A descriptive and follow-up study of 40 parricidal patients hospitalized in a French secure unit over a 15-year period.

Parricide is rare and represents 3% of all homicides in France, and 4% of resolved homicides in North America. Consequently, related international literature is sparse, especially concerning the evolution of offenders, and most studies concern small samples or anecdotal cases. We wished to identify the main characteristics of parricidal subjects and their victims, and to assess the socioclinical evolution of the offenders after the assault. To this end, we first studied the sociodemographic, clinical and forensic characteristics of all parricidal patients admitted to France's Henri Colin secure unit between 1996 and 2010 (40 patients). We also assessed the evolution of the 36 patients who had left the secure unit, using questionnaires sent to the psychiatric hospitals where the patients were transferred. We found most offenders to be men (97.5%), with a mean age of 28 years, who were mostly single, unemployed, living with the victim prior to the assault (77.5%), and with a history of psychiatric disorder (72.5%). The population of offenders also displayed an overrepresentation of schizophrenia (87.5%), significant toxic exposure and criminal or violent history. Some patients had attempted suicide before or right after the offense. The assault was mostly committed in the parent's house with an edged weapon, and was characterized by brutality and lack of premeditation. Precipitating factors included substance use and cessation of psychotropic medication. Matricide was more frequent than patricide. At the time of this study, half of the parricidal patients were working or attending therapeutic activities, and most were actively keeping in contact with their family, living as compliant outpatients with no signs of violent behavior. The results of our study on 40 parricidal patients are consistent with data in the literature. With regard to sample evolution, family and community reintegration was relatively effective considering the seriousness of the offense. Several biases in our study disallow the generalization of these findings, and further studies are needed.

The effect of anaesthetic agents on induction, recovery and patient preferences in adult day case surgery: a 7-day follow-up randomized controlled trial.

BACKGROUND AND OBJECTIVE: To compare induction, pre- and post-discharge recovery characteristics and patient preferences between four anaesthetic regimens in adult day-surgery. METHODS: Randomized controlled trial. In all, 1158 adults assigned to: propofol induction and maintenance, propofol induction with isoflurane/N2O, or sevoflurane/N2O maintenance, or sevoflurane/N2O alone. We prospectively recorded induction and pre-discharge recovery characteristics, collected 7-day post-discharge recovery characteristics using patient diaries and patient preferences by telephone follow-up. RESULTS: Recruitment rate was 73%--of the 425 refusals, 226 were not willing to risk a volatile induction. During induction, excitatory movements and breath holding were more common with sevoflurane only (P < 0.01). Injection pain and hiccup were more common with propofol induction (P < 0.01). In the recovery room and the postoperative ward, both nausea and vomiting were more common with sevoflurane only (P < 0.01). This difference disappeared within 48 h. There was no difference between groups in the mental state on awakening, recovery time, time to discharge or overnight admissions; then was also no difference in pain between the four groups for each of the seven postoperative days (P < 0.01), nor any differences in concentration or forgetfulness. Patients took 6.5 days (95% CI: 6.0-7.0, n = 693) to resume normal activities. Patients who received sevoflurane only were more likely to recall an unpleasant induction and least likely to want the same induction method again (P < 0.01). CONCLUSION: Differences in outcome between the four regimens are transient; sevoflurane is not an ideal sole agent for adult day case anaesthesia and, in this setting, patients base their preferences for future anaesthetics on the method of induction.

Are GP practice prescribing rates for coronary heart disease drugs equitable? A cross sectional analysis in four primary care trusts in England.

STUDY OBJECTIVE: To analyse the associations between proxies of healthcare need and GP practice prescribing rates for five major coronary heart disease (CHD) drug groups. DESIGN: Cross sectional secondary analysis. SETTING: Four primary care trusts (PCTs 1-4) in the north west of England, encompassing 132 GP practices. RESULTS: Prescribing rates were generally positively associated with the percentage of patients aged 55-74 years and PASS-PUs (regionally specific prevalence, age, and sex standardised prescribing units). However, the percentage of patients aged over 75 years showed a lack of association with prescribing rates in all PCTs other than PCT2. Correlations with the proportion of South Asian patients were generally negative, particularly in PCT2, PCT4, and the combined dataset. There was a general lack of association with deprivation proxies and SMRs for CHD, although there were negative associations with both variables in PCT4 and the combined dataset. Scatter plots showed that GP practices with similar prescribing rates had widely differing levels of comparative healthcare need, and GP practices with similar levels of healthcare need had widely differing prescribing rates. CONCLUSION: GP prescribing rates in some PCTs were negatively associated with proxies of healthcare need based on patient age (patients aged over 75 years), ethnicity, levels of deprivation, and SMRs for CHD. As such, this study suggests that prescribing rates in these PCTs may be inequitable as they are not positively associated with healthcare need. This study may form the baseline for further studies to assess the effectiveness of the NSF for CHD in reducing the inequities in prescribing rates.

Clinical and economic choices in anaesthesia for day surgery: a prospective randomised controlled trial.

We compared the cost-effectiveness of general anaesthetic agents in adult and paediatric day surgery populations. We randomly assigned 1063 adult and 322 paediatric elective patients to one of four (adult) or two (paediatric) anaesthesia groups. Total costs were calculated from individual patient resource use to 7 days post discharge. Incremental cost-effectiveness ratios were expressed as cost per episode of postoperative nausea and vomiting (PONV) avoided. In adults, variable secondary care costs were higher for propofol induction and propofol maintenance (propofol/propofol; p < 0.01) than other groups and lower in propofol induction and isoflurane maintenance (propofol/isoflurane; p < 0.01). In both studies, predischarge PONV was higher if sevoflurane/sevoflurane (p < 0.01) was used compared with use of propofol for induction. In both studies, there was no difference in postdischarge outcomes at Day 7. Sevoflurane/sevoflurane was more costly with higher PONV rates in both studies. In adults, the cost per extra episode of PONV avoided was pound 296 (propofol/propofol vs. propofol/ sevoflurane) and pound 333 (propofol/sevoflurane vs. propofol/isoflurane).

Propofol and halothane versus sevoflurane in paediatric day-case surgery: induction and recovery characteristics.

BACKGROUND: The aim of this study was to compare the induction and recovery characteristics associated with propofol induction and halothane maintenance with sevoflurane anaesthesia in paediatric day surgery. METHODS: In total, 322 children were assigned randomly to i.v. propofol induction and halothane/nitrous oxide maintenance or sevoflurane/nitrous oxide alone. The patients' age, sex, and type of surgery were recorded, as were the times required for anaesthetic induction, maintenance, recovery and time to discharge home. Postoperative nausea and vomiting, and the incidence of adverse events during induction and recovery were also noted. RESULTS: No significant differences were detected in age, sex, type of surgery performed or intraoperative opioid administration. Excitatory movement was more common during induction with sevoflurane. The mean time required for induction with propofol was 3.1 min compared with 5 min in the sevoflurane group (P<0.001). The recovery time was shorter in the sevoflurane group compared with propofol/halothane (23.2 vs 26.4 min, P<0.002). The incidence of delirium in recovery was greater in the sevoflurane group (P<0.001). There was no difference between groups in the time spent on the postoperative ward before discharge home. On the postoperative ward the incidence of both nausea and vomiting was significantly higher in the sevoflurane group (P=0.034). Five children were admitted to hospital overnight, none for anaesthetic reasons. CONCLUSIONS: The increased incidence of adverse events during induction, postoperative nausea and vomiting and postoperative delirium in the sevoflurane group suggests that sevoflurane is not ideal as a sole agent for paediatric day case anaesthesia.

Developing prevalence-based prescribing units for analysing variations in general practitioner prescribing: a case study using statins.

OBJECTIVE: To develop regionally specific prevalence-, age- and sex-standardized prescribing units (PASS-PUs) and to relate these to statin prescribing. DESIGN: Cross-sectional. SETTING: Ninety-four general practitioner (GP) practices within one health authority in the north-west of England. MAIN OUTCOME MEASURES: Comparisons between specific therapeutic group age-sex-related prescribing units (STAR-PUs) and PASS-PUs for statin prescribing. RESULTS: STAR-PUs and PASS-PUs were calculated for all GP practices and there was a high degree of correlation (Spearman's rank coefficient 0.88; P < 0.001). Using actual prescribing data for statins for a 12-month period, a statistically significant correlation was found between net ingredient cost per patient and STAR-PUs per patient (Spearman's rank coefficient 0.36; P < 0.01). However, the correlation between average daily quantities per patient and PASS-PUs per patient was not statistically significant. A scatter plot revealed a pattern whereby GP practices with high proportions of patients aged over 75 years exhibited low statin prescribing in relation to the expected prevalence of treated coronary heart disease (CHD) in their patient population. CONCLUSIONS: Low weightings for patients aged over 75 years in calculating STAR-PUs lead to a much lower number of prescribing units within GP practice populations when compared with PASS-PUs. Current statin prescribing across GP practices in this study correlates with national prescribing cost patterns (as measured by STAR-PUs) although not with expected prevalence of treated CHD (as measured by PASS-PUs). PASS-PUs reflect prevalence of treated CHD and may therefore be used to monitor and predict GP prescribing arising from the implementation of the National Service Framework targets for CHD. In addition, PASS-PUs maybe derived for a wide range of therapeutic areas.

Screening for cognitive impairment in older African-Caribbeans.

BACKGROUND: There are increasing numbers of older African-Caribbeans in the United Kingdom. Screening instruments are commonly used in the detection of cognitive impairment, but have not been assessed within this population. This study aimed to develop culturally modified versions of screening instruments for cognitive impairment (Mini-Mental State Examination (MMSE) and Abbreviated Mental Test (AMT)) and to determine their sensitivity and specificity in the diagnosis of dementia. METHODS: The instruments were modified using a process involving a community group of African-Caribbeans and an academic group of health professionals. They were used in a two-stage study involving community resident African-Caribbeans aged 60 years or over in inner-city Manchester, comparing the screening instruments against a computerized diagnostic interview. RESULTS: One hundred and thirty people completed the study. The results for the largest subgroup, the Jamaicans (N = 96) were analysed. Effects of gender, age and education on the MMSE and AMT scores were evaluated. The correlations between the screening instruments and diagnostic interview were highly significant (P < 0.001). At appropriate cut-offs both screening instruments demonstrated high sensitivity and acceptable specificity levels. CONCLUSIONS: A defined process with lay input has assisted in producing culturally modified versions of the MMSE and AMT that perform well compared with a diagnostic interview, if an appropriate cut-off is used. They are easy to administer and acceptable to older African-Caribbean people. The results need to be viewed within the limitations of the current study.

Validating screening instruments for cognitive impairment in older South Asians in the United Kingdom.

BACKGROUND: The numbers of older South Asians in the United Kingdom are rising. Investigation of their mental health has been neglected compared to their physical health. OBJECTIVES: This study aimed to determine the sensitivity and specificity of modified versions of two screening instruments for cognitive impairment (Mini-Mental State Examination and Abbreviated Mental Test) in a community-based population. DESIGN: Two-stage study comparing screening instruments against diagnostic interview. SETTING: South, central and north Manchester. SUBJECTS: Community-resident South Asians aged 60 years and over. METHODS: Subjects were approached via their general practitioners and interviewed at home. Sensitivity and specificity for the screening instruments were calculated using receiver operating characteristic (ROC) curve analysis. RESULTS: For the Gujarati population, the MMSE cutoff was >/=24 (sensitivity 100%, specificity 95%) and AMT>/=6 (sensitivity 100%, specificity 95%). For the Pakistani population, the MMSE cutoff was >/=27 (sensitivity 100%, specificity 77%) and AMT>/=7 (sensitivity 100%, specificity 87%). CONCLUSIONS: Culturally modified versions of the Mini-Mental State Examination and Abbreviated Mental Test are acceptable and may have a high degree of sensitivity. They may assist with the recognition of cognitive impairment, if an appropriate cutoff is used.

Screening for depression in African-Caribbean elders.

BACKGROUND: There are increasing numbers of older African-Caribbeans in the UK. Primary care staff often feel less confident about diagnosing depression in this group. Screening instruments may assist in making diagnoses in cross-cultural consultations. OBJECTIVE: We aimed to determine the sensitivity and specificity of screening instruments for depression in older African-Caribbean people in Manchester, UK. METHODS: We carried out a two-stage study to compare three screening instruments for depression (Geriatric Depression Scale, Brief Assessment Schedule Depression Cards, Caribbean Culture Specific Screen), with a computerized diagnostic interview for mental health disorders in older adults (Geriatric Mental State). The study was set in inner-city Manchester. The subjects were community-resident African-Caribbeans aged 60 years and over; 227 subjects were approached. Of the 160 people screened, 130 agreed to diagnostic interview. The main outcome measures were Spearman correlation coefficients; these were calculated between each screening instrument and the diagnostic interview. Receiver-operating characteristic (ROC) curve analysis was used to determine appropriate sensitivity and specificity for each instrument. RESULTS: The results for the largest subgroup, the Jamaicans (n = 96/130), demonstrated highly significant correlations between screening instruments and diagnostic interview (P < 0.001). Each instrument had a high sensitivity: Brief Assessment Schedule depression cards (cut-off > or =6; sensitivity 90.9% (95% CI 58.8-99.8), specificity 82.1% (95% CI 74.0-90.3)), Caribbean Culture Specific Screen (cut-off > or =6; sensitivity 90.9% (95% CI 58.8-99.8), specificity 74.1% (95% CI 64.8-83.4)), and Geriatric Depression Scale (cut-off > or =4; sensitivity 100% (95% CI 97.1-100), specificity 69.1% (95% CI 59.6-79.2)). CONCLUSIONS: These screening instruments demonstrate high sensitivity levels, if an appropriate cut-off point is used. The culture-specific instrument did not perform better than the traditional instruments. Health professionals should approach the consultation in a culturally sensitive manner and use the validated instrument they are most familiar with.

Interventions to increase breast screening uptake: do they make any difference?

BACKGROUND: Breast screening has an important role in improving survival from breast cancer through early detection and treatment. Increasing uptake of screening in areas of low uptake is important in improving the effectiveness of the national screening programme. This review looks at which initiatives to boost uptake have been successful. OBJECTIVE: To evaluate the effectiveness of the different interventions to increase breast screening uptake. METHOD: A systematic review of interventions to promote breast screening uptake was undertaken. Studies were included if uptake was used as an outcome measure of the intervention and if relevant to the UK screening programme. RESULTS: Twenty eight studies were found among 25 citations. Interventions were grouped into "person directed", "system directed", "social network directed", and "multistrategy" categories. Most were person directed. These interventions were more likely to be effective in boosting uptake, be simple in design, and to have been evaluated by a randomized trial design. Evidence of effectiveness in the other groups is limited both by the number of studies and the study designs. A summary of the interventions reviewed is presented. CONCLUSIONS: Simple, brief, and effective interventions exist to boost breast screening uptake. More complicated approaches are not necessarily any more effective. These findings also have implications for other population based screening programmes of the future. In inner city areas the best approach to raising uptake rates is likely to be multistrategy.

Screening for abdominal aortic aneurysm: a computer assisted cost-utility analysis.

OBJECTIVES: To evaluate the effects of introducing routine ultrasonic screening for the identification and elective surgical treatment of abdominal aortic aneurysms (AAA) at high risk of rupture in the U.K. population of men aged 65-74 years. DESIGN: A computer assisted simulation of an AAA screening programme. The simulation incorporated assumptions gleaned from the literature about the epidemiology of AAA and the costs of screening. In addition, up-to-date costings based on recent Manchester (U.K.) vascular surgery experience are used. SETTING: A dialogue between National Health Service commissioners and providers to explore the feasibility and desirability of introducing AAA screening. CHIEF OUTCOME MEASURE: Cost per quality adjusted life year (QALY) gained. MAIN RESULTS: The absolute cost (circa 1992/3) per QALY gained from screening for and treating aneurysms of > or = 6 cm in diameter of pounds 1500 (benefit not discounted). Offsetting current treatment costs of ruptured aneurysms gives a net additional cost per QALY of pounds 1300. Screening and treating aneurysms of > or = 5 cm leads to a cost per QALY gained exceeding pounds 20000. The findings are robust under sensitivity analysis. CONCLUSIONS: Routine screening for AAAs of size > or = 6 cm compares favourably in terms of cost per QALY gained with services such as breast and cervical cancer screening.

Hearing aids: value for money and health gain.

BACKGROUND: The aim of this study was to assess the ability of hearing aids to reduce the handicap associated with hearing impairment in adults. METHODS: Fifty adults aged over 60 who were supplied with an NHS hearing aid had their hearing handicap and communication function recorded at initial hearing aid assessment, and after three months of aid use. Hearing communication function was assessed by a key informant. RESULTS: Hearing aid use was associated with considerable score improvements for social and emotional function [20.5, 95 per cent confidence interval (Cl) 15.4-25.6] and communication function (22.9, 95 percent Cl 14.6-31.2). Younger people recorded the greatest reduction in handicap. Overall satisfaction with hearing aid performance was high. CONCLUSIONS: Hearing aids are effective in reducing hearing handicap in adults. They represent a good buy for purchasers seeking to achieve health gain for adults with hearing impairment.

Response by women aged 65-79 to invitation for screening for breast cancer by mammography: a pilot study.

OBJECTIVE: To determine whether there is sufficient benefit to be gained by offering screening for breast cancer with mammography to women aged 65-79, who are not normally invited for screening. DESIGN: Pilot study of women eligible for screening but not for personal invitation. The results of this study were compared with the results of routinely screened younger women (aged 50-64) from the same general practice. SETTING: One group general practice in south Manchester. PATIENTS: The 631 women aged 65-79 on the practice list. A total of 42 (7%) were excluded by the general practitioner, and 22 (4%) invitation letters were returned by the post office. MAIN OUTCOME MEASURES: Response rates to invitation for screening assessed by three indices: crude population coverage ratio, crude invited population coverage ratio, and corrected invited population coverage ratio. RESULTS: 344 Patients aged 65-79 (61% of those invited, excluding those who could not be traced) were screened compared with 77% of women aged 50-64. The three response indices were higher for younger women than older: crude population coverage ratio = 66.5%, crude invited population coverage ratio = 69.3%, corrected invited population coverage ratio = 76.8% for women aged 50-64, compared with 54.5%, 58.4%, and 60.7% respectively for women aged 65-79. All four biopsies done in the older women gave positive results, giving a cancer detection rate of 11.6/1000 compared with 4.1/1000 among younger women. CONCLUSIONS: These results show that there is a potential for high attendance at routine screening by older women if they are invited in the same way as younger women. If these results are found elsewhere the costs and benefits of screening older women should be reassessed.

Would a healthier population consume fewer health service resources? A life-table analysis using hospital in-patient enquiry (HIPE) bed-usage statistics as a proxy for hospital treatment costs.

The long-term effects upon acute-care hospital costs of reductions of morbidity and mortality from various causes are explored. The daily number of beds used per million population for all diagnostic categories is suggested as a proxy measure of hospital costs. An index of lifetime bed usage for a hypothetical cohort of persons living out their lives under specified age-specific mortality and morbidity patterns is derived. Examples of the application of this index are given for differing assumptions about mortality and morbidity in males. It is shown that reducing ischaemic heart disease or cancer morbidity will lead to increased overall hospital costs whereas reductions in the rate of occurrence of accidents, injuries and poisonings would reduce overall costs. The assumptions underlying the use of the index are discussed and extensions to the population model are proposed.

Analysis of secular trends in surgery for glue ear in the North Western Region (1975-1984).

Hospital Activity Analysis (HAA) data relating to operations for glue ear and tonsillectomy performed on residents of the North Western Region, aged 0-9 years during the period 1975-1984 were studied. The rate of surgery for glue ear has risen from 45/10,000 to 107/10,000 representing an increase of 137 per cent. The tonsillectomy rate by comparison has undergone a more modest increase of 19 per cent. The study casts doubt on a 'vacuum effect', as has been argued by Black. Marked variation in rates of surgery between Districts in the Region were noted, and the possible explanations discussed. A review of the literature revealed considerable controversy concerning the management of glue ear and the need for a definitive trial is highlighted.