Evaluation of the Warrior Programme intervention among UK ex-service personnel.

BACKGROUND: Research has shown that of the myriad services available to veterans in the UK, very few have been independently evaluated. This report presents the results of a randomized controlled trial assessing the impact of Time Line Therapy™ delivered by the Warrior Programme (a third-sector organization). AIMS: This study was aimed to determine if the intervention is effective in reducing emotional and functional difficulties in ex-service personnel. METHODS: A mixed-design analysis of variance model was used to investigate whether the Warrior Programme had a statistically significant impact on self-reported scores. The intervention and control group provided data on measures prior to and immediately after the intervention, and at 3-month follow-up. RESULTS: Those in the intervention group (n = 23) reported statistically significant improvements in self-reported scores immediately following intervention: the Clinical Outcomes in Routine Evaluation (CORE) scores (CORE global distress mean difference [MD] = 45.0, 95% confidence interval [CI] 31-60) (CORE subjective well-being MD = 5.9, 95% CI 3.5-8.3) (CORE functioning MD = 16.7, 95% CI 11.4-21.9) (CORE problems/symptoms MD = 19.4, 95% CI 13.1-25.7), general self-efficacy (MD = -9.8, 95% CI -13.6 to -6.8), anxiety (MD = 8.6, 95% CI 5.2-12.1), depression (MD = 10, 95% CI 6.6-13.5), post-traumatic stress disorder (MD = 26.3, 95% CI 17-25) and functional impairment (MD = 11.1, 95% CI 5.3-16.8) over time, compared to the control group (n = 29). However, score improvement was not sustained over time or statistically significant at follow-up. CONCLUSIONS: The Warrior Programme was effective in reducing emotional and functional difficulties in ex-service personnel immediately after the intervention, but the effect was not sustained at 3-month follow-up.

Community-engaged healthcare model for currently under-served individuals involved in the healthcare system.

In the US, many people are excluded from healthcare structures and systems, due to multiple macro and micro factors. Poverty, health ecosystems, mental health, and community amenities are some of the issues confronting those who are not able to access appropriate support. This population is often referred to as 'high needs, high cost' (HNHC), a term that has been applied to refer to people who repeatedly utilize services without significant benefit (we have replaced this term with 'currently under-served'; C-US). For many traditional health solutions may not address the fundamental issues confronting their health. Community-Engaged Healthcare (CEH) is an approach that equips members of the community to levy power to advocate for their own health or social solutions, designing their own interventions to address needs with support from health providers. A realist review was conducted to identify the existing literature around CEH. This yielded ten papers that were reviewed by at least two authors and rated in terms of quality. A model describing the processes underpinning CEH was then iteratively generated, resulting in additional terms that were used in a second review of the literature. A further 16 peer-reviewed articles were identified and were independently reviewed and quality rated. These articles were used to refine further iterations of the model and included in the review where appropriate. The resulting model schematically posits a set of relational factors identified to be important in the establishment of CEH. Notably, the transfer of autonomy and power over health decision-making processes is emphasized, which will require revolutionary thinking about how healthcare is delivered for patients.

Development of a fluid-bed coating process for soil-granule-based formulations of Metarhizium brunneum, Cordyceps fumosorosea or Beauveria bassiana.

AIM: Granule-based products of solid state fermented micro-organisms are available for biocontrol. Because liquid fermentation has several advantages, we investigated fluid-bed coating with liquid fermented biomass. METHODS AND RESULTS: Biomass containing mycelium or mycelium and submerged spores of the entomopathogenic fungi Metarhizium brunneum, Cordyceps fumosorosea and Beauveria bassiana were produced in liquid culture, separated and different biomass concentrations were adjusted. Based on the examined thermo-tolerance, we defined fluid-bed coating adjustments and investigated granule colonization and sporulation on granules. Granule colonization depended on the biomass concentration and strain. For C. fumosorosea and B. bassiana, concentrations of 0·003%dry weight resulted in nearly 100% granule colonization, for M. brunneum with concentrations of 0·7%dry weight in only 50%. The conidiation on granules in sterile soil was highly influenced by the moisture content. Because the granule colonization of M. brunneum was unsatisfactory, we pre-coated nutrients followed by coating with biomass, submerged spores or conidia. Malt extract had a positive effect on the granule colonization for biomass and submerged spores. Furthermore, aerial conidia can also be coated. CONCLUSIONS: Fluid-bed coating of fungal biomass is suitable for the development of granules. SIGNIFICANCE AND IMPACT OF THIS STUDY: With this technology, cost-efficient biocontrol products can be developed.

Three year Experience of Non-Melanoma Skin Cancer in a General Practice.

We report 85 lesions of non-melanoma skin cancer in 58 patients, representing 9% of the minor surgical workload of a single general practitioner. Cases were studied in order to describe pathology, management and outcomes. Eighteen percent of lesions were referred, mainly because of central facial site and larger size. Of the lesions treated in the surgery, all but four were treated surgically. Quantitative margins of lateral and deep excision were reported for 50% and 30% of specimens respectively. Lateral histological margins of clearance were narrower for head and neck lesions. Incomplete excision occurred in 4%. There was one recurrent lesion after two years of follow-up. A majority of non-melanoma skin cancers at this clinic were managed safely without referral to secondary care. Quantitative reporting of tumour free margins for skin cancer is lacking.

Primary care referral practice, variability and socio-economic deprivation in colorectal cancer.

AIM: The reasons for pre-hospital delay of the diagnosis of cancer are multifactorial, but include a physician-related component. Urgent cancer pathways and direct-to-test approaches have been implemented, but the emergency presentation of colorectal cancer (CRC) remains little changed over recent years. We examined the variability between primary care providers in referral patterns and its effect on outcome. METHOD: A retrospective analysis was performed of a prospectively maintained database for 2009-2014 in a UK district hospital providing bowel cancer screening and tertiary rectal cancer services. RESULTS: Of 1145 CRC patients, 937 (81.8%) were diagnosed with a symptomatic cancer; 229/937 (24.4%) initially presented as an emergency. Between 44 primary care providers, emergency presentation varied between 8.3% and 57.1%. Patients of providers with high levels of emergency presentations (HV) had more advanced cancers than those of providers with medium (MV) or low levels (LV) [103/253 (40.7%), 154/461 (33.4%), 65/223 (29.1%); P = 0.025] and a lower 3-year overall survival (50.2%, 57.8%, 65.6%; P = 0.013), but with no difference in case-mix or deprivation levels. In adjusted analysis, this difference remained significant (advanced disease, OR 1.663, P = 0.011; 3-year hazard ratio 1.479, P = 0.010; comparing HV with LV). Conversely, elective suspected cancer referrals were less often used amongst diagnosed cancers [LV 136/223 (61.0%), MV 228/461 (49.5%), HV 114/253 (45.1%), P < 0.001] with limited evidence for a more selective approach in the use of the 2-week rule amongst all 2-week rule referrals [LV 136/2508 (5.4%); MV 228/4239 (5.4%); HV 115/1526 (7.8%); positive cancer diagnosis, P = 0.005]. CONCLUSION: Significant variability in emergency presentation of CRC requires local audit and examination of the reasons for delay in diagnosis and targeted measures to improve performance in non-emergency referral pathways.

Laparotomy for a patient with warfarin-induced large bowel obstruction.

Many commonly prescribed drugs can interact with warfarin and prolong bleeding time beyond therapeutic limits. We report a patient who developed a rectus sheath haematoma following inadvertent over anticoagulation. Despite conservative management, the patient went on to develop large bowel obstruction from the expanding haematoma and operative intervention became necessary.

Phenomenological evidence for two types of paranoia.

OBJECTIVE: Two types of paranoia have been identified, namely persecution (or 'Poor Me') paranoia, and punishment (or 'Bad Me') paranoia. This research tests predicted differences in phenomenology--specifically, in person evaluative beliefs, self-esteem, depression, anxiety, and anger. METHOD: Fifty-three people with current paranoid beliefs were classified as Poor Me, Bad Me, or neither (classification was reliable). Key dependent variables were measured. RESULTS: All predictions were supported, except the one relating to anger, where the two groups did not differ. The Bad Me group had lower self-esteem, more negative self-evaluative thinking, lower negative evaluations about others, higher depression and anxiety. Importantly, the differences in self-esteem and self-evaluations were not fully accounted for by differences in depression. CONCLUSION: Data support the presence of two distinct topographies of paranoia. Future research is needed to explore the theory further and examine clinical implications.

Chiral separations of transition metal complexes using capillary zone electrophoresis.

Several buffer additives that may facilitate chiral separation for optically active transition metal (TM) systems are investigated using capillary zone electrophoresis. The TM complexes evaluated exhibit considerable heterogeneity with respect to total complex charge (0 to 4+), ligand type, and identity of the central metal including Ru2+, Ni2+, Cr3+, and Co3+, threo-D[+]-Isocitrate, potassium antimonyl-d-tartrate and dibenzoyl-L-tartrate are identified as the most efficient chiral selectors. Interestingly, TM complexes exhibiting a (3+) total complex charge exhibit a reversal of enantiomer elution order versus all other complexes when separated using the tartrate additives. Operating parameters including pH, temperature, and capillary length are discussed, and chiral separations of complex mixtures are demonstrated.

Effect of a skills programme on minor surgical workload in general practice.

It is important that educational programmes designed to meet the surgical training needs of general practitioners be demonstrably effective. To measure change in surgical workload and repertoire among participants in a surgical skills training programme. Log diary of surgical workload of five general practitioners during and four years following a surgical skills programme in 1992. Respondents operated on twice as many surgical cases in the follow-up period as in the baseline period. The increased volume of work was made up of a wider range of procedures for all respondents. Referral of minor surgical cases fell from 22% to 1.4% between periods. Surgical workload and repertoire is increased among participants in a minor surgical skills programme four years later.

Photobehavior of (alpha-diimine)dimesitylplatinum(II) complexes.

The photobehavior of complexes of the type Pt(diimine)(mes)2 is investigated (where diimine = 2,2'-bipyridine (bpy), 1,10-phenanthroline (phen), 3,4,7,8-tetramethyl-1,10-phenanthroline (tmp), 2,9-dimethyl-1,10-phenanthroline (2,9-dmp), 5,6-dimethyl-1,10-phenanthroline (5,6-dmp), and 4,7-diphenyl-1,10-phenanthroline (dpp) and mes = the mesityl (2,4,6-trimethylphenyl) anion). For all compounds studied, solution RT emission is observed to be weak and excited-state lifetimes are found to be short (< or = 20 ns) regardless of solvent choice. Evidence is presented for energy-transfer quenching of Pt(dpp)(mes)2 luminescence in toluene by dissolved O2 (primarily producing singlet oxygen) with an observed quenching rate constant of kq > or = 1.3 x 10(9) M-1 s-1. Electron-transfer quenching is also observed in the presence of 3,5-dinitrobenzonitrile, yielding a quenching rate constant of kq > or = 1.6 x 10(9) M-1 s-1. The latter observation suggests that phase Pt(II) systems may have future value as excited-state reductants. All of the complexes display a much more intense and longer-lived luminescence in the solid state at room temperature. Several possible explanations for this dependence on phase are proposed, with the most probable mechanism involving radiationless deactivation in solution via rotation of the o-methyl groups of the mesityl ligands.

Smoking and quitting among Irish teenage males.

Nicotine addiction in adulthood is usually preceded by exposure to cigarettes in adolescence. A minimal exposure may be sufficient to produce addiction. Strategies to reduce adult smoking must address those factors, which influence teenage smoking. In this study we aimed to establish the prevalence of smoking in male secondary schools, to measure the association between student's smoking status and parental, peer and sibling smoking and to describe attempted quitting. An anonymous questionnaire was given to 1070 male secondary school pupils in two schools in County Louth. Twenty-seven percent of respondents smoked every day or on most days. Having a best friend who smoked was associated with personal smoking (O.R. 11.75, C.I. 8.6-16.08) as was sibling smoking (O.R. 3.49, C.I. 2.67-4.57.) Seventy percent of smokers stated that they wanted to stop and 75% that they had tried to stop. Only five smokers (1.2%) had been advised to quit by their general practitioner. We conclude that smoking is as prevalent among teenage boys in Ireland as it has been shown to be elsewhere and that most teenagers are unable rather than unwilling to stop.

Special hospitals. Models of imperfection.

Forensic mental healthcare needs radical change. National standards should be established. An effective model needs to integrate special hospitals, secure units and community care.

Mobility screening in the elderly and resulting referral.

The aims of this study were to test the usefulness of the Royal College of General Practitioners' (RCGP) mobility screening questionnaire in Irish general practice and to use it to assess the level of mobility problems in the over-75 year old population. Questionnaire screening survey in six faculty areas of the Irish College of General Practitioners(ICGP) well-spread geographically to be representative of the Irish population. Participants were a random sample of 627 people aged 75 years or over, from the General Medical Services list of 92 volunteer general practitioners. The Royal College of General Practitioners' screening questionnaire for mobility was administered by each person's doctor. Suggested interventions were also noted. 92% felt able to get around the house independently, with 78% able to manage stairs independently. The commonest aid to mobility was a stick, used by 27%. Mental impairment was closely associated with inability to get around the house (86% of those not independent around the house scored less than 8 on the Abbreviated Mental Test Score). Analysis of referral patterns indicated possible deficiencies in the availability of physiotherapy in certain areas. The RCGP mobility screening questionnaire was easy to use, and helpful in detecting problems which might require attention.

A study of self-care among Irish doctors.

Little is known about the self care employed by Irish doctors, though studies in other countries suggest this is likely to be less than ideal. In this study 76 doctors; general practitioner trainees, general practitioners and hospital consultants, completed a questionnaire on their self management of illness. High levels of self-prescribing and referral were discovered. The implications for the health of doctors in Ireland and the need for an occupational health service for doctors are discussed.

Do Irish general practitioners know how often their patients consult?

We report a study of the accuracy with which nine General Practitioners estimated the consulting rate of 889 patients over the preceding year. We found that their estimates were exact in 34% and that only 13 of 118 high frequency attenders were not detected. We conclude that single-handed GPs are aware of patient consulting rate, which has been shown to be a marker for unmet medical need.

Effect of three novel polyamine oxa-analogues (MTR-OSPD, DIP-SPN and APPO-TFA) on the growth and proliferation of Swiss 3T3 cells.

In order to investigate their biological function on cellular polyamine content, cell growth and proliferation, three novel polyamine oxa-analogues, 5-(4-methoxy-2,3,6-trimethylbenzenesulfonyl)-6-oxa-spermidine (MTR-OSPD); 6,9-dioxa-5,10-di-(2,2,5,7,8-pentamethylchroman-6-sulfonyl) spermine (DIP-SPN) and 3-aminopropyl N-(3-phthalimidopropyloxy) trifluoroacetimidate (APPO-TFA) were tested for their ability to stop or slow down the growth of Swiss 3T3 cells. Cells at 50-60% confluency were grown for 24 or 48 hr in the presence of a wide range of polyamine oxa-analogue concentrations and the number of cells counted. To determine whether the drugs were cytotoxic or cytostatic, the analogue-containing medium in some vials was replaced with fresh culture medium after 48 hr and the cells incubated for a further 24 hr. Cellular protein, RNA, DNA, polyamine contents and the activities of ornithine decarboxylase, S-adenosyl-L-methionine decarboxylase and spermidine/spermine N1-acetyltransferase were also determined at the lowest effective analogue concentration. All three inhibitors stopped cell proliferation at concentrations over 100 microM. Both MTR-OSPD and DIP-SPN were cytotoxic, since the cells could not be revived by removing the inhibitor from the medium, whereas APPO-TFA was only cytostatic. At the lowest effective concentration the analogues had little effect on protein, RNA and DNA content of the cells, but had varying effects on polyamine metabolism. The most interesting analogue was APPO-TFA. This drug showed concentration-dependent growth inhibition between concentrations of 5 nM and 5 microM. These novel analogues may be of value in elucidating the precise functions of polyamines in cellular metabolism. Their exact mode of action is now under investigation.

What do Dublin GPs expect from a psychiatric referral?

The advent of community psychiatry has tended to blur the interface between primary and secondary psychiatric care. We used a postal questionnaire to investigate each new referral from general practice to the public outpatient clinics of three West Dublin Psychiatric Sectors. 70 referrals, from 35 general practitioners, over a four month period in 1991 were analysed, regarding reason for referral and prior management in general practice. On average patients had seen their GP six times over a period of ten months. Mixed anxiety/depression was the most common diagnosis (23%). Medication had been prescribed for 61% of patients and 67% had counselling before referral. Common reasons for referral were: Access to therapies not available directly to the GP (30%); Failure of treatment (20%); To share the burden of chronic care (14%). In only 13% of referrals did the GP wish the psychiatrist to take over care. We conclude that the GPs surveyed undertake extensive pre-referral management of patients with psychological illness. They have well defined expectations of referral and are keen to follow up patients themselves. Future plans for community psychiatric services should take account of this pattern of care.

Immunohistochemical localization of glutathione S-transferase in preneoplastic and neoplastic lesions of the human uterine cervix.

A mouse monoclonal antibody and a rabbit polyclonal antibody prepared against the placental form of the enzyme glutathione S-transferase (GST-pi) were used to immunohistochemically stain normal and neoplastic human uterine cervical tissues from 88 cases. Of 65 cases of preneoplastic squamous lesions and invasive carcinomas of the cervix, 94% stained with the monoclonal antibody and 100% with the polyclonal antibody. In the 23 benign tissues, staining of ectocervical squamous epithelium was generally not observed; however, areas of reserve-cell hyperplasia, immature squamous metaplasia and adjacent endocervical cells did show staining (68% with the monoclonal antibody and 95% with the polyclonal antibody). Many of the positive tissue types showed a variety of staining patterns and intensities. These findings do not support the concept that GST-pi staining can be used to distinguish preneoplastic lesions of the cervix from benign reactive or proliferative processes. These results are of interest in the investigation of cervical carcinogenesis since GST-pi may be involved in an early stage of neoplastic transformation of the cervical epithelium. The correlation of these findings with the results of human papillomavirus testing and DNA content analysis should be of interest in determining the relationship of this enzyme to cervical neoplasia.