The effect of psychiatric decision unit services on inpatient admissions and mental health presentations in emergency departments: an interrupted time series analysis from two cities and one rural area in England.

AIMS: High-quality evidence is lacking for the impact on healthcare utilisation of short-stay alternatives to psychiatric inpatient services for people experiencing acute and/or complex mental health crises (known in England as psychiatric decision units [PDUs]). We assessed the extent to which changes in psychiatric hospital and emergency department (ED) activity were explained by implementation of PDUs in England using a quasi-experimental approach. METHODS: We conducted an interrupted time series (ITS) analysis of weekly aggregated data pre- and post-PDU implementation in one rural and two urban sites using segmented regression, adjusting for temporal and seasonal trends. Primary outcomes were changes in the number of voluntary inpatient admissions to (acute) adult psychiatric wards and number of ED adult mental health-related attendances in the 24 months post-PDU implementation compared to that in the 24 months pre-PDU implementation. RESULTS: The two PDUs (one urban and one rural) with longer (average) stays and high staff-to-patient ratios observed post-PDU decreases in the pattern of weekly voluntary psychiatric admissions relative to pre-PDU trend (Rural: -0.45%/week, 95% confidence interval [CI] = -0.78%, -0.12%; Urban: -0.49%/week, 95% CI = -0.73%, -0.25%); PDU implementation in each was associated with an estimated 35-38% reduction in total voluntary admissions in the post-PDU period. The (urban) PDU with the highest throughput, lowest staff-to-patient ratio and shortest average stay observed a 20% (-20.4%, CI = -29.7%, -10.0%) level reduction in mental health-related ED attendances post-PDU, although there was little impact on long-term trend. Pooled analyses across sites indicated a significant reduction in the number of voluntary admissions following PDU implementation (-16.6%, 95% CI = -23.9%, -8.5%) but no significant (long-term) trend change (-0.20%/week, 95% CI = -0.74%, 0.34%) and no short- (-2.8%, 95% CI = -19.3%, 17.0%) or long-term (0.08%/week, 95% CI = -0.13, 0.28%) effects on mental health-related ED attendances. Findings were largely unchanged in secondary (ITS) analyses that considered the introduction of other service initiatives in the study period. CONCLUSIONS: The introduction of PDUs was associated with an immediate reduction of voluntary psychiatric inpatient admissions. The extent to which PDUs change long-term trends of voluntary psychiatric admissions or impact on psychiatric presentations at ED may be linked to their configuration. PDUs with a large capacity, short length of stay and low staff-to-patient ratio can positively impact ED mental health presentations, while PDUs with longer length of stay and higher staff-to-patient ratios have potential to reduce voluntary psychiatric admissions over an extended period. Taken as a whole, our analyses suggest that when establishing a PDU, consideration of the primary crisis-care need that underlies the creation of the unit is key.

Developing and testing a principle-based fidelity index for peer support in mental health services.

PURPOSE: Evidence suggests that the distinctive relational qualities of peer support-compared to clinical-patient relationships-can be eroded in regulated healthcare environments. Measurement of fidelity in trials of peer support is lacking. This paper reports the development and testing of a fidelity index for one-to-one peer support in mental health services, designed to assess fidelity to principles that characterise the distinctiveness of peer support. METHODS: A draft index was developed using expert panels of service user researchers and people doing peer support, informed by an evidence-based, peer support principles framework. Two rounds of testing took place in 24 mental health services providing peer support in a range of settings. Fidelity was assessed through interviews with peer workers, their supervisors and people receiving peer support. Responses were tested for spread and internal consistency, independently double rated for inter-rater reliability, with feedback from interviewees and service user researchers used to refine the index. RESULTS: A fidelity index for one-to-one peer support in mental health services was produced with good psychometric properties. Fidelity is assessed in four principle-based domains; building trusting relationships based on shared lived experience; reciprocity and mutuality; leadership, choice and control; building strengths and making connections to community. CONCLUSIONS: The index offers potential to improve the evidence base for peer support in mental health services, enabling future trials to assess fidelity of interventions to peer support principles, and service providers a means of ensuring that peer support retains its distinctive qualities as it is introduced into mental health services.

A temperature model for laser lithotripsy.

OBJECTIVE: To derive and validate a mathematical model to predict laser-induced temperature changes in a kidney during kidney stone treatment. METHODS: A simplified mathematical model to predict temperature change in the kidney for any given renal volume, irrigation flow rate, irrigation fluid temperature, and laser power was derived. We validated our model with matched in vitro experiments. RESULTS: Excellent agreement between the mathematical model predictions and laboratory data was obtained. CONCLUSION: The model obviates the need for repeated experimental validation. The model predicts scenarios where risk of renal tissue damage is high. With real-time knowledge of flow rate, irrigating fluid temperature and laser usage, safety warning levels could be predicted. Meanwhile, clinicians should be aware of the potential risk from thermal injury and take measures to reduce the risk, such as using room temperature irrigation fluid and judicious laser use.

What is the impact of psychiatric decision units on mental health crisis care pathways? Protocol for an interrupted time series analysis with a synthetic control study.

BACKGROUND: The UK mental health system is stretched to breaking point. Individuals presenting with mental health problems wait longer at the ED than those presenting with physical concerns and finding a bed when needed is difficult - 91% of psychiatric wards are operating at above the recommended occupancy rate. To address the pressure, a new type of facility - psychiatric decision units (also known as mental health decision units) - have been introduced in some areas. These are short-stay facilities, available upon referral, targeted to help individuals who may be able to avoid an inpatient admission or lengthy ED visit. To advance knowledge about the effectiveness of this service for this purpose, we will examine the effect of the service on the mental health crisis care pathway over a 4-year time period; the 2 years proceeding and following the introduction of the service. We use aggregate service level data of key indicators of the performance of this pathway. METHODS: Data from four mental health Trusts in England will be analysed using an interrupted time series (ITS) design with the primary outcomes of the rate of (i) ED psychiatric presentations and (ii) voluntary admissions to mental health wards. This will be supplemented with a synthetic control study with the same primary outcomes, in which a comparable control group is generated for each outcome using a donor pool of suitable National Health Service Trusts in England. The methods are well suited to an evaluation of an intervention at a service delivery level targeting population-level health outcome and the randomisation or 'trialability' of the intervention is limited. The synthetic control study controls for national trends over time, increasing our confidence in the results. The study has been designed and will be carried out with the involvement of service users and carers. DISCUSSION: This will be the first formal evaluation of psychiatric decision units in England. The analysis will provide estimates of the effect of the decision units on a number of important service use indicators, providing much-needed information for those designing service pathways. TRIAL REGISTRATION: primary registry: isrctn.com Identifying number: ISRCTN77588384 Link: Date of registration in primary registry: 27/02/2020. PRIMARY SPONSOR: St George's, University of London, Cramner Road, Tooting, SW17 ORE. Primary contact: Joe Montebello.

Out of the silence: towards grassroots and trauma-informed support for people who have experienced sexual violence and abuse.

To experience sexual violence and abuse is to experience silence. This commentary explores some of the ways in which psychiatry reinforces the silencing of sexual violence survivors. We argue that current psychiatric responses to sexual violence typically constitute iatrogenic harm including through: a failure to provide services that meet survivors' needs, a failure to believe or validate disclosures; experiences of medicalisation and diagnoses which can delegitimise people's own knowledge and meaning; 'power over' relational approaches which can prevent compassionate responses and result in staff having to develop their own coping strategies; and poorly addressed and reported experiences of sexual violence within psychiatric settings. We argue that these multiple forms of silencing have arisen in part because of biomedical dominance, a lack of support and training in sexual violence for staff, inconsistent access to structured, reflective supervision, and the difficulties of facing the horror of sexual violence and abuse. We then describe community-based and grassroots responses, and consider the potential of trauma-informed approaches. Whilst this paper has a UK focus, some aspects will resonate globally, particularly given that Western psychiatry is increasingly being exported around the globe.

[The Confusion Assessment Method: Transcultural adaptation of a French version]. / Adaptation transculturelle francophone de la Confusion Assessment Method.

INTRODUCTION: The Confusion Assessment Method (CAM) is a validated key tool in clinical practice and research programs to diagnose delirium and assess its severity. There is no validated French version of the CAM training manual and coding guide (Inouye SK). The aim of this study was to establish a consensual French version of the CAM and its manual. METHODS: Cross-cultural adaptation to achieve equivalence between the original version and a French adapted version of the CAM manual. RESULTS: A rigorous process was conducted including control of cultural adequacy of the tool's components, double forward and back translations, reconciliation, expert committee review (including bilingual translators with different nationalities, a linguist, highly qualified clinicians, methodologists) and pretesting. A consensual French version of the CAM was achieved. CONCLUSION: Implementation of the CAM French version in daily clinical practice will enable optimal diagnosis of delirium diagnosis and enhance communication between health professionals in French speaking countries. Validity and psychometric properties are being tested in a French multicenter cohort, opening up new perspectives for improved quality of care and research programs in French speaking countries.

Psychological treatments for early psychosis can be beneficial or harmful, depending on the therapeutic alliance: an instrumental variable analysis.

BACKGROUND: The quality of the therapeutic alliance (TA) has been invoked to explain the equal effectiveness of different psychotherapies, but prior research is correlational, and does not address the possibility that individuals who form good alliances may have good outcomes without therapy. METHOD: We evaluated the causal effect of TA using instrumental variable (structural equation) modelling on data from a three-arm, randomized controlled trial of 308 people in an acute first or second episode of a non-affective psychosis. The trial compared cognitive behavioural therapy (CBT) over 6 weeks plus routine care (RC) v. supportive counselling (SC) plus RC v. RC alone. We examined the effect of TA, as measured by the client-rated CALPAS, on the primary trial 18-month outcome of symptom severity (PANSS), which was assessed blind to treatment allocation. RESULTS: Both adjunctive CBT and SC improved 18-month outcomes, compared to RC. We showed that, for both psychological treatments, improving TA improves symptomatic outcome. With a good TA, attending more sessions causes a significantly better outcome on PANSS total score [effect size -2.91, 95% confidence interval (CI) -0.90 to -4.91]. With a poor TA, attending more sessions is detrimental (effect size +7.74, 95% CI +1.03 to +14.45). CONCLUSIONS: This is the first ever demonstration that TA has a causal effect on symptomatic outcome of a psychological treatment, and that poor TA is actively detrimental. These effects may extend to other therapeutic modalities and disorders.

Direct to consumer genetic testing: a systematic review of position statements, policies and recommendations.

In healthcare settings, genetic tests to determine whether an individual had inherited a genetic mutation are ordered by a health professional, and the results are interpreted and conveyed to the patient by that person. However, direct to consumer genetic testing (DTCGT) has enabled individuals to purchase genetic tests and receive results without the intervention of a health professional. To inform a set of guidelines for consumers and health professionals, we undertook a systematic review of position statements, policies and recommendations on the use of DTCGT. We performed a search of seven databases and the Internet for relevant documents. The search terms were 'direct to consumer' and 'genetic test', and documents in English published from 2002 to 2011 were included. The search retrieved 314 items, of which 14 were eligible for review. Five themes were derived from thematic analysis: motivation for use, potential benefits, potential harms, recommendations to guide consumers and need for research. The authors of these documents described more potential harms than benefits, but, although some stated that direct to consumer testing should be actively discouraged, others supported consumer rights to make autonomous choices. Further research into the impact of direct to consumer testing on health services and consumers is required to inform policies.

An association of lower serum citrulline levels within 30 days of acute rejection in patients following small intestine transplantation.

INTRODUCTION: In a prospective protocol we studied whether serum citrulline level within 30 days of an acute rejection was predictive of the episode. METHODS: An acute rejection episode was defined as the date of occurrence of any biopsy-proven rejection in which treatment was initiated until two successive biopsies showed no further rejection. We compared the mean citrulline level based on values determined within 30 days of the start of an acute rejection episode with the mean citrulline level measured on the same patient during a rejection-free period. Serum citrulline measurements were available immediately prior to the occurrence of rejection for 22 patients who experienced 37 episodes. RESULTS: For the 12 episodes of mild rejection, the mean serum citrulline level +/- SE (standard error) was 15.0 + 2.3 micromol/L prior to rejection and 18.8 +/- 2.4 micromol/L during the rejection-free periods. A paired t test of the mean differences was not significant (P = 17). For the 25 episodes of moderate or severe rejection, the mean serum citrulline level was 12.4 +/- 1.1 micromol/L before rejection and 18.8 +/- 2.0 micromol/L during the rejection-free periods. A paired t test of the mean difference was statistically significant (P = .002). CONCLUSIONS: Although further study of citrulline as a marker for the early detection of acute rejection episodes is needed, our hope is that its use will help to prevent some of these early episodes from evolving into full-blown moderate or severe grades of rejection.

The minimal clinically important difference of the Carpal Tunnel Syndrome Symptom Severity Scale.

PURPOSE: To identify the change score in the Symptom Severity Scale (SSS) of the Carpal Tunnel Syndrome (CTS) Questionnaire that is associated with an important change in clinical status. METHODS: Twenty-eight patients with CTS treated with a carpal tunnel steroid injection completed the Brigham and Women's Hospital CTS Questionnaire before steroid injections and at the 3-week follow-up visit. Satisfaction was determined by postcare review of the clinical management. To calculate the minimal clinically important difference, receiver operating characteristic curves were created. The area under the curve was calculated to determine and compare the responsiveness of the entire SSS and the pain and sensory questions in isolation. RESULTS: The SSS of the CTS Questionnaire, including its pain and sensory domain, can show a meaningful clinical improvement after carpal tunnel injection. The SSS, its sensory domain, and its pain domain were statistically better than chance. All 3 measures showed predictive ability; however, the total SSS was the most sensitive in detecting a change. The minimal clinically important difference in the score of the SSS after carpal tunnel steroid injection was found to be 1.04. CONCLUSIONS: The SSS can be used to distinguish a clinically important change after carpal tunnel injection. A decrease of 1.04 or more in the SSS score may indicate a clinically important change in a patient's state of health. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic, Level I.

Pilot study of correlation of pulp stones with cardiovascular disease.

We propose that calcification of dental pulp may have a similar pathogenesis as calcified atheromas and could lead to use of routine dental radiographs as a rapid screening method for early identification of potential cardiovascular disease (CVD). Fifty-five dental patients ages 20 to 55 were chosen because pulp stones in pulpally noninflamed teeth were not expected in this age group. They completed a questionnaire regarding their CVD status and that of their parents and siblings. Entry criteria included at least one asymptomatic, minimally restored, noncarious molar and no history of gout, renal disease, or renal lithiasis. Patients' periapical radiographs of record were viewed to determine the presence of pulp stones. There was a significant relationship between pre-existing CVD and pulp stones (odds ratio of 4.4 with a 95% confidence interval of 1.1, 18.7), but no relationship was found for family history of CVD and pulp stones (odds ratio of 1.7 with a 95% confidence interval of 0.5, 5.5). Seventy-four percent (14/19) of patients with reported CVD had detectable pulp stones while only 39% (14/36) of patients without a history of CVD had pulp stones. This pilot study demonstrates that patients with CVD have an increased incidence of pulp stones in teeth with noninflamed pulps compared to patients with no history of CVD. No relationship was found between presence of pulp stones and family history of CVD. The findings suggest that dental radiographic determination of the presence or absence of pulp stones may have possibilities for use in CVD screening.

Computer-assisted cognitive therapy for depression: maintaining efficacy while reducing therapist time.

OBJECTIVE: The aim of this investigation was to compare the efficacy of computer-assisted cognitive therapy against standard cognitive therapy and a control group without treatment for outpatients with nonpsychotic major depressive disorder. METHOD: Medication-free participants (N=45) with major depressive disorder were randomly assigned to cognitive therapy (N=15), computer-assisted cognitive therapy (N=15), or a wait list (N=15). Both active treatments consisted of nine sessions over 8 weeks. Therapist time was reduced after the first visit for computer-assisted cognitive therapy, with 25-minute sessions rather than 50-minute sessions. Assessments were completed pretreatment, after 4 and 8 weeks of therapy, and 3 and 6 months posttreatment. RESULTS: Computer-assisted cognitive therapy and standard cognitive therapy were superior to the wait list control group for treatment of depression and did not differ from each other on the primary outcome variables. Very large between-group effect sizes were observed. Improvement in depression for both computer-assisted cognitive therapy and standard cognitive therapy was maintained at the 3- and 6-month follow-up evaluations. Computer-assisted cognitive therapy had more robust effects, relative to being wait-listed, than standard cognitive therapy in reducing measures of cognitive distortion and in improving knowledge about cognitive therapy. CONCLUSIONS: A multimedia, computer-assisted form of cognitive therapy with reduced therapist contact was as efficacious as standard cognitive therapy. Computer-assisted therapy could decrease costs and improve access to cognitive therapy for depression.

The influence of water storage on durometer hardness of 5 soft denture liners over time.

PURPOSE: This laboratory study investigated the influence of water storage on the durometer hardness of 2 RTV and 3 HTV soft denture liners over a 1-year period. MATERIALS AND METHODS: Five soft denture liners were used: 2 HTV silicone rubber (Luci-Sof and Molloplast-B), 1 RTV silicone rubber (Tokuyama), 1 HTV polyphosphazene (Novus), and an RTV plasticized acrylic (PermaSoft) that uses a surface sealer. They were processed following manufacturers' instructions, cured, and stored in tap water at 37 degrees C. The water was changed every 2 weeks. Five durometer A hardness measurements were made at logarithmically spaced intervals of 16.7 minutes, 27.8 hours, 11.6 days, 34.7 days, 115 days, and 347 days. Repeated measures analysis of variance (MANOVA), one-way analysis of variance (ANOVA), Pillai trace statistic, the difference scores (last-first) among the groups, and the Tamhane T2 multiple comparison test were used to compare the groups over time, all on SPSS V. 7.5 and 9.0. RESULTS: The order of highest initial indentation hardness was Luci-Sof, Molloplast-B, Novus (H(D)= 38 to 33). Tokuyama and PermaSoft as a group were softer (H(D)= 18 to 22). Tokuyama Soft Relining changed the least over 347 days, followed by Luci-Sof, Novus, Molloplast-B, and PermaSoft in that order (p < or = 0.05). Within the PermaSoft group, sealer applied only once changed the least over 347 days, followed by no sealer, and then sealer applied every month (p < 0.0005). CONCLUSIONS: After 347 days of water storage, Tokuyama had the lowest indentation hardness changes, followed by Luci-Sof, Novus, PermaSoft with sealer applied once; Molloplast-B, PermaSoft without sealer; and PermaSoft with sealer applied every month. All HTV soft denture liners had higher indentation hardness than RTV liners initially. After 347 days, PermaSoft without sealer and with sealer every month became the hardest.

What is the pathogenesis of acne?

For a long time, the mantra of acne pathogenesis debates has been that acne vulgaris lesions develop when (supposedly largely androgen-mediated) increased sebum production, ductal hypercornification, and propionibacteria come together with local inflammatory process in the unlucky affected individual. And yet, the exact sequence, precise interdependence, and choreography of pathogenic events in acne, especially the 'match that lights the fire' have remained surprisingly unclear, despite the venerable tradition of acne research over the past century. However, exciting recent progress in this--conceptually long somewhat stagnant, yet clinically, psychologically, and socioeconomically highly relevant--everyday battlefield of skin pathology encourages one to critically revisit conventional concepts of acne pathogenesis. Also, this provides a good opportunity for defining more sharply key open questions and intriguing acne characteristics whose underlying biological basis has far too long remained uninvestigated, and to emphasize promising new acne research avenues off-the-beaten-track--in the hope of promoting the corresponding development of innovative strategies for acne management.

Switching depot antipsychotic drug responders to oral olanzapine.

In an open-label study, 13 patients taking depot antipsychotic medication for greater than 3 years were switched to oral olanzapine. The first 3-month experience has been previously reported. We now describe a second 3-month experience and integrate our observations into a cumulative 6-month report. Monthly, we assessed patients using clinical ratings [Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning (GAF), Mini-Mental State Exam (MMSE), and Clinical Global Improvement Scale (CGI)] and side effect parameters [Abnormal Involuntary Movement Scale (AIMS), Association for Methodology and Documentation in Psychiatry psychotropic side effect rating scale (AMDP-5), and weights]. Olanzapine patients showed statistically significant improvement (baseline to endpoint sixth month) in GAF (p=0.015), MMSE (p=0.022), CGI improvement, and AIMS (p=0.038). There was no statistically significant change in PANSS, CGI severity, or AMDP-5 overall side effects. Weight gain over 6 months averaged 8.9 lb. All patients completed the study. Compliance was estimated at 90%, and 81% of patients chose to continue on the oral olanzapine. One patient was hospitalized at the conclusion of the study. Our findings suggest that clinicians may consider oral olanzapine as a viable alternative to depot antipsychotic medications, balancing clinical improvement in some clinical measures with lack of improvement in other clinical measures; and balancing improvement in abnormal involuntary movements with weight gain and its sequelae.

Effect of multi-adhesive layering on retention of extraoral maxillofacial silicone prostheses in vivo.

STATEMENT OF PROBLEM: Loss of retention of maxillofacial prostheses often makes the margin visible or the prosthesis dislodge. Using several medical adhesives in combination may improve retention. PURPOSE: The purpose of this study was to investigate the effect of single- and multi-adhesive layering of 2 adhesives on the retention of maxillofacial silicone elastomer strips adhered to the skin of human forearms using a peel test. MATERIAL AND METHODS: Power analysis from a previous study and a pilot trial specified at least 20 subjects. Eight Silastic Adhesive A/MDX4-4210 silicone rubber strips (N=240) were applied in a predetermined random order to the left and right ventral forearms of 30 IRB-approved human subjects. Skin-Prep Protective Dressing was applied. Secure 2 Medical Adhesive (SMA) and Epithane-3 (E3) adhesive were used alone or as SMA/E3 or E3/SMA sandwiches (from skin to prosthesis) to adhere strips. Strips were peeled 6 hours later in a universal testing machine at 10 cm/min and data reported in N/m. Paired t tests were used to evaluate left and right arm differences. A Friedman test for nonparametric correlated data with within-subject design was performed, determining differences between both adhesives singly and in combination (alpha=.05). RESULTS: Tests of left-right differences were insignificant ( P =0.43), so the data from both arms were combined. Many strips with E3 did not adhere before testing and were counted as 0 adhesion. Median peel strengths (and 25th and 75th percentiles) in N/m were: SMA = 76.1 (47.1-107), E3 = 6.75 (0.0-25.9), SMA/E3 = 107 (78.0-132), and E3/SMA= 19.6 (6.99-42.4). All 4 variables were significantly different ( P <.0005). CONCLUSION: The multi-adhesive combination of SMA/E3 had the highest adhesion, followed, in order, by SMA alone, E3/ SMA, and E3 alone. Both E3 groups left a difficult-to-remove residue on the skin. SMA/E3 left a halo-like residue on the skin at the periphery of the strips from the E3 leaking around the SMA. SMA remained adherent to the prosthetic material.