Spurious elevation of serum potassium concentration measured in samples with thrombocytosis.

BACKGROUND: Several factors that can lead to falsely elevated values of serum. Thrombocytosis is one of these factors, since breakage or activation of platelets during blood coagulation in vitro may lead to spurious release of potassium. The purpose of the study was to evaluate to which extent the platelet count may impact on potassium in both serum and plasma. METHODS: The study population consisted of 42 subjects with platelets values comprised between 20 and 750×109/L. In each sample potassium was measured in both serum and plasma using potentiometric indirect method on the analyzer Modular P800 (Roche, Milan, Italy). Platelet count was performed with the hematological analyzer Advia 120 (Siemens, Milano, Italy). RESULTS: Significant differences were found between potassium values in serum and in plasma. A significant correlation was also observed between serum potassium values and the platelet count in whole blood, but not with the age, sex, erythrocyte and leukocyte counts in whole blood. No similar correlation was noticed between plasma potassium and platelet count in whole blood. The frequency of hyperkalemia was also found to be higher in serum (20%) than in plasma (7%) in samples with a platelet count in whole blood >450×109/L. CONCLUSIONS: The results of this study show that platelets in the biological samples may impact on potassium measurement when exceeding 450×109/L. We henceforth suggest that potassium measurement in plasma may be more accurate than in serum, especially in subjects with thrombocytosis.

The effectiveness and cost-effectiveness of diversion and aftercare programmes for offenders using class A drugs: a systematic review and economic evaluation.

BACKGROUND: The societal costs of problematic class A drug use in England and Wales exceed £15B; drug-related crime accounts for almost 90% of costs. Diversion plus treatment and/or aftercare programmes may reduce drug-related crime and costs. OBJECTIVES: To assess the effectiveness and cost-effectiveness of diversion and aftercare for class A drug-using offenders, compared with no diversion. POPULATION: Adult class A drug-using offenders diverted to treatment or an aftercare programme for their drug use. INTERVENTIONS: Programmes to identify and divert problematic drug users to treatment (voluntary, court mandated or monitored services) at any point within the criminal justice system (CJS). Aftercare follows diversion and treatment, excluding care following prison or non-diversionary drug treatment. DATA SOURCES: Thirty-three electronic databases and government online resources were searched for studies published between January 1985 and January 2012, including MEDLINE, PsycINFO and ISI Web of Science. Bibliographies of identified studies were screened. The UK Drug Data Warehouse, the UK Drug Treatment Outcomes Research Study and published statistics and reports provided data for the economic evaluation. METHODS: Included studies evaluated diversion in adult class A drug-using offenders, in contact with the CJS. The main outcomes were drug use and offending behaviour, and these were pooled using meta-analysis. The economic review included full economic evaluations for adult opiate and/or crack, or powder, cocaine users. An economic decision analytic model, estimated incremental costs per unit of outcome gained by diversion and aftercare, over a 12-month time horizon. The perspectives included the CJS, NHS, social care providers and offenders. Probabilistic sensitivity analysis and one-way sensitivity analysis explored variance in parameter estimates, longer time horizons and structural uncertainty. RESULTS: Sixteen studies met the effectiveness review inclusion criteria, characterised by poor methodological quality, with modest sample sizes, high attrition rates, retrospective data collection, limited follow-up, no random allocation and publication bias. Most study samples comprised US methamphetamine users. Limited meta-analysis was possible, indicating a potential small impact of diversion interventions on reducing drug use [odds ratio (OR) 1.68, 95% confidence interval (CI) 1.12 to 2.53 for reduced primary drug use, and OR 2.60, 95% CI 1.70 to 3.98 for reduced use of other drugs]. The cost-effectiveness review did not identify any relevant studies. The economic evaluation indicated high uncertainty because of variance in data estimates and limitations in the model design. The primary analysis was unclear whether or not diversion was cost-effective. The sensitivity analyses indicated some scenarios where diversion may be cost-effective. LIMITATIONS: Nearly all participants (99.6%) in the effectiveness review were American (Californian) methamphetamine users, limiting transfer of conclusions to the UK. Data and methodological limitations mean it is unclear whether or not diversion is effective or cost-effective. CONCLUSIONS: High-quality evidence for the effectiveness and cost-effectiveness of diversion schemes is sparse and does not relate to the UK. Importantly this research identified a range of methodological limitations in existing evidence. These highlight the need for research to conceptualise, define and develop models of diversion programmes and identify a core outcome set. A programme of feasibility, pilot and definitive trials, combined with process evaluation and qualitative research is recommended to assess the effectiveness and cost-effectiveness of diversionary interventions in class A drug-using offenders. FUNDING DETAILS: The National Institute for Health Research Health Technology Assessment programme.

Longitudinal trends in using physical interventions to manage aggression and self-harm in mental health services.

OBJECTIVES: Repetitive aggression by a patient receiving mental health inpatient care is likely to elicit various patterns of response from care staff over time. This study sought to examine patterns of coercive physical intervention in relation to repeated episodes of aggression by particular patients. METHODS: A data set of 9,945 aggression and self-harm incidents over a five-year period in one mental health service in England was constructed. Incidents by a specific individual were categorized according to their position in a sequence (first, second, and so on) and by the use of physical intervention by staff to manage the incident. RESULTS: Trends in the use of physical intervention varied across settings. There was a significant tendency in general (nonforensic) services for use of physical intervention to increase in response to physical aggression (physical intervention in first versus subsequent incidents: odds ratio [OR]=.69, 95% confidence interval [CI]=.54-.90) and to decrease in response to threats (physical intervention in first threat versus subsequent threats: OR=1.62, CI=1.09-2.39). CONCLUSION: There were significant trends over time in the use of physical intervention to manage violence and self-harm. However, the dynamics behind this finding will remain unclear without further research.

IL-37: a new anti-inflammatory cytokine of the IL-1 family.

The IL-1 family of cytokines encompasses eleven proteins that each share a similar ß-barrel structure and bind to Ig-like receptors. Some of the IL-1-like cytokines have been well characterised, and play key roles in the development and regulation of inflammation. Indeed, IL-1α (IL-1F1), IL-1ß (IL-1F2), and IL-18 (IL-1F4) are well-known inflammatory cytokines active in the initiation of the inflammatory reaction and in driving Th1 and Th17 inflammatory responses. In contrast, IL-1 receptor antagonist (IL-1Ra, IL-1F3) and the receptor antagonist binding to IL-1Rrp2 (IL-36Ra, IL-1F5) reduce inflammation by blocking the binding of the agonist receptor ligands. In the case of IL-37 (IL-1F7), of which five different splice variants have been described, less is known of its function, and identification of the components of a heterodimeric receptor complex remains unclear. Some studies suggest that IL-37 binds to the α chain of the IL-18 receptor in a non-competitive fashion, and this may explain some of the disparate biological effects that have been reported for mice deficient in the IL-18R. The biological properties of IL-37 are mainly those of down-regulating inflammation, as assessed in models where human IL-37 is expressed in mice. In this review, an overview of the role of IL-37 in the regulation of inflammation is presented. The finding that IL-37 also locates to the nucleus, as do IL-1α and IL-33, for receptor-independent organ/tissue-specific regulation of inflammation is also reviewed.

Self-harm or attempted suicide? Do suicide notes help us decide the level of intent in those who survive?

A suicide note can be a very powerful communication to the family and friends of the deceased. However, in a number of cases a note is written by an individual who survives an apparent act of attempted suicide. These cases will frequently present at a hospital accident and emergency department (A&E) and will be classified as incidents of self-harm. Despite the importance of suicide notes in determining the motivation of people who die by their own hand, research findings have been patchy and ambiguous. This is also true when someone writes a suicide note but survives an act of apparent attempted suicide. In such cases the question is raised whether the person truly intended to complete suicide or whether their actions had some other motivation. This paper seeks to throw some light on this matter by examining the meaning that should be attributed to a suicide note when it has been written by someone who presents at a hospital accident and emergency department after intentionally harming or injuring themselves. More specifically, the study addresses the question whether the presence of a suicide note in such cases is more likely to reflect a serious act of attempted suicide than it is to reflect an act of self-harm with low suicidal intent. Using a large dataset collected over a 5-year period the authors compare note-leavers with self-harm patients who have not written a suicide note, focussing on the presence or absence of other known risk indicators for completed suicide in each of the two patient groups. The aim is to test the hypothesis that patients presenting at A&E with self-harm who have left a suicide note, are at higher risk of future completed suicide than are self-harm presenters who have not left a note. The conclusion reached is that clinical staff in the emergency department should err on the side of caution and regard the presence of a suicide note as an indication of a failed but serious attempt at suicide.

Self-harm patients who take early discharge from the accident and emergency department: how do they differ from those who stay?

There is evidence that patients presenting at a hospital Accident and Emergency (A&E) department with self-harm are considerably more likely than many others to discharge themselves before their assessment or treatment are complete. This paper reports a study that is part of a broader analysis of all self-harm presentations to a hospital A&E department over a five-year period. Self-harm patients who chose to remain for assessment and treatment were compared with those who chose to discharge themselves prematurely. We found a mean proportion of 18% of self-harm patients per annum took early discharge between 1996 and 2000 and noted that these patients were more likely than other self-harm patients to have consumed alcohol in the hours immediately prior to their self-harm and attendance at the hospital. Self-harm patients who took early discharge were less likely than other self-harm patients to be admitted to an in-patient bed and less likely to receive a psychosocial assessment from a mental health specialist. We also found that aftercare arrangements were significantly less likely to be made for those patients who took early discharge. Some suggestions are made about approaches that clinical staff could adopt in order to reduce early discharge in self-harm patients.

Exercise training and heart failure: a systematic review of current evidence.

Chronic heart failure (CHEF) is a growing public health problem. Current guidelines provide detailed information regarding pharmacotherapy but little guidance about the value of exercise/cardiac rehabilitation programmes for individuals with this condition. To investigate the effects of exercise training upon CHF patients, a systematic literature review was carried out of trials (from 1966 to December 2000) which used as their main outcome measures the effects of exercise training upon: (a) physical performance; or (b) quality of life; or (c) morbidity/mortality. Databases searched include: MedLine; Science Citation Index; Social Sciences Citation Index; BIDS, Bandolier; Cochrane Database of Systematic Reviews (CDSR); NHS National Research Register (NRR); and Current Research in Britain (CRIB). Relevant bibliographic references from identified articles were also reviewed. Thirty-one trials were identified, comprising randomised controlled trials (RCTs) (14/31), randomised crossover trials (8/31), non-RCTs (2/31), and pre-test/post-test (7/31). Sample sizes were: 25 participants or fewer (20/31); 26 to 50 participants (7/31); 51 to 150 participants (4/31). Participants were predominantly younger with a mean age in 23/31 studies of 65 years or less, and male. Patients with comorbidities were often excluded. Positive effects were reported on physical performance (27/31), quality of life (11/16), mortality (1/31), and readmission rates (1/31). No cost-effectiveness analyses were identfied. We conclude that short-term physical exercise training in selected subgroups of patients with CHF has physiological benefits and positive effects on quality of life. This review highlights the continuing problem of clinical trials that include participants who are not representative of the general population of CHF patients seen in primary care. Further investigation of the utility and applicability of exercise training is essential.