Linking data on women in public family law court proceedings concerning their children to mental health service records in South London.

INTRODUCTION: Maternal mental health problems and substance misuse are key risk factors for child neglect or abuse and court-mandated placement into care. Linkage between mental health records and family court data could raise awareness about parent mental health needs and inform approaches to address them. OBJECTIVES: To evaluate data linkage between administrative family court data and electronic mental health records for a population-based mental health service for 1.3 million people in South London. METHODS: We deterministically linked administrative family court data for women (n=5463) involved in care proceedings in South London with service user records from the South London and Maudsley NHS Mental Health Trust (SLaM). We restricted the cohort to women involved in proceedings between 2007 and 2019, in local authorities where SLaM solely provides secondary/tertiary mental health services and the Improving Access to Psychological Therapies (IAPT) (n=3226). We analysed the associations between match status and sociodemographic/case characteristics using multivariable logistic regression. RESULTS: Two-thirds (2317/3226; 66%) of women linked to a SLaM service user record at some point; most (91%) who linked accessed secondary/tertiary mental health services, indicating serious mental illness. Accounting for possible missed matches, we estimated that 70-83% of women accessed SLaM services at some point. Older women at index proceedings (>35yrs OR: 0.69, 95%CI: 0.54-0.88vs <25yrs) and Black women or women from other ethnic groups (Black ethnic groups 0.65, 0.50-0.83; other ethnicity 0.59, 0.43-0.81 vs White ethnic groups) had lower odds of linking. Odds of linking were higher for women with an infant in proceedings (1.42, 1.18-1.71), or with curtailed/terminated parental responsibility (1.44, 1.20-1.73). CONCLUSION: Our linkage supports growing evidence of a high burden of mental health problems and substance misuse among women whose children enter care in England, compared to the general population. Research using this linkage should inform strategies to address the considerable mental health needs of vulnerable women and their children.

Mobile telephone delivered contingency management for encouraging adherence to supervised methadone consumption: feasibility study for an RCT of clinical and cost-effectiveness (TIES).

BACKGROUND: Prescription methadone or buprenorphine enables people with opioid use disorder to stop heroin use safely while avoiding withdrawal. To ensure methadone is taken as prescribed and to prevent diversion onto the illicit market, people starting methadone take their daily dose under a pharmacist's supervision. Many patients miss their daily methadone dose risking withdrawal, craving for heroin and overdose due to loss of heroin tolerance. Contingency management (CM) can improve medication adherence, but remote delivery using technology may be resource-light and cost-effective. We developed an innovative way to deliver CM by mobile telephone. Software monitors patients' attendance and supervised methadone consumption through an internet self-login at the pharmacy and sends reinforcing text messages to patients' mobile telephones. A linked system sends medication adherence reports to prescribers and provides early warning alerts of missed doses. A pre-paid debit card system provides financial incentives. METHODS: A cluster randomised controlled trial design was used to test the feasibility of conducting a future trial of mobile telephone CM to encourage adherence to supervised methadone in community pharmacies. Each cluster (drug service/3 allied pharmacies) was randomly allocated to provide patient's presenting for a new episode of opiate agonist treatment (OAT) with either (a) mobile telephone text message CM, (b) mobile telephone text message reminders, or (c) no text messages. We assessed acceptability of the interventions, recruitment, and follow-up procedures. RESULTS: Four drug clinics were approached and three recruited. Thirty-three pharmacists were approached and 9 recruited. Over 3 months, 173 individuals were screened and 10 enrolled. Few patients presented for OAT and high numbers were excluded due to receiving buprenorphine or not attending participating pharmacies. There was 96% consistency in recording medication adherence by self-login vs. pharmacy records. In focus groups, CM participants were positive about using self-login, the text messages, and debit card. Prescribers found weekly reporting, time saving, and allowed closer monitoring of patients. Pharmacists reported that the tablet device was easy to host. CONCLUSION: Mobile telephone CM worked well, but a planned future trial will use modified eligibility criteria (existing OAT patients who regularly miss their methadone/buprenorphine doses) and increase the number of participating pharmacies. TRIAL REGISTRATION: The trial is retrospectively registered, ISRCTN 58958179 .

Assertive outreach treatment versus care as usual for the treatment of high-need, high-cost alcohol related frequent attenders: study protocol for a randomised controlled trial.

BACKGROUND: Alcohol-related hospital admissions have doubled in the last ten years to > 1.2 m per year in England. High-need, high-cost (HNHC) alcohol-related frequent attenders (ARFA) are a relatively small subgroup of patients, having multiple admissions or attendances from alcohol during a short time period. This trial aims to test the effectiveness of an assertive outreach treatment (AOT) approach in improving clinical outcomes for ARFA, and reducing resource use in the acute setting. METHODS: One hundred and sixty ARFA patients will be recruited and following baseline assessment, randomly assigned to AOT plus care as usual (CAU) or CAU alone in equal numbers. Baseline assessment includes alcohol consumption and related problems, physical and mental health comorbidity and health and social care service use in the previous 6 months using standard validated tools, plus a measure of resource use. Follow-up assessments at 6 and 12 months after randomization includes the same tools as baseline plus standard measure of patient satisfaction. Outcomes for CAU + AOT and CAU at 6 and 12 months will be compared, controlling for pre-specified baseline measures. Primary outcome will be percentage of days abstinent at 12 months. Secondary outcomes include emergency department (ED) attendance, number and length of hospital admissions, alcohol consumption, alcohol-related problems, other health service use, mental and physical comorbidity 6 and 12 months post intervention. Health economic analysis will estimate the economic impact of AOT from health, social care and societal perspectives and explore cost-effectiveness in terms of quality adjusted life years and alcohol consumption at 12-month follow-up. DISCUSSION: AOT models piloted with alcohol dependent patients have demonstrated significant reductions in alcohol consumption and use of unplanned National Health Service (NHS) care, with increased engagement with alcohol treatment services, compared with patients receiving CAU. While AOT interventions are costlier per case than current standard care in the UK, the rationale for targeting HNHC ARFAs is because of their disproportionate contribution to overall alcohol burden on the NHS. No previous studies have evaluated the clinical and cost-effectiveness of AOT for HNHC ARFAs: this randomized controlled trial (RCT) targeting ARFAs across five South London NHS Trusts is the first. TRIAL REGISTRATION: International standard randomized controlled trial number (ISRCTN) registry: ISRCTN67000214, retrospectively registered 26/11/2016.

Positive reinforcement targeting abstinence in substance misuse (PRAISe): Study protocol for a Cluster RCT & process evaluation of contingency management.

There are approximately 256,000 heroin and other opiate users in England of whom 155,000 are in treatment for heroin (or opiate) addiction. The majority of people in treatment receive opiate substitution treatment (OST) (methadone and buprenorphine). However, OST suffers from high attrition and persistent heroin use even whilst in treatment. Contingency management (CM) is a psychological intervention based on the principles of operant conditioning. It is delivered as an adjunct to existing evidence based treatments to amplify patient benefit and involves the systematic application of positive reinforcement (financial or material incentives) to promote behaviours consistent with treatment goals. With an international evidence base for CM, NICE recommended that CM be implemented in UK drug treatment settings alongside OST to target attendance and the reduction of illicit drug use. While there was a growing evidence base for CM, there had been no examination of its delivery in UK NHS addiction services. The PRAISe trial evaluates the feasibility, acceptability, clinical and cost effectiveness of CM in UK addiction services. It is a cluster randomised controlled effectiveness trial of CM (praise and financial incentives) targeted at either abstinence from opiates or attendance at treatment sessions versus no CM among individuals receiving OST. The trial includes an economic evaluation which explores the relative costs and cost effectiveness of the two CM intervention strategies compared to TAU and an embedded process evaluation to identify contextual factors and causal mechanisms associated with variations in outcome. This study will inform UK drug treatment policy and practice. Trial registration ISRCTN 01591254.

Inter-comparison of radon detectors for one to four week measurement periods.

Seven different types of radon detectors (Atmos 12 dpx, RAD7, RStone, Sun Nuclear 1028, Ramon 2.2, Canary and CR-39) were compared for exposure periods of 1, 2, 3 and 4 weeks. The comparison was conducted under two conditions: (a) in a purpose-built radon chamber with an average radon concentration of 2560 Bq m(-3) (b) in a home environment with a radon concentration of 57 Bq m(-3), in both cases measured by the reference detector (Atmos 12 dpx) with a ±10% uncertainty range. In (a) 5 out of 8 detectors recorded radon concentrations within the Atmos uncertainty range and all detectors recorded within ±15%; in (b) 3 out of 9 detectors recorded within the Atmos uncertainty range and 6 out of 9 measured within ±20%, for a 4 week measurement. The results from this study show that radon surveys can be conducted for shorter periods than the recommended 3 months where a rapid indication is needed of whether the radon concentration is above the reference level, such as when assessing the concentration during and after remediation work.

An outdoor radon survey and minimizing the uncertainties in low level measurements using CR-39 detectors.

Long term outdoor radon measurements were recorded in Ireland using CR-39 track etch detectors. A measurement protocol was designed for this study, which was optimized for the relatively low radon concentrations expected outdoors. This protocol included pre-etching the detectors before exposure to allow radon tracks to be more easily distinguished from background. The average outdoor radon concentration for the Republic of Ireland was found to be 5.6 ± 0.7 Bq m(-3). A statistically significant difference between inland and coastal radon concentrations was evident but no difference between mean radon concentrations on the east coast and those on the west coast was observed.

Investigation of occupational radiation exposures to NORM at an Irish peat-fired power station and potential use of peat fly ash by the construction industry.

Annually, approximately 15% of Ireland's electricity requirement is provided through the combustion of 3 x 10(6) tonnes of peat. While the literature on coal-fired power generation is quite abundant, studies on the peat-fired power generation industry from a radiological point of view are scarce. A study of the largest Irish peat-fired power plant was initiated to review the potential occupational radiation exposures arising from the occurrence of naturally occurring radioactive material (NORM) at different stages of the industrial process and to investigate any radiological health consequences that may arise should peat fly ash be used as a component of building materials. Ambient gamma dose rate measurements, radon measurements, quantification of the occupational exposure from inhalation of airborne particles (personal air sampling) and gamma spectrometry analysis of peat, peat ash and effluent samples from the ash ponds were undertaken. The results indicate that the radiation dose received by any worker involved in the processing of the peat and the handling of the ash resulting from peat combustion does not exceed 150 microSv per annum. Regulatory control of the peat-fired power generation is therefore unnecessary according to the Irish legislation with regards to NORM. The potential use of peat fly ash as a by-product in the building industry was also found to have a negligible radiological impact for construction workers and for members of the public.

Natural radioactivity in building materials in the Republic of Ireland.

This paper presents the findings of a study undertaken to determine the natural radioactivity present in building materials in the Republic of Ireland. A total of 70 samples of commonly used building materials were collected from various manufacturers and suppliers throughout the country and analyzed using a HPGe gamma ray spectrometer. The specific activities of 226Ra, 232Th, and 40K were measured in all samples, and results ranged from minimum values of <1, <1, and 4 Bq kg(-1) to maximum values of 139, 57, and 1,977 Bq kg(-1), with mean values of 32, 18, and 353 Bq kg(-1), respectively. Results obtained were compared with relevant national, EU, and international legislation and guidance, and with the results of similar studies undertaken in other countries. These activities would suggest that the use of such building materials in the construction of domestic dwellings or workplaces in Ireland is unlikely to give rise to any significant radiation exposure to the occupants. In general, these activities were comparable to the results of similar studies undertaken in other countries. 137Cs activity was also detected in some samples.

Excessive alcohol consumption and drinking expectations among clients in methadone maintenance.

Excessive alcohol consumption and related problems are common among clients in methadone maintenance treatment (MMT), yet relatively little is known about the psychological and social determinants of alcohol-related attitudes and behaviors during treatment. This study reports on the prevalence of alcohol dependence, patterns of alcohol consumption and preliminary findings about clients' beliefs that they will change their drinking behavior in the future. Data were gathered from personal interviews with 66 clients attending a MMT program in South London (some 80.5% of the eligible caseload). Forty-one percent of the overall sample met DSM-IV criteria for alcohol dependence in the past 12 months. Among clients who reported drinking in the past month (n = 50), 54% were classified as dependent, and these clients reported consuming an average of 23.5 UK standard units of absolute alcohol (188g/6.58 ounces) on a typical drinking day in the past month. Exploratory analyses suggested that expectations to change drinking behavior were predicted by subjective norms (social pressures), perceived functions of alcohol use, past drinking levels and current dose of methadone. Clinicians engaged in alcohol problems assessment and counseling during MMT could usefully examine these influences to strengthen treatment provision.

Drug switching patterns among patients taking non-steroidal anti-inflammatory drugs: a retrospective cohort study of a general practitioners database in the United Kingdom.

OBJECTIVE: To examine the frequency and determinants of switching between different non-steroidal anti-inflammatory drugs (NSAIDs) and the relationship with co-prescription of gastro-protective drugs (GPDs). DESIGN: This was an analysis of 30,654 patients receiving a total of 209,140 NSAID prescriptions in the UK from 1 January 1997 to 31 December 1998 identified through the MediPlus database. Analyses examined switching, repeat, termination and GPD co-prescription rates in new and continuing takers according to age and sex. RESULTS: Each patient received an average of 6.8 prescriptions in the year of study. Of the prescriptions 72.2% were for one of three NSAIDs, ibuprofen, diclofenac, or naproxen, and 7.2% of prescriptions were for fixed combination products of an NSAID plus a gastroprotective drug. At least 16.0% of continuing takers, and 28.5% of new takers switched to another NSAID in the review period. On average, new patients switched more frequently than continuing patients (0.39 switches/patient/year versus 0.23 switches/patient/year, p < 0.001). Switching between NSAIDs decreased with age and was less common in women (p < 0.05). Switching was associated with a 24% and 33% increased probability of GPD prescription in new and continuing takers, respectively. DISCUSSION: The frequency of switching, and of GPD co-prescription at switching, suggest that dissatisfaction with NSAIDs is frequent, and that gastrointestinal intolerance is a common feature of this dissatisfaction.

Local calcium release in dendritic spines required for long-term synaptic depression.

We have used rats and mice with mutations in myosin-Va to evaluate the range and function of IP3-mediated Ca2+ signaling in dendritic spines. In these mutants, the endoplasmic reticulum and its attendant IP3 receptors do not enter the postsynaptic spines of parallel fiber synapses on cerebellar Purkinje cells. Long-term synaptic depression (LTD) is absent at the parallel fiber synapses of the mutants, even though the structure and function of these synapses otherwise appear normal. This loss of LTD is associated with selective changes in IP3-mediated Ca2+ signaling in spines and can be rescued by photolysis of a caged Ca2+ compound. Our results reveal that IP3 must release Ca2+ locally in the dendritic spines to produce LTD and indicate that one function of dendritic spines is to target IP3-mediated Ca2+ release to the proper subcellular domain.

Randomized trial of supervised injectable versus oral methadone maintenance: report of feasibility and 6-month outcome.

AIM: To assess the feasibility of a randomized clinical trial of supervised injectable versus oral methadone maintenance and to assess medium-term treatment outcomes. DESIGN: Randomized clinical trial of supervised injectable versus supervised oral methadone maintenance treatment (MMT). Trial participants were dependent illicit opiate injectors allocated at intake to supervised injectable or oral methadone maintenance treatment. SETTING: Specialist addictions treatment centre in South London. SUBJECTS: Forty dependent illicit opiate injectors seeking methadone maintenance treatment. INTERVENTIONS: Daily supervised injectable and oral methadone maintenance, delivered at the treatment centre. MAIN OUTCOME MEASURES: Frequency of illicit heroin use and frequency of illicit drug injecting during 30 days before intake to treatment and prior to 6-month follow-up. SECONDARY OUTCOME MEASURES: frequency of use of illicit methadone, crack cocaine, benzodiazepines and alcohol, physical and psychological health symptoms and acquisitive crime. RESULTS: Injectable and oral MMT were both generally acceptable to the study participants: there was a high level of agreement to enter the randomized trial, and subsequent retention in treatment was good. The average number of days of illicit heroin use reduced from 22.2 to 7.6 for the injectable MMT group and from 22.4 to 8.7 for the oral MMT group. The average number of days of illicit injecting reduced from 25.7 to 10.8 days for the injectable group and from 20.1 to 11.9 days for the oral group. Patients' physical and psychological health symptoms and involvement in acquisitive crime also reduced in both groups. Treatment satisfaction ratings at follow-up were higher among patients in the injectable MMT group. The ratio for the actual medication costs between injectable and oral MMT was 6.8:1, and for the direct operational costs was 4.7:1. There was some evidence of a differential patient response with greater reductions in heroin use occurring among patients who were daily illicit injectors and had poorer psychological and physical health (at entry) who were allocated to injectable MMT. CONCLUSIONS: Conduct of the trial has demonstrated that it is feasible to implement supervised injectable methadone maintenance treatment in the context of (although separate from) a specialist oral methadone maintenance service. Patients assigned to receive either supervised injectable or oral MMT had broadly equivalent, positive during-treatment outcomes at 6-month follow-up. Future studies should seek to identify patient characteristics which are linked to good outcome in injectable MMT. Practical evidence-based guidance to physicians about determining which patients are more suitable for injectable MMT is urgently needed.

Changing epidemiology of pertussis in the United States: increasing reported incidence among adolescents and adults, 1990-1996.

Since 1990, the reported incidence of pertussis has increased in the United States with peaks occurring every 3-4 years. On the basis of analysis of pertussis cases reported to the Centers for Disease Control and Prevention, the incidence remained stable among children aged younger than 5 years, most of whom were protected by vaccination. In contrast to 1990-1993, during 1994-1996, the average incidence among persons aged 5-9 years, 10-19 years, and 20 years or older increased 40%, 106%, and 93%, respectively. Since 1990, 14 states reported pertussis incidences of > or =2 cases per 100,000 population during at least 4 years between 1990 and 1996; seven of these states also reported that a high proportion of cases occurred in persons aged 10 years or older. Analysis of national data on pertussis did not provide sufficient information to fully elucidate the relative importance of multiple possible explanations for the increase in the incidence of pertussis in adolescents and adults. Improvement in diagnosis and reporting of pertussis in this age group, particularly in some states, is an important factor contributing to the overall increase.

Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects.

BACKGROUND AND PURPOSE: The purpose of this study was to examine the physical impairments and functional limitations of individuals with total knee arthroplasty (TKA), as compared with individuals with no diagnosed knee disease (control subjects). SUBJECTS: Twenty-nine individuals 1 year following TKA (13 women, 16 men) and 40 age- and gender-matched control subjects (18 women, 22 men) were assessed. METHODS: Walking speed, stair-climbing ability, knee torque (in newton-meters), and total work performed during 15 repeated contractions were evaluated. RESULTS: Walking speeds for men with TKA were 13% and 17% slower at normal and fast speeds, respectively. Their stair-climbing ability was even more compromised (51% slower). Walking speeds for women with TKA were 17% and 18% slower at normal and fast speeds, respectively. Similarly, their stair-climbing time was more compromised (43% slower). Men with TKA were 37% to 39% weaker and performed 36% to 37% less total work of their knee extensors compared with the control subjects. Similarly, women with TKA had knee extensor strength deficits of 28% to 29% and performed 24% less total work. CONCLUSION AND DISCUSSION: One year after TKA, marked physical impairments and functional limitations persisted. [Walsh M, Woodhouse LJ, Thomas SG, Finch E. Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects.

Functional ability perceived by individuals following total knee arthroplasty compared to age-matched individuals without knee disability.

A comparison of function of individuals 1 year after total knee arthroplasty (TKA) with healthy control subjects (controls) meaningfully describes outcome in these patients. Perception of function measured by two questionnaires, the Lower Extremity Activity Profile (LEAP) and the Western Ontario McMaster Osteoarthritis Index (WOMAC), and walking and stair performance was compared between 29 patients, 1 year after TKA, and 40 controls. There was significantly greater perceived difficulty with function in patients with TKA than in controls. In TKA men, LEAP and WOMAC scores correlated respectively with self-paced walk speed (r = -.71 and -.55) and stair performance time (r = 0.70 and 0.68). In TKA women, LEAP difficulty score correlated with self-paced walk speed (r = -.41) and stair performance time (r = -0.71). By 1 year, TKA subjects regained 80% of the function of controls. Perception of function after TKA can be measured by either questionnaire in men; however, the LEAP is the preferable questionnaire with women.

Local calcium signalling by inositol-1,4,5-trisphosphate in Purkinje cell dendrites.

The second messenger inositol-1,4,5-trisphosphate (InsP3) releases Ca2+ from intracellular Ca2+ stores by activating specific receptors on the membranes of these stores. In many cells, InsP3 is a global signalling molecule that liberates Ca2+ throughout the cytoplasm. However, in neurons the situation might be different, because synaptic activity may produce InsP3 at discrete locations. Here we characterize InsP3 signalling in postsynaptic cerebellar Purkinje neurons, which have a high level of InsP3 receptors. We find that repetitive activation of the synapse between parallel fibres and Purkinje cells causes InsP3-mediated Ca2+ release in the Purkinje cells. This Ca2+ release is restricted to individual postsynaptic spines, where both metabotropic glutamate receptors and InsP3 receptors are located, or to multiple spines and adjacent dendritic shafts. Focal photolysis of caged InsP3 in Purkinje cell dendrites also produces Ca2+ signals that spread only a few micrometres from the site of InsP3 production. Uncaged InsP3 produces a long-lasting depression of parallel-fibre synaptic transmission that is limited to synapses where the Ca2+ concentration is raised. Thus, in Purkinje cells InP3 acts within a restricted spatial range that allows it to regulate the function of local groups of parallel-fibre synapses.

Route of drug use and its implications for drug effect, risk of dependence and health consequences.

Route of administration has a profound, but often overlooked, influence on the actual experience of the drug use itself, on the risk of resulting development of dependence, and on the nature of the harms to which drug users are exposing themselves. These three areas are reviewed. The influence of route of administration on drug effect is considered first with regard to overall effectiveness of absorption, and also with regard to speed of onset of effect. The implications for risk of dependence cover animal and human laboratory studies of reinforcement schedules, epidemiological studies, the attitudes of drug users themselves to the different routes of possible drug use and associated dependence risk and the postulated influences on progression to dependence. Finally, the relationship between route of drug use and health sequelae is explored for the three most widely used routes of administration of illicit drugs-snorting, smoking and injecting.

Interrater reliability of six tests of trunk muscle function and endurance.

Some studies have shown a relationship between trunk muscle strength and low back pain. Measures of trunk muscle strength and endurance, which are feasible in the clinical setting, are needed. The purpose of this study was to determine interrater reliability of six tests of abdominal and trunk extensor muscle strength and endurance. The tests included abdominal and extensor dynamic endurance, hand-held dynamometry of isometric flexion and extension, and abdominal and extensor static endurance. Thirty-nine healthy workers were recruited as subjects. Each was tested by three raters on 3 days within 1 week. Intraclass correlation coefficients (ICC) and the standard error of measurement (SEM) were calculated: abdominal dynamic endurance ICC = .89, SEM = 8 repetitions; extensor dynamic endurance ICC = .78, SEM = 9 repetitions; abdominal isometric force ICC = .25, SEM = 60 N; extensor isometric force ICC = .24, SEM = 68 N; abdominal static endurance ICC = .51, SEM = 35 seconds; extensor static endurance ICC = .59, SEM = 20 seconds. The dynamic endurance tests had acceptable interrater reliability. For the others, reliability was poor and the SEMs were large.