National survey of nurse prescribing in mental health services; a follow-up 6 years on.

WHAT IS KNOWN ON THE SUBJECT?: Nurse prescribing allows nurses, after specific training, to prescribe medications under certain conditions. This article describes the third in a series of surveys of mental health services in England to understand how nurse prescribing is being used across the country. While there is research evidence that shows nurse prescribing to be as safe as prescribing by doctors and that service users typically find it at least as acceptable, there is a lack of detailed evidence about current forms of nurse prescribing practice specifically in mental health services. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The survey found that the number of nurse prescribers has increased over the last few years. Nurse prescribers are increasingly prescribing in a form ('independent prescribing') that makes them independently responsible for prescribing decisions without working to a plan laid out by a doctor. Mental health organisations are increasingly planning in a systematic way how to identify, train and ensure good practice in nurse prescribing. This study demonstrates that growth in numbers of nurse prescribers can take place over an extended time period. The study demonstrates that the exact model of nurse prescribing will influence its applicability in different types of service. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurse prescribing is becoming increasingly common in mental health services, changing roles for nurses and the experience of services for service users. However, there is great variation between organisations in this regard. Research is needed regarding the outcomes and any risks of independent nurse prescribing specifically in mental health compared to medical prescribing. ABSTRACT: Introduction This paper reports the latest in a series of national surveys of nurse prescribing in mental health organizations in England. Aim To describe and understand changes and trends in the use of nurse prescribing nationally. Methods Postal survey to all 53 National Health Service Mental Health Trusts (publicly funded provider organizations); 75% responded (n = 40). Results Numbers of nurse prescribers (NPs) have grown significantly in the last 6 years, although remain a small percentage of the total Mental Health Nursing workforce. Most NPs are in community services, particularly community mental health teams and drug/alcohol services. Independent prescribing has now become the most common form of NP, replacing supplementary prescribing. Discussion Overall growth in numbers of NPs has continued, but remains marked by large variance in numbers between organizations. The study evidences that the particular form of nurse prescribing will influence its applicability in different clinical settings and that sustained increase over time in NP numbers is feasible at a national level, even with local variation in uptake. Implications for practice Nurse prescribing has become well embedded in many organizations although large-scale adoption may be hindered by the lack of a definitive evidence base as to outcomes compared with those from medical prescribing.

An evaluation of team and individual formularies to support independent prescribing in mental health care.

Mental health nurses have been entitled to train to become independent prescribers since May 2006; although the number of trained nurse prescribers seems to have increased steadily, a significant number of them have not actually undertaken prescribing roles on completion of their training or have limited their practice to supplementary prescribing. In order to support existing independent prescribers and to assist those nurses who have trained but are yet to prescribe independently, a mental health trust has piloted the use of individual and team formularies. An evaluation of this project indicated that formularies were well received by existing independent prescribers and were seen as a helpful instrument to support newly qualified and supplementary prescribers in their bid to become independent. Formularies can clarify and formalize each prescriber's area of competence, thus setting clear boundaries, reducing uncertainty and enhancing prescribers' confidence and willingness to take on this new role. Formularies may also be used to enhance communication with service users and further develop shared decision making. Effective procedures need to be in place to ensure formularies are up to date and reflect local practice.

Nurse prescribing in mental health: national survey.

Mental health nurses can now train to become independent prescribers as well as supplementary prescribers. Independent nurse prescribing can potentially help to reorganize mental health services, increase access to medicines and improve service user information, satisfaction and concordance. However, mental health nursing has been slow to undertake prescribing roles, and there has been little work conducted to look at where nurse prescribing is proving successful, and those areas where it is less so. This survey was designed to collect information from directors of nursing in mental health trusts about the numbers of mental health prescribers in England, gather views about prescribing in practice, and elicit intentions with regards to the development of nurse prescribing. In some Trusts, the number of mental health nurse prescribers has increased to the point where wider impacts on workforce, the configuration of teams and services are inevitable. Currently, the way that prescribing is used within different organizations, services and teams varies and it is unclear which setting is most appropriate for the different modes of prescribing. Future work should focus on the impact of mental health nurse prescribing on service delivery, as well as on service users, colleagues and nurses themselves.

Gene duplications and the time thereafter - examples from plant secondary metabolism.

Gene duplications are regarded as one of the central mechanisms for the origin of new genes. Recent studies in plant secondary metabolism have provided several examples of genes that originated by duplication with successive diversification. In this review, the mechanisms of gene duplication are explained and several models discussed that suggest the way that gene duplicates develop into genes with new functions. Signatures of gene duplication and diversification processes are discussed using the biosynthesis of benzoxazinones and of pyrrolizidine alkaloids as examples.

Cloning and expression of homospermidine synthase from Senecio vulgaris: a revision.

Homospermidine synthase. which catalyses the first pathway-specific reaction in pyrrolizidine alkaloid biosynthesis, was cloned from root cultures of Senecio vulgaris and expressed in E. coli. The open reading frame encodes a protein of 370 amino acids with a molecular mass of 40,740 Da. The enzyme is strictly dependent on spermidine as aminobutyl donor since it cannot be substituted by putrescine. The homospermidine synthase from S. vulgaris showed 97.9 and 99.3% nucleic acid identity with two HSS sequences from the closely related species Senecio vernalis. This report also revises data from a previous publication (Kaiser, A., 1999. Cloning and expression of a cDNA encoding homospermidine synthase from Senecio vulgaris (Asteraceae) in Escherichia coli. Plant J. 19. 195 201.) that is incorrect.

Phylogenetic origin of a secondary pathway: the case of pyrrolizidine alkaloids.

Recent studies have revealed high sequence similarity between homospermidine synthase (HSS), the first pathway-specific enzyme in the biosynthesis of pyrrolizidine alkaloids, a class of sporadically occurring plant defence compounds, and deoxyhypusine synthase (DHS), a ubiquitous enzyme involved in the post-translational activation of the eukaryotic initiation factor 5A (eIF5A). The recruitment of DHS during the evolution of the alkaloid pathway is discussed and interpreted as evolution by change of function.

Homospermidine synthase, the first pathway-specific enzyme of pyrrolizidine alkaloid biosynthesis, evolved from deoxyhypusine synthase.

Pyrrolizidine alkaloids are preformed plant defense compounds with sporadic phylogenetic distribution. They are thought to have evolved in response to the selective pressure of herbivory. The first pathway-specific intermediate of these alkaloids is the rare polyamine homospermidine, which is synthesized by homospermidine synthase (HSS). The HSS gene from Senecio vernalis was cloned and shown to be derived from the deoxyhypusine synthase (DHS) gene, which is highly conserved among all eukaryotes and archaebacteria. DHS catalyzes the first step in the activation of translation initiation factor 5A (eIF5A), which is essential for eukaryotic cell proliferation and which acts as a cofactor of the HIV-1 Rev regulatory protein. Sequence comparison provides direct evidence for the evolutionary recruitment of an essential gene of primary metabolism (DHS) for the origin of the committing step (HSS) in the biosynthesis of pyrrolizidine alkaloids.

Deoxyhypusine synthase from tobacco. cDNA isolation, characterization, and bacterial expression of an enzyme with extended substrate specificity.

Deoxyhypusine synthase catalyzes the formation of a deoxyhypusine residue in the translation eukaryotic initiation factor 5A (eIF5A) precursor protein by transferring an aminobutyl moiety from spermidine onto a conserved lysine residue within the eIF5A polypeptide chain. This reaction commences the activation of the initiation factor in fungi and vertebrates. A mechanistically identical reaction is known in the biosynthetic pathway leading to pyrrolizidine alkaloids in plants. Deoxyhypusine synthase from tobacco was cloned and expressed in active form in Escherichia coli. It catalyzes the formation of a deoxyhypusine residue in the tobacco eIF5A substrate as shown by gas chromatography coupled with a mass spectrometer. The enzyme also accepts free putrescine as the aminobutyl acceptor, instead of lysine bound in the eIF5A polypeptide chain, yielding homospermidine. Conversely, it accepts homospermidine instead of spermidine as the aminobutyl donor, whereby the reactions with putrescine and homospermidine proceed at the same rate as those involving the authentic substrates. The conversion of deoxyhypusine synthase-catalyzed eIF5A deoxyhypusinylation pinpoints a function for spermidine in plant metabolism. Furthermore, and quite unexpectedly, the substrate spectrum of deoxyhypusine synthase hints at a biochemical basis behind the sparse and skew occurrence of both homospermidine and its pyrrolizidine derivatives across distantly related plant taxa.

Doppler pulse waveform analysis of carotid and middle cerebral artery flow in a patient with an intra-aortic balloon pump.

A 60-year-old man with intractable congestive heart failure (CHF) had an intra-aortic balloon pump placed to augment coronary artery perfusion. During the evaluation prior to heart transplant, carotid and transcranial Doppler ultrasonography (TCD) was performed. The authors report the findings of Doppler waveform analysis and the presence of balloon pump artifact which caused difficulty in distinguishing between internal and external carotid arteries. Higher blood flow velocity during diastole and diastolic runoff characteristically seen while insonating the internal carotid artery enabled that distinction.

Purification, molecular cloning and expression in Escherichia coli of homospermidine synthase from Rhodopseudomonas viridis.

Homospermidine synthase (HSS) catalyzes the synthesis of the polyamine homospermidine from 2 mol putrescine in an NAD(+)-dependent reaction. In this study, the enzyme was purified from anaerobically grown cultures of the photosynthetic bacterium Rhodopseudomonas viridis to electrophoretic homogeneity using a three-step procedure. The enzyme was shown to be a homodimer of 52-kDa subunits. Six endopeptidase LysC fragments were sequenced from the purified protein. With the aid of degenerate primers designed against these peptides, specific PCR products from R. viridis DNA were obtained that were used as hybridization probes to isolate the hss gene from a library constructed in lambda EMBL4. The hss gene and flanking regions were sequenced and were shown to exist as a single copy in the R. viridis genome. HSS is translated from a monocistronic mRNA and possesses no detectable similarity to previously sequenced gene products. Escherichia coli, which lacks HSS activity, was transformed with an expression plasmid containing the hss coding region under the control of a bacteriophage T7 promoter. Upon induction, transformed F. coli cells accumulate enzymatically active and highly stable R. viridis HSS at levels corresponding to 40-50% of the soluble protein in crude extracts.