The impact of Recovery Colleges on mental health staff, services and society.

AIMS: Recovery Colleges are opening internationally. The evaluation focus has been on outcomes for Recovery College students who use mental health services. However, benefits may also arise for: staff who attend or co-deliver courses; the mental health and social care service hosting the Recovery College; and wider society. A theory-based change model characterising how Recovery Colleges impact at these higher levels is needed for formal evaluation of their impact, and to inform future Recovery College development. The aim of this study was to develop a stratified theory identifying candidate mechanisms of action and outcomes (impact) for Recovery Colleges at staff, services and societal levels. METHODS: Inductive thematic analysis of 44 publications identified in a systematised review was supplemented by collaborative analysis involving a lived experience advisory panel to develop a preliminary theoretical framework. This was refined through semi-structured interviews with 33 Recovery College stakeholders (service user students, peer/non-peer trainers, managers, community partners, clinicians) in three sites in England. RESULTS: Candidate mechanisms of action and outcomes were identified at staff, services and societal levels. At the staff level, experiencing new relationships may change attitudes and associated professional practice. Identified outcomes for staff included: experiencing and valuing co-production; changed perceptions of service users; and increased passion and job motivation. At the services level, Recovery Colleges often develop somewhat separately from their host system, reducing the reach of the college into the host organisation but allowing development of an alternative culture giving experiential learning opportunities to staff around co-production and the role of a peer workforce. At the societal level, partnering with community-based agencies gave other members of the public opportunities for learning alongside people with mental health problems and enabled community agencies to work with people they might not have otherwise. Recovery Colleges also gave opportunities to beneficially impact on community attitudes. CONCLUSIONS: This study is the first to characterise the mechanisms of action and impact of Recovery Colleges on mental health staff, mental health and social care services, and wider society. The findings suggest that a certain distance is needed in the relationship between the Recovery College and its host organisation if a genuine cultural alternative is to be created. Different strategies are needed depending on what level of impact is intended, and this study can inform decision-making about mechanisms to prioritise. Future research into Recovery Colleges should include contextual evaluation of these higher level impacts, and investigate effectiveness and harms.

Dietary Diversity on the Swahili Coast: The Fauna from Two Zanzibar Trading Locales.

Occupants of coastal and island eastern Africa-now known as the 'Swahili coast'-were involved in long-distance trade with the Indian Ocean world during the later first millennium CE. Such exchanges may be traced via the appearance of non-native animals in the archaeofaunal record; additionally, this record reveals daily culinary practises of the members of trading communities and can thus shed light on subsistence technologies and social organisation. Yet despite the potential contributions of faunal data to Swahili coast archaeology, few detailed zooarchaeological studies have been conducted. Here, we present an analysis of faunal remains from new excavations at two coastal Zanzibar trading locales: the small settlement of Fukuchani in the north-west and the larger town of Unguja Ukuu in the south-west. The occurrences of non-native fauna at these sites-Asian black rat (Rattus rattus) and domestic chicken (Gallus gallus), as well as domestic cat (Felis catus)-are among the earliest in eastern Africa. The sites contrast with one another in their emphases on wild and domestic fauna: Fukuchani's inhabitants were economically and socially engaged with the wild terrestrial realm, evidenced not only through diet but also through the burial of a cache of wild bovid metatarsals. In contrast, the town of Unguja Ukuu had a domestic economy reliant on caprine herding, alongside more limited chicken keeping, although hunting or trapping of wild fauna also played an important role. Occupants of both sites were focused on a diversity of near-shore marine resources, with little or no evidence for the kind of venturing into deeper waters that would have required investment in new technologies. Comparisons with contemporaneous sites suggest that some of the patterns at Fukuchani and Unguja Ukuu are not replicated elsewhere. This diversity in early Swahili coast foodways is essential to discussions of the agents engaged in long-distance maritime trade.

Bax deficiency prolongs cerebellar neurogenesis, accelerates medulloblastoma formation and paradoxically increases both malignancy and differentiation.

Correction to: Oncogene (2013) 32, 2304­2314; doi:10.1038/onc. 2012.248; published online 18 June 2012. Since the publication of the above paper, the author listed as C Ryan Miller has requested that the listing of his name be changed to CR Miller.

ASC deficiency suppresses proliferation and prevents medulloblastoma incidence.

Apoptosis-associated speck-like protein containing a caspase recruitment domain (ASC) is silenced by promoter methylation in many types of tumors, yet ASC's role in most cancers remains unknown. Here, we show that ASC is highly expressed in a model of medulloblastoma, the most common malignant pediatric brain cancer; ASC is also expressed in human medulloblastomas. Importantly, while ASC deficiency did not affect normal cerebellar development, ASC knockout mice on the Smoothened (ND2:SmoA1) transgenic model of medulloblastoma exhibited a profound reduction in medulloblastoma incidence and a delayed tumor onset. A similar decrease in tumorigenesis with ASC deficiency was also seen in the hGFAP-Cre:SmoM2 mouse model of medulloblastoma. Interestingly, hyperproliferation of the external granule layer (EGL) was comparable at P20 in both wild-type and ASC-deficient SmoA1 mice. However, while the apoptosis and differentiation markers remained unchanged at this age, proliferation makers were decreased, and the EGL was reduced in thickness and area by P60. This reduction in proliferation with ASC deficiency was also seen in isolated SmoA1 cerebellar granule precursor cells in vitro, indicating that the effect of ASC deletion on proliferation was cell autonomous. Interestingly, ASC-deficient SmoA1 cerebella exhibited disrupted expression of genes in the transforming growth factor-ß pathway and increased level of nuclear Smad3. Taken together, these results demonstrate an unexpected role for ASC in Sonic hedgehog-driven medulloblastoma tumorigenesis, thus identifying ASC as a promising novel target for antitumor therapy.

Bax deficiency prolongs cerebellar neurogenesis, accelerates medulloblastoma formation and paradoxically increases both malignancy and differentiation.

Neurogenesis requires negative regulation through differentiation of progenitors or their programmed cell death (PCD). Growth regulation is particularly important in the postnatal cerebellum, where excessive progenitor proliferation promotes medulloblastoma, the most common malignant brain tumor in children. We present evidence that PCD operates alongside differentiation to regulate cerebellar granule neuron progenitors (CGNPs) and to prevent medulloblastoma. Here, we show that genetic deletion of pro-apoptotic Bax disrupts regulation of cerebellar neurogenesis and promotes medulloblastoma formation. In Bax(-/-) mice, the period of neurogenesis was extended into the third week of postnatal life, and ectopic neurons and progenitors collected in the molecular layer of the cerebellum and adjacent tectum. Importantly, genetic deletion of Bax in medulloblastoma-prone ND2:SmoA1 transgenic mice greatly accelerated tumorigenesis. Bax-deficient medulloblastomas exhibited strikingly distinct pathology, with reduced apoptosis, increased neural differentiation and tectal migration. Comparing Bax(+/+) and Bax(-/-) medulloblastomas, we were able to identify upregulation of Bcl-2 and nuclear exclusion of p27 as tumorigenic changes that are required to mitigate the tumor suppressive effect of Bax. Studies on human tumors confirmed the importance of modulating Bax in medulloblastoma pathogenesis. Our results demonstrate that Bax-dependent apoptosis regulates postnatal cerebellar neurogenesis, suppresses medulloblastoma formation and imposes selective pressure on tumors that form. Functional resistance to Bax-mediated apoptosis, required for medulloblastoma tumorigenesis, may be a tumor-specific vulnerability to be exploited for therapeutic benefit.

Sacral fracture associated with small bowel entrapment: a case report.

We report the third documented case of small bowel entrapment within a sacral fracture leading to small bowel obstruction. This important diagnosis is rare and difficult to make, even with current imaging methods. We report a case in which a segment of small bowel trapped in a Denis II fracture of the sacrum required laparotomy, small bowel resection, and an omental patch over the fracture site. In this case the outcome was favorable with no residual sequelae.

Rapid diagnosis of massive pulmonary embolism in a district general hospital.

Effective treatment of massive pulmonary embolism is more likely if diagnostic tests are rapidly available, including during out-of-hours. An agreed protocol was implemented in November 1997, which allowed initiation of thrombolysis by junior doctors within an hour of clinical suspicion of the diagnosis of massive pulmonary embolism in six patients in the subsequent year. A similar approach could be considered by other acute hospitals.

The effect of orientation on the clarity of Hermann grid illusory lines.

To test the hypothesis that Hermann grid illusory lines are most clear when the grid is presented at a 45 deg, each of 20 participants underwent 10 trials in each of two conditions ('make the lines least clear' and 'make the lines most clear') which were run using a method of adjustment. A matched-pairs t-test applied to the means of the two conditions was significant beyond the 0.01 level. One-group t-tests supported the claim that the illusory lines are least clear for a vertical/horizontal orientation of the grid and most clear when it is rotated 45 deg. The results substantiate, in a systematic manner, 70 years of claims about the effects of grid orientation on illusory line clarity.

Health needs assessment in primary care: the evolution of a practical public health approach.

The purpose of the paper is to place health needs assessment in its primary care context. This is a dynamic context where changes in policies, staff roles and patient expectations have all to be considered. Given this complexity and the variations between practices, it is necessary to help primary health care teams (PHCTs) to understand their stage of development and how this will directly affect any health needs assessment. The technical and methodological aspects of health needs assessment have been explored and described by others, and that work will not be duplicated here. This paper reviews the health needs assessment (HNA) work of the Ribblesdale Total Purchasing Project (RTPP) and then sets this review against the political, organisational, professional and practical pressures that currently confront primary care. Out of this analysis emerges a diagnostic and development tool which links together, and emphasises the intimate relationships between, five stages of development needed for effective primary care-oriented health needs assessment work. The emphasis is on understanding the place of health needs assessment within the general processes and systems of the primary health care team. The paper concludes by suggesting ways in which public health practitioners and specialists might approach the task of supporting and influencing the evolution of the recently proposed Primary Care Groups and Primary Care Trusts. The overall intention of the article is to stimulate debate and action.

Detection of viable and non-viable cells in connective tissue explants using the fixable fluoroprobes 5-chloromethylfluorescein diacetate and ethidium homodimer-1.

The efficacy of connective tissue explants is difficult to determine, particularly where autopsy material is required for research or clinical applications. We report here an optimised protocol using 5-chloromethylfluorescein diacetate (CMFDA) and ethidium homodimer-1 to distinguish viable and non-viable cells in a range of connective tissue explants. Biopsies and explants of corneae, arteries, cartilage and skin were loaded with fluoroprobes for extended periods (< or = 24h) at low temperatures (4 degrees C), fixed in paraformaldehyde, and processed using a variety of embedding, sectioning, autoradiographic, and immunohistochemical procedures. Detection of fluorescent green CMFDA and red ethidium homodimer was achieved using epi-illuminated light or dual channel confocal microscopy, and clearly differentiated live from dead cells throughout the explants. Furthermore, the intracellular distribution of CMFDA provided superior images of cell shape and morphology not previously available using conventional histochemical techniques. Adaptations of this protocol could prove valuable in a variety of research and clinical applications.

Clinical experience with a new lead combining active fixation with steroid elution.

The Medtronic lead engineering model number 10335A represents a new concept in lead design combining active fixation with steroid elution. It aims for immediate stability and low chronic thresholds. Twenty-one leads, 9 atrial and 12 ventricular, were implanted in 13 patients (10 males, mean age 68; range 22-91 years). The atrial leads showed no rise in pulse width threshold at a voltage of 1.6 volts (mean thresholds at implant, 1, and 26 weeks; 0.1 +/- 0.09 msec, 0.15 +/- 0.04 msec, and 0.1 +/- 0.03 msec, respectively). The ventricular leads had a small but significant rise between implant and 1 week at an output of 1.6 volts (0.07 +/- 0.03 msec increasing to 0.11 +/- 0.04 msec; P < 0.02) but no significant later rise (0.1 +/- 0.04 msec at 2 weeks and 0.1 +/- 0.05 msec at 6 months). These low chronic thresholds would allow early reprogramming of the unit to low voltages resulting in a battery saving with prolongation of the unit's life. There were no significant changes in the P and R wave amplitudes, but there was a fall in lead impedance in the ventricular leads between implantation and 1 week (P < 0.02) but none subsequently, and there was no significant change in atrial impedance. There were no sensing failures and no lead displacements. Despite impressive pacing characteristics, the study was suspended because of a high level of mechanical complications. Of the 96 patients implanted worldwide with 136 leads there were eight helix deformations, which will require redesign.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of a patent foramen ovale on arterial saturation during exercise and on cardiovascular responses to deep breathing, Valsalva manoeuvre, and passive tilt: relation to history of decompression illness in divers.

OBJECTIVE: To determine whether the presence of a patent foramen ovale could result in significant arterial desaturation and affect the responses of heart rate and blood pressure to physiological manoeuvres and to determine whether responses differed between those with and those without prior clinical events associated with a patent foramen ovale. DESIGN: Blind controlled study. SETTING: Teaching hospital. PATIENTS: Divers with a large patent foramen ovale shown by contrast echocardiography and divided into those who had neurological decompression illness that started within 30 minutes of surfacing (group 1), those who had no history of decompression illness (group 2), and age and sex matched control divers who had no evidence of intracardiac shunts (group 3). MAIN OUTCOME MEASURES: The change in percentage haemoglobin oxygen saturation during treadmill exercise and the response of heart rate and blood pressure to physiological manoeuvres. RESULTS: There were no significant differences between the three groups but two divers in group 1 showed clinically important desaturation during exercise and unusual blood pressure and heart rate responses to passive tilt. These divers were notable for having the greatest number of episodes and the most severe single episode of spinal cord decompression illness. CONCLUSION: A large patent foramen ovale may be associated with clinically significant arterial desaturation and unusual responses of heart rate and blood pressure in some healthy subjects.

Differences in autonomic nerve function in patients with silent and symptomatic myocardial ischaemia.

BACKGROUND: Autonomic neuropathy provides a mechanism for the absence of symptoms in silent myocardial ischaemia, but characterisation of the type of neuropathy is lacking. AIM: To characterise and compare autonomic nerve function in patients with silent and symptomatic myocardial ischaemia. METHODS AND RESULTS: The Valsalva manoeuvre, heart rate variation (HRV) in response to deep breathing and standing, lower body negative pressure, isometric handgrip, and the cold pressor test were performed by patients with silent (n = 25) and symptomatic (n = 25) ambulatory ischaemia and by controls (n = 21). No difference in parasympathetic efferent function between patients with silent and symptomatic ischaemia was recorded, but both had significantly less HRV in response to standing than the controls (p < 0.005 for silent and p < 0.01 for symptomatic). Patients with silent ischaemia showed an increased propensity for peripheral vasodilatation compared with symptomatic patients (p < 0.02) and controls (p < 0.04). Impaired sympathetic function was found in patients with pure silent ischaemia (n = 4) compared with the remaining patients with silent ischaemia whose pain pathways were presumed to be intact. CONCLUSIONS: Patients with silent ischaemia and pain pathways presumed to be intact have an enhanced peripheral vasodilator response, and if this applied to the coronary vasculature it could provide a mechanism for limiting ischaemia to below the pain threshold. Patients with pure silent ischaemia have evidence of sympathetic autonomic dysfunction.

Impedance cardiography during exercise in patients with coronary heart disease.

Impedance cardiography may be a simple way of assessing left ventricular performance during exercise. Measurements were therefore made during exercise testing in 102 consecutive male patients with suspected coronary disease prior to cardiac catheterization. These were subsequently divided into four groups: group A, normal; group B, 1- or 2-vessel disease; group C, 3-vessel disease (groups A, B, and C, left ventricular ejection fraction (LVEF) > 55%); and group D, 3-vessel disease with LVEF < 55%. Immediately after peak exercise several impedance measures were significantly correlated with resting LVEF, especially dZ/dtmax (R = 0.41, P < 0.001) and Heather index (R = 0.46, P < 0.001). Heather index was the best discriminator between the disease groups with mean values (95% confidence intervals) of 25.7 (22.2-29.2) (group A), 21.9 (20.6-23.2) (group B), 18.4 (16.2-20.6) (group C), and 15.3 (10.3-20.3) omega s-2 (group D) but there was considerable overlap between groups (risk ratios 1.17 and 3.15 for any and triple-vessel coronary disease respectively). Measurements were therefore of little diagnostic value. The majority of patients with abnormal responses could be identified more simply by their poor exercise tolerance or abnormal blood pressure response.

Creatine phosphate (Neoton) as an additive to St. Thomas' Hospital cardioplegic solution (Plegisol). Results of a clinical study.

Experimentally, creatine phosphate (CP) added to St. Thomas' Hospital cardioplegic solution (STH) improved post-ischaemic recovery of cardiac function in the rat heart. We investigated the effect of adding CP (10.0 mmol/l) to STH. Fifty open-heart surgery patients were randomized into control (STH) and treated (STH + CP) groups (25 per group). Patients underwent (a) monitoring for peri- and postoperative arrhythmias (48-h Holter monitoring). (b) quantitative birefringence assessment of intraoperative myocardial protection in left and right ventricular biopsies sampled at start of bypass (pre-isch.), end of bypass (end-isch.) and after 10 min reperfusion (post-isch.), and (c) measurement of serum creatine kinase-MB isozyme (CK-MB) values for up to 4 days postoperatively; results were assessed with respect to (d) haemodynamics and postoperative clinical outcome. Inotropic support (adrenaline) was required in three patients (12%) from each group; no patient died. All patients required defibrillation, and the number of direct current shocks required for sinus rhythm was the same in each group. The occurrence and incidence of reperfusion-induced arrhythmias were the same in both groups. Serum CK and CK-MB values were similar throughout the sampling period in both groups of patients; one patient in the control group had raised CK-MB levels postoperatively, but perioperative infarction was not indicated by the electrocardiogram.(ABSTRACT TRUNCATED AT 250 WORDS)

Choosing the pacemaker; a rational approach to the use of modern pacemaker technology.

Sophisticated pacemakers now afford greater benefit than only relief of syncope for patients with symptomatic bradyarrhythmia. For clinical reasons it is inappropriate to implant ventricular demand (VVI) pacemakers in every patient, but for both clinical and economic reasons it is also undesirable to use dual-lead or rate-responsive systems indiscriminately. However, the published guidelines for pacemaker choice and investigation are inadequate. We have analysed the clinical assessment and the investigations required in a series of 150 patients with various electrophysiological disorders, considered consecutively for pacemaker implantation using an algorithm to assist decisions. Holter electrocardiography in 77.3%, exercise testing--formal (in 9.3%) or informal (during Holter electrocardiography), electrophysiology study (EPS)--full in 15.3% and partial in 29.3%, and trial of pacing (10.7%) were all used to characterize dysfunction and to define appropriate pacing mode. 142 patients were paced--57.0% with single lead modes (12.7%) AAI, 44.3% VVI) and 43.0% dual-lead (2.8% DVI, 23.9% VDD or VAT, 16.2% DDD). Three patients received rate-responsive systems (VVIR) which, if available, would have been used in nine; four would have been suitable for AAIR and four for dual-lead responsive pacing (DVIR, DDIR or DDDR). We offer a rational approach based on published data for investigation and pacemaker choice in the management of patients with bradyarrhythmia.