to women's crisis houses compared with traditional psychiatric wards: pilot patient-preference randomised controlled trial.

BACKGROUND: Women's crisis houses have been developed in the UK as a less stigmatising and less institutional alternative to traditional psychiatric wards. AIMS: To examine the effectiveness and cost-effectiveness of women's crisis houses by first examining the feasibility of a pilot patient-preference randomised controlled trial (PP-RCT) design (ISRCTN20804014). METHOD: We used a PP-RCT study design to investigate women presenting in crisis needing informal admission. The four study arms were the patient preference arms of women's crisis house or hospital admission, and randomised arms of women's crisis house or hospital admission. RESULTS: Forty-one women entered the randomised arms of the trial (crisis house n = 19, wards n = 22) and 61 entered the patient-preference arms (crisis house n = 37, ward n = 24). There was no significant difference in outcomes (symptoms, functioning, perceived coercion, stigma, unmet needs or quality of life) or costs for any of the groups (randomised or preference arms), but women who obtained their preferred intervention were more satisfied with treatment. CONCLUSIONS: Although the sample sizes were too small to allow definite conclusions, the results suggest that when services are able to provide interventions preferred by patients, those patients are more likely to be satisfied with treatment. This pilot study provides some evidence that women's crisis houses are as effective as traditional psychiatric wards, and may be more cost-effective.

Impact of a modified Valsalva manoeuvre in the termination of paroxysmal supraventricular tachycardia.

BACKGROUND: Paroxysmal supraventricular tachycardia (SVT) is a relatively common problem presented to the emergency department. Most sources advocate the use of vagal manoeuvres as first-line management, including Valsalva manoeuvre. Despite this, there is lack of standardisation as to how the technique is performed. There is currently no 'gold standard' Valsalva manoeuvre. We propose a modified Valsalva manoeuvre, based on techniques described in small-scale electrophysiological studies, but no large clinical trials. OBJECTIVE: The study was designed to assess the impact of introducing this modified Valsalva manoeuvre as the departmental standard for non-pharmacological reversion of SVT. METHODS: A retrospective audit reviewing the preceding 6-month presentations of SVT was performed, and a questionnaire assessing techniques used and anticipated success rates was completed by a representative sample of emergency department doctors. Finally, a prospective trial of the impact of the modified Valsalva manoeuvre on patients presenting in SVT to the emergency department was performed. After meeting the study criteria and giving consent, the patients were instructed to perform the modified Valsalva manoeuvre, that is, while lying supine on the bed in a Trendelenberg position, they forcefully expire into a section of suction tubing and pressure gauge for at least 15 s and at a pressure of at least 40 mm Hg. RESULTS: The retrospective 6-month audit revealed only one successful reversion with Valsalva from a sample of 19 patients. Thirty-two doctors completed the questionnaire describing a variety of different Valsalva techniques highlighting a lack of consensus. 27 patients were recruited to the prospective trial, of whom 19 were correctly diagnosed as having paroxysmal SVT. Of these 19 patients, 6 reverted with the modified Valsalva manoeuvre. CONCLUSION: Our findings support previous observations that there is lack of standardisation as to how Valsalva is performed, and an apparent reliance on adenosine. The impact of introducing this technique as our departmental standard was a raise in non-pharmacological reversion from 5.3% to 31.7% with no reported significant adverse effects.

Women's experiences of hospital admission.

The primary aim of this study was to examine women's experiences of inpatient psychiatric services. A secondary aim was to use the emerging themes in service planning and to develop an evaluation tool. Focus groups and individual interviews with women in receipt of psychiatric services in Croydon were used. The findings suggest continuity with both negative and positive aspects of institutional care described before the policy of community care was introduced. The attempts to 'normalize' institutional care by desegregating wards appear rather to have compounded problems faced by women. Women were clear about what they felt they wanted and needed. Women are dissatisfied about many aspects of care aside from the problems associated specifically with mixed sex wards. This suggests that sexual segregation of wards alone is a necessary but an insufficient measure to improve inpatient care. The findings can inform development of a women-only service in Croydon and of a tool to evaluate it.

Surgery in a Palestinian refugee camp.

From 1985 to 1987, three Palestinian refugee camps in Lebanon were attacked several times by a Lebanese militia. We present a review of 1276 casualties who were wounded in the refugee camp of Bourj al-Barajneh during two such attacks between December 1985 and April 1987. All were treated in Haifa Hospital (30-40 beds), which had limited equipment, was situated inside the refugee camp and was badly damaged by war. During both attacks, the refugee camp was surrounded and put under siege such that patients could not be evacuated and supplies were not allowed in. The second period lasted almost 6 months resulting in severe shortages of medicines, equipment and food, leading to a rationing of resources and modification of treatment. More than 300 operations were carried out under general anaesthesia, the remainder under local or without anaesthesia. The overall operative mortality was 3.2 per cent. Despite the deprivation, many patients survived severe and complicated wounds because they were quickly brought to the hospital, provided with adequate quantities of fresh blood for transfusion, and sound surgical principles were followed.

Medial fasciocutaneous flap of thigh for release of post-burn groin contractures.

Post-burn groin contractures, though uncommon, cause some patients distressing symptoms which are difficult to treat. Recurrence of contracture and symptoms is common and multiple operations are often required to control symptoms. We describe the use of the medial thigh fasciocutaneous flap for release of these contractures. Six flaps have been raised in four patients and symptomatic relief has been excellent in three. There have been no contracture recurrences.

Heel pain and body weight.

Body weight has been implicated as a factor in plantar heel pain. In this study, a statistically significant correlation between heel pain and increased body weight is documented in a series of consecutive plantar heel pain patients.

A review of the first 12 months of a hand clinic.

The potential problems faced on setting up a hand clinic and how they may be overcome are discussed. In its first 12 months there were 199 new referrals over 50% of which were either lacerations, fingertip injuries or fractures. The management of these cases is discussed.

Varicose veins: optimum compression following sclerotherapy.

There is uncertainty regarding the most satisfactory technique of lower limb compression following sclerotherapy for varicose veins. We have compared a standard bandaging technique with a high pressure compression stocking in a randomised trial. Efficacy was judged on the success of injections, complications of the treatment and patient satisfaction. In the stockinged legs 144 of 156 injections were successful, compared with 117 of 147 in the bandaged group (P less than 0.001) (Chi squared). The incidence of superficial thrombophlebitis was also reduced in the stocking group. In addition, the stocking technique costs less in materials than conventional bandaging. We would recommend compression stockings for evaluation in sclerotherapy of varicose veins.

The technique of controlled delivery as a weapon in dealing with illicit traffic in narcotic drugs and psychotropic substances.

The technique of controlled delivery is used when a consignment of illicit drugs is detected and allowed to go forward under the control and surveillance of law enforcement officers in order to secure evidence against the organizers of such illicit drug traffic. This technique has been proved effective in some countries in identifying and bringing to justice principals, organizers and financiers of the illicit drug traffic. The controlled delivery technique is compatible with the requirements of the Single Convention on Narcotic Drugs, 1961, but its application depends on the particular legal and administrative provisions in the countries concerned. The technique merits wider use, and it does not involve any element of entrapment. It has been used most effectively when illicit drugs are discovered in unaccompanied freight consignments or in the post. Controlled deliveries involving a courier present special difficulties and should be treated with caution. In a controlled delivery, security of information is of paramount importance as is the appropriate knowledge and co-operation of the law enforcement authorities. Such co-operation is essential between the country in which the initial detection of drugs has occurred, transit countries and the country of final destination. A number of important detections have been made as a result of speedy international co-operation of this type between law enforcement authorities.