Perinatal mental healthcare in Northern Ireland: challenges and opportunities.

Perinatal mental health is a vital component of public mental health. The perinatal period represents the time in a woman's life when she is at the highest risk of developing new-onset psychiatric disorders or relapse of an existing mental illness. Optimisation of maternal mental health in the perinatal period is associated with both short- and long-term benefits not only for the mother, but also for her infant and family. However, perinatal mental health service provision remains variable across the world. At present in Northern Ireland, 80% of women do not have access to specialist community perinatal mental health services, and without access to a mother and baby unit, mothers who require a psychiatric admission in the postnatal period are separated from their baby. However, following successful campaigns, funding for development of specialist perinatal mental health community teams has recently been approved. In this article, we discuss the importance of perinatal mental health from a public health perspective and explore challenges and opportunities in the ongoing journey of specialist service development in Northern Ireland.

The association between childhood trauma, parental bonding and depressive symptoms and interpersonal functioning in depression and bipolar disorder.

OBJECTIVES: This study explores rates of a history of childhood trauma in adult patients with bipolar disorder and depression and the impact of such trauma and parental bonding patterns on depressive mood and interpersonal functioning at the time of assessment. METHODS: A cross-sectional design was used and a sample of 49 participants was recruited from a mental health outpatient service in Northern Ireland. Data were subject to correlations, one-way analysis of variance and hierarchal regression analyses. A cut-off point of r=±0.25 was used to select variables for inclusion in the hierarchal regression analyses. RESULTS: High rates of childhood trauma were present in both samples: 74% in bipolar disorder and 82% in depression. Childhood trauma and poor parental bonding (with mother) were significant predictors of higher rates of current inter-episode depressive mood and interpersonal difficulties. CONCLUSIONS: This finding adds to the evidence that routine assessment of early childhood experience is likely to prove helpful in clinical care.

An evidence-based treatment algorithm for colorectal polyp cancers: results from the Scottish Screen-detected Polyp Cancer Study (SSPoCS).

OBJECTIVES: Colorectal polyp cancers present clinicians with a treatment dilemma. Decisions regarding whether to offer segmental resection or endoscopic surveillance are often taken without reference to good quality evidence. The aim of this study was to develop a treatment algorithm for patients with screen-detected polyp cancers. DESIGN: This national cohort study included all patients with a polyp cancer identified through the Scottish Bowel Screening Programme between 2000 and 2012. Multivariate regression analysis was used to assess the impact of clinical, endoscopic and pathological variables on the rate of adverse events (residual tumour in patients undergoing segmental resection or cancer-related death or disease recurrence in any patient). These data were used to develop a clinically relevant treatment algorithm. RESULTS: 485 patients with polyp cancers were included. 186/485 (38%) underwent segmental resection and residual tumour was identified in 41/186 (22%). The only factor associated with an increased risk of residual tumour in the bowel wall was incomplete excision of the original polyp (OR 5.61, p=0.001), while only lymphovascular invasion was associated with an increased risk of lymph node metastases (OR 5.95, p=0.002). When patients undergoing segmental resection or endoscopic surveillance were considered together, the risk of adverse events was significantly higher in patients with incomplete excision (OR 10.23, p<0.001) or lymphovascular invasion (OR 2.65, p=0.023). CONCLUSION: A policy of surveillance is adequate for the majority of patients with screen-detected colorectal polyp cancers. Consideration of segmental resection should be reserved for those with incomplete excision or evidence of lymphovascular invasion.

Paediatric intraocular lens implants: accuracy of lens power calculations.

PurposeThis study aims to evaluate the accuracy of lens prediction formulae on a paediatric population.MethodsA retrospective case-note review was undertaken of patients under 8 years old who underwent cataract surgery with primary lens implantation in a regional referral centre for paediatric ophthalmology, excluding those whose procedure was secondary to trauma. Biometric and refractive data were analysed for 43 eyes, including prediction errors (PE). Statistical measures used included mean absolute error (MAE), median absolute error (MedAE), Student's t-test and Lin's correlation coefficient.ResultsThe mean PE using the SRK-II formula was +0.96 D (range -2.47D to +2.41 D, SD 1.33 D, MAE 1.38 D, MedAE 1.55, n=15). The mean PE was smaller using SRK/T (-0.18 D, range -3.25 D to +3.95 D, SD 1.70 D, MAE 1.30 D, MedAE 1.24, n=27). We performed an analysis of the biometry data using four different formula (Hoffer Q, Holladay 1, SRK-II and SRK/T). Hoffer Q showed a smaller MedAE than other formulae but also a myopic bias.ConclusionOur clinical data suggest SRK/T was more accurate in predicting post-operative refraction in this cohort of paediatric patients undergoing cataract surgery. Hoffer Q may have improved accuracy further.

Psychotropic prescribing patterns among adolescents in Northern Ireland presenting with psychotic symptoms during a 5-year period.

OBJECTIVE: To report new prescriptions of psychotropic medications among adolescents presenting with new onset psychotic symptoms during a 5-year period. METHODS: The Northern Ireland Early Onset Psychosis Study is a naturalistic longitudinal observational study of patients with an early onset first psychotic episode. All patients aged <18 years presenting to specialist mental health services across Northern Ireland with new onset psychotic symptoms between 2001 and 2006 were recruited (n=113). Clinical case notes were analysed retrospectively for details of subsequent treatment with psychotropic medications. RESULTS: A total of 100 patients (88.5%) were prescribed some form of psychotropic medication. Over three-quarters of patients received an antipsychotic as their first medication. Risperidone (45.8%), olanzapine (24.0%) and chlorpromazine (12.5%) were the most commonly prescribed first-line antipsychotic medications. Of a total of 160 antipsychotic prescriptions, 81 (50.6%) were off-label. Prescriptions were most likely to have been deemed off-label owing to medications not being licensed in under-18s (71.6% of off-label prescriptions) but other reasons were medications being used outside licensed age ranges (23.5%) and outside licensed indications (4.9%). CONCLUSIONS: This is the first study examining psychotropic prescribing patterns in a complete sample of all children and adolescents presenting with early onset psychotic episodes in a single geographical area. The observation of risperidone as the most commonly prescribed antipsychotic was in keeping with previous studies in child and adolescent populations. Rates of off-label prescribing were lower than previously observed although our study was the first to investigate off-label prescribing solely in children and adolescents presenting with psychotic symptoms.

On the antioxidant properties of erythropoietin and its association with the oxidative-nitrosative stress response to hypoxia in humans.

AIM: The aim of this study was to examine if erythropoietin (EPO) has the potential to act as a biological antioxidant and determine the underlying mechanisms. METHODS: The rate at which its recombinant form (rHuEPO) reacts with hydroxyl (HO˙), 2,2-diphenyl-1-picrylhydrazyl (DPPH˙) and peroxyl (ROO˙) radicals was evaluated in-vitro. The relationship between the erythopoietic and oxidative-nitrosative stress response to poikilocapneic hypoxia was determined separately in-vivo by sampling arterial blood from eleven males in normoxia and following 12 h exposure to 13% oxygen. Electron paramagnetic resonance spectroscopy, ELISA and ozone-based chemiluminescence were employed for direct detection of ascorbate (A(˙-) ) and N-tert-butyl-α-phenylnitrone spin-trapped alkoxyl (PBN-OR) radicals, 3-nitrotyrosine (3-NT) and nitrite (NO2-). RESULTS: We found rHuEPO to be a potent scavenger of HO˙ (kr = 1.03-1.66 × 10(11) m(-1) s(-1) ) with the capacity to inhibit Fenton chemistry through catalytic iron chelation. Its ability to scavenge DPPH˙ and ROO˙ was also superior compared to other more conventional antioxidants. Hypoxia was associated with a rise in arterial EPO and free radical-mediated reduction in nitric oxide, indicative of oxidative-nitrosative stress. The latter was confirmed by an increased systemic formation of A˙(-) , PBN-OR, 3-NT and corresponding loss of NO2- (P < 0.05 vs. normoxia). The erythropoietic and oxidative-nitrosative stress responses were consistently related (r = -0.52 to 0.68, P < 0.05). CONCLUSION: These findings demonstrate that EPO has the capacity to act as a biological antioxidant and provide a mechanistic basis for its reported cytoprotective benefits within the clinical setting.

A controlled trial of early interventions to promote maternal adjustment and development in infants born with severe congenital heart disease.

Abstract Background Congenital heart disease can have a negative impact on both infant development and maternal adjustment. This study considered the impact of a new programme of early psychosocial interventions on such outcomes, following the birth of a child with severe congenital heart disease. Methods Seventy infants and their mothers were assigned to an intervention or control group based on order of presentation to the unit. Interventions aimed at bolstering mother-infant transactions, through psychoeducation, parent skills training and narrative therapy techniques were implemented. Results Clinically and statistically significant gains were observed at 6-month follow-up on the mental (but not the psychomotor) scale of the Bayleys-II. Positive gains were also manifested on feeding practices, maternal anxiety, worry and appraisal of their situation. Conclusions A programme of generalizable psychosocial interventions is shown to have a positive impact on the infant with severe congenital heart disease and the mother.

Determinants of neuropsychological and behavioural outcomes in early childhood survivors of congenital heart disease.

AIMS: To evaluate the relative effect of cyanosis, surgical interventions and family processes on neuropsychological and behavioural outcomes in 4-year-old survivors of serious congenital heart disease (CHD). METHODS: 90 children with a range of cyanotic and acyanotic conditions, who underwent either corrective or palliative surgery, completed a neuropsychological and behavioural evaluation. Families of participants were also profiled by evaluation of maternal mental health, worry, social support, parenting style and family functioning. RESULTS: Compromised neuropsychological outcomes were associated with a combination of cyanotic conditions and open-heart surgery, but this was not exacerbated by having a complex, palliative, status. Both cyanotic and acyanotic conditions were associated with specific sensorimotor delays, regardless of method of the correction. Only children with complex conditions and palliative interventions seemed at risk of poor behavioural outcomes; indeed, children with cyanosis with complete repair showed favourable behavioural outcomes compared with controls. Multivariate analyses highlighted the sometimes greater relevance of family processes (eg parenting style, maternal mental health and worry), rather than disease or surgical factors, in predicting especially behavioural outcomes. CONCLUSIONS: The findings (1) suggest a more complex relationship between cyanosis, surgical methods of correction, neuropsychological and behavioural outcomes than previously charted, (2) highlight that family processes may be aetiologically more important than disease and surgical factors, and (3) indicate specific targets for secondary prevention programmes for this at-risk population.

Analysis of stress distribution in lumbar interbody fusion.

STUDY DESIGN: A 2-dimensional axisymmetric finite element model of an intervertebral segment was used to investigate the stress patterns in the adjacent vertebrae of fused spinal segment incorporating 4 common cage designs. The same was used to study the effect of maturation of bone graft on stress distribution pattern. OBJECTIVES: To study and compare the stress distribution patterns in a normal spinal segment and in the adjacent vertebrae of a fused spinal segment. The effect of bone graft incorporation around the mesh cage was also investigated. SUMMARY OF BACKGROUND DATA: Lumbar fusion surgery is thought to relieve discogenic low back pain by eliminating the abnormal intersegmental movement at the level of disc degeneration. Successful spinal fusion does not guarantee symptomatic pain relief. Discogenic pain is also known to be associated with an abnormal load transmission pattern across the degenerate disc. We hypothesized that the lumbar interbody fusion results in relief of discogenic pain by normalizing the load distribution pattern. METHODS: We used a 2-dimensional axisymmetric finite element model of an intervertebral segment to investigate the stress patterns in the vertebrae adjacent to a fused spinal segment incorporating 4 common cage designs: (1) anterior lumbar interbody fusion, (2) posterior lumbar interbody fusion rectangular, (3) posterior lumbar interbody fusion threaded, and (4) mesh cage. RESULTS: High stress concentrations and abnormal overall stress patterns were noted for all the cage designs studied. The anterior lumbar interbody fusion cage with its larger contact area showed the least abnormal stress magnitude in comparison with the other cages. Incorporation of bone in and around the mesh cage increased the area of contact and decreased the abnormal high stresses. The spine fusion model representing final bony healing showed restoration of near physiologic stress pattern. CONCLUSIONS: Interbody fusion cages with larger area of contact between cage and vertebral endplate produces a lower stress distribution pattern. A successful bony fusion restores near physiologic stress distribution pattern. Restoration of near normal load distribution pattern may become an important aim of surgery for discogenic low back pain.

Evaluation of a distance-learning immunology and pathology module in a postgraduate biomedical science course.

An electronic presentation of materials for a distance-learning immunology and pathology module from a postgraduate biomedical science course is evaluated. Two different electronic presentation formats for the delivery of the educational material to distance learners are assessed. Responses from users of this material highlighted a preference for a format that has a design tailored to distance learning. There was no significant difference in learning outcome between those taking the module on campus and by distance learning. This suggests that the prerequisites for entry, learning materials and direction given to the students studying by distance learning are adequate for these students to achieve the learning objectives outlined in the course. The evaluation also gave direction for areas within the (CAL) application that can be improved for future students.

Pilonidal sinus of the penis.

A pilonidal sinus is a subcutaneous sinus containing hair. It is most commonly found in the natal cleft of hirsute men. Here we describe the unusual finding of a pilonidal sinus arising on the male foreskin.

Vitamin C decreases intracellular calcium level in human lymphoid cells.

Human lymphocytes have low levels of many antioxidant enzymes however they are know to concentrate vitamin C. Cell injury, including oxidative stress effects, is associated with calcium influx so the influence of vitamin C on the maintenance of calcium levels in leukocytes was studied. Incubation of Molt-3 human lymphoblastoid cells with physiologically relevant concentrations of vitamin C and the calcium ionophore A23187 reversed the calcium influx and increased nuclear protein level associated with the ionophore alone. It is concluded that intracellular vitamin C can inhibit calcium influx into leukocytes so helping to minimise cell damage.

Interactions between vitamins C and E in human subjects.

Despite convincing in vitro evidence, a vitamin C-E interaction has not been confirmed in vivo. This study was designed to examine the effects of supplementation with either vitamin C or E on their respective plasma concentrations, other antioxidants, lipids and some haemostatic variables. Fasting blood was collected before and after intervention from thirty healthy adults in a double-blinded crossover study. Baselines for measured variables were established after 2 weeks of placebo supplementation, followed by daily supplementation with 73.5 mg RRR-alpha-tocopherol acetate or 500 mg ascorbic acid, and placebo, for 6 weeks. A 2 month washout preceded supplement crossover. Mean values showed that plasma lipid standardised alpha-tocopherol increased with ascorbic acid supplementation: from 4.09 (sem 0.51) to 4.53 (sem 0.66) micromol/mmol total cholesterol plus triacylglycerol (P < 0.05), and plasma ascorbic acid increased from 62.8 (sem 14.9) to 101.3 (sem 22. 2) micromol/l (P < 0.005). Supplementation with (RRR)-alpha-tocopherol acetate increased plasma alpha-tocopherol from 26.8 (sem 3.9) to 32.2 (sem 3.8) micromol/l (P < 0.05), and lipid-standardised alpha-tocopherol from 4.12 (sem 0.48) to 5.38 (sem 0.52) micromol/mmol (P < 0.001). Mean plasma ascorbic acid also increased with vitamin E supplementation, from 64.4 (sem 13.3) to 76. 4 (sem 18.4) micromol/l (P < 0.05). Plasma ferric reducing (antioxidant) power and glutathione peroxidase (U/g haemoglobin) increased in both groups, while urate, total cholesterol and triacylglycerol levels decreased (P < 0.05 throughout). Results are supportive of an in vivo interaction between vitamins C and E.

Depressive symptoms in stable chronic schizophrenia: prevalence and relationship to psychopathology and treatment.

The prevalence and correlates of the depressive syndrome were explored in a population of 120 patients with stable, chronic schizophrenia living in the community. The presence of clinically significant depressive symptoms was defined by a score of 17 or greater on the Beck Depression Inventory. Patients were examined to assess severity of schizophrenic symptoms and medication side-effects. Sixteen of the 120 patients (13.3%) had significant depressive symptoms. Depressive symptoms were significantly correlated with the hostility/suspiciousness (P<0.0001), the positive symptom (P=0.0009) factor of the BPRS and with scores on the Significant Others Scale, a measure of patients' perceived lack of social support (P=0.0004). The association between depression and akathisia approached significance (P=0.007). There was no correlation with demographic variables, alcohol intake, antipsychotic dosage or anticholinergic dosage. Using a scale that rates the subjective aspects of the depressive syndrome, we found no evidence of a relationship between depression and negative symptoms in this population. These results indicate that persistent depressive symptoms in stable patients in the community are related to the degree of persistent positive psychotic symptoms, patient perceptions of social support and, weakly, to the degree of akathisia but not other aspects of antipsychotic treatment.

Applications of computer-aided learning in biomedical sciences: considerations in design and evaluation.

Multimedia computer-aided learning (CAL) is an area that has become increasingly prevalent in biomedical science. Here we describe the advances that have taken place in the computing industry that have led to this trend. We also outline areas within the subject of biomedical science that can most benefit from using multimedia CAL as a teaching aid. Furthermore, issues concerning the design of CAL (i.e. iterative design, structure, development tools) are discussed. As the evaluation of CAL is an essential part of the iterative design process, we look at new approaches to evaluation that have emerged in response to the superficial focus on usability that many evaluations take.

Frequency of fruit and vegetable consumption and blood antioxidants in the Caerphilly cohort of older men.

OBJECTIVE: To assess the number of portions of fruit and vegetables consumed daily by a large representative sample of older men, and to determine how blood antioxidant (vitamins E, A and carotenoids) concentrations vary with fruit and vegetable consumption. DESIGN: Cross-sectional study of free-living men. SUBJECTS: Men aged 55-69 y (dietary data, n=1957; blood data, n=1874) participating in Phase III (1989-1993) of the Caerphilly and Speedwell Collaborative Heart Disease Studies. METHODS: Dietary data were obtained by semi-quantitative food-frequency questionnaire and blood samples were analysed for antioxidant vitamins. Men were subdivided into groups on the basis of portions per day of fruit and vegetables. Within these sub-groups, mean and 95% ranges of intakes and of blood antioxidant levels were obtained. Log transformations were performed where appropriate. RESULTS: Only 4.3% of the men met the recommended target of five portions, while 33.3% of the men consumed one or fewer portions of fruit and vegetables per day. Those men who consumed the poorest diets with respect to fruit and vegetable intakes were more likely to be from lower socio-economic classes, drink more alcohol and be current smokers. Fruit and vegetable intake reflected plasma concentrations of antioxidants, which showed a dose-response relationship to frequency of consumption. CONCLUSIONS: Older men in the UK consume much less fruit and vegetables than current recommendations. Major difficulties are likely to be encountered in trying to meet a dietary target that is clearly much higher than the fruit and vegetable consumption of large sections of the older population in the UK. SPONSORSHIP: This work was supported by the Medical Research Council.