Development of palliative care clinical practice guidelines and referral care pathways for primary care practitioners in Pakistan.

BACKGROUND: Despite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan. METHODS: A GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The "National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021" was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either "Adopt," "Adapt" or "Exclude". The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines. RESULTS: Twenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made. CONCLUSION: The described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.

A comprehensive review on transethosomes as a novel vesicular approach for drug delivery through transdermal route.

Drug delivery through transdermal route is one of the effective methods for the application of drugs. It overcomes many drawbacks which are encountered with the oral route. Moreover, many drugs are not able to pass through the stratum corneum, which is the main barrier for the transdermal drug delivery. Formation of ultra-deformable vesicles (UDVs) is a novel technique for the transdermal applications of the drugs. Transethosomes (TEs), ethosomes, and transferosomes are all part of the UDV. Because of the presence of increased concentrations of ethanol, phospholipids, and edge activators, TEs provide improved drug permeation through the stratum corneum. Because of the elasticity of TEs, drug penetration into the deeper layer of skin also increases. TEs can be prepared using a variety of techniques, including the cold method, hot method, thin film hydration method, and the ethanol injection method. It increases patient adherence and compliance because it is a non-invasive procedure of administering drugs. Characterization of the TEs includes pH determination, size and shape, zeta potential, particle size determination, transition temperature, drug content, vesicle stability, and skin permeation studies. These vesicular systems can be utilized to deliver a variety of medications transdermally, including analgesics, antibiotics, antivirals, and anticancer and arthritis medications. This review aims to describe vesicular approaches that had been used to overcome the barrier for the transdermal delivery of drug and also describes brief composition, method of preparation, characterization tests, mechanism of penetration of TEs, as well as highlighted various applications of TEs in medicine.

Efficacy and Safety of Intranasal Fentanyl in Pediatric Emergencies: A Systematic Review and Meta-analysis.

BACKGROUND: Intranasal fentanyl (INF) has gained popularity in pediatric emergency departments (EDs) as an effective alternative to intravenous morphine for treating acute moderate to severe pain. Intranasal fentanyl eliminates the need for invasive access, making it advantageous for patients with minor injuries. Our study aims to provide a comprehensive evaluation of the available evidence regarding the effectiveness and safety of INF administration in pediatric emergency wards, particularly compared with other treatment options described in the literature. METHODS: A thorough search strategy identified randomized controlled trials assessing INF in the pediatric emergency ward. Eligible studies were independently screened, and relevant data were extracted. The analysis used pooled risk ratio (RR) for dichotomous outcomes and the standardized mean difference (SMD) for continuous ones. Randomized controlled trials' quality was assessed using the Cochrane Risk of Bias Assessment Tool 2. RESULTS: In our study, 8 randomized controlled trials involving 806 patients, INF demonstrated superior effectiveness in reducing pain compared with other comparators at the 15- to 20-minute mark (SMD, -0.23; 95% confidence interval, -0.37 to -0.08; P = 0.002). However, no significant differences were found at the 30- and 60-minute time points (SMDs, -0.16; 95% CI, -0.50, 0.19; P = 0.37; and -0.16; 95% CI, -0.50 to 0.19; P = 0.78) except when excluding one study to resolve heterogeneity at the 30-minute mark (RR, -0.02; 95% CI, -0.24 to 0.20; P = 0.87). Intranasal fentanyl also exhibited a better adverse outcome profile, with a lower risk of total adverse events and nausea/vomiting (RR, 0.66; 95% CI, 0.48-0.91; P = 0.01; and RR, 0.43; 95% CI, 0.30-0.63; P > 0.001) compared with other analgesics. However, no significant differences were observed for dizziness and hallucination (RR, 0.43; 95% CI, 0.30-0.63; P = 0.68; and RR, 0.43; 95% CI, 0.30-0.63; P = 0.35). CONCLUSIONS: Our study assessed the effectiveness of INF compared with other analgesics in pain reduction. Intranasal fentanyl demonstrated superior pain reduction at the 15- to 20-minute point but showed no significant differences at 30 and 60 minutes. Intranasal fentanyl also had a more favorable adverse event profile, with a lower risk of nausea and vomiting than other analgesics. However, no significant differences were observed in dizziness and hallucination between the groups.

Formulation and evaluation of miconazole lipogel for enhanced drug permeation.

Hydrophilic drugs could be incorporated into the skin surface by manes of Lipogel. This study aimed to prepare miconazole lipogel with natural ingredients to enhance drug permeability using dimethyl Sulfoxide (DMSO). The miconazole lipogels, A1 (without DMSO) and A2 (with DMSO) were formulated and evaluated for organoleptic evaluation, pH, viscosity, stability studies, freeze-thawing, drug release profile and drug permeation enhancement. Results had stated that prepared lipogel's pH falls within the acceptable range required for topical delivery (4 to 6) while both formulations show good results in organoleptic evaluation. The A2 formulation containing DMSO shows better permeation of miconazole (84.76%) on the artificial skin membrane as compared to A1 lipogel formulation (50.64%). In in-vitro drug release studies, A2 for-mulation showed 87.48% drug release while A1 showed just 60.1% drug release from lipogel. Stability studies were performed on model formulations under environmental conditions and both showed good spreadibility, stable pH, free of grittiness and good consistency in formulation. The results concluded that A2 formulation containing DMSO shows better results as compared to DMSO-free drug lipogel.

Impact of an outpatient palliative care consultation and symptom clusters in terminal patients at a tertiary care center in Pakistan.

BACKGROUND: Patients with terminal diseases may benefit physically and psychosocially from an outpatient palliative care visit. Palliative care services are limited in Pakistan. An improved understanding of the symptom clusters present in our population is needed. The first outpatient palliative care center in Karachi, Pakistan, was established at our tertiary care institution. The primary aim of this study was to evaluate the impact of a palliative care outpatient consultation on symptom burden in patients with a terminal diagnosis. The secondary aim was to analyze the symptom clusters present in our population. METHODS: Patients with a terminal diagnosis referred to our outpatient palliative department between August 2020-August 2022 were enrolled. The Edmonton Symptom Assessment Scale (ESAS) questionnaire was administered at the initial visit and the first follow-up visit at one month. Change in symptom burden was assessed using a Wilcoxon signed ranks test. A principal component analysis with varimax rotation was performed on the symptoms reported at the initial visit to evaluate symptom clusters. The palliative performance scale (PPS) was used to measure the performance status of palliative care patients. RESULTS: Among the 78 patients included in this study, the average age was 59 ± 16.6 years, 52.6% were males, 99% patients had an oncological diagnosis, and the median duration between two visits was 14 (Q1-Q3: (7.0, 21.0) days. The median PPS level was 60% (Q1-Q3: 50-70). Overall, ESAS scores decreased between the two visits (6.0 (2.8, 11.0), p < 0.001) with statistically significant improvement in pain (5.0 vs. 2.5, p < 0.001), loss of appetite (5.0 vs. 4.0, p = 0.004), depression (2.0 vs. 0.0, p < 0.001), and anxiety (1.5 vs. 0.0, p = 0.032). Based on symptoms at the initial visit, 3 clusters were present in our population. Cluster 1 included anxiety, depression, and wellbeing; cluster 2 included nausea, loss of appetite, tiredness, and shortness of breath; and cluster 3 included drowsiness. CONCLUSION: An outpatient palliative care visit significantly improved symptom burden in patients with a terminal diagnosis. Patients may benefit from further development of outpatient palliative care facilities to improve the quality of life in terminally ill patients.

Solid lipid nanoparticles: a versatile approach for controlled release and targeted drug delivery.

Solid Lipid Nanoparticles (SLN), the first type of lipid-based solid carrier systems in the nanometer range, were introduced as a replacement for liposomes. SLN are aqueous colloidal dispersions with solid biodegradable lipids as their matrix. SLN is produced using processes like solvent diffusion method and high-pressure homogenization, among others. Major benefits include regulated release, increased bioavailability, preservation of peptides and chemically labile compounds like retinol against degradation, cost-effective excipients, better drug integration, and a broad range of applications. Solid lipid nanoparticles can be administered via different routes, such as oral, parenteral, pulmonary, etc. SLN can be prepared by using high shear mixing as well as low shear mixing. The next generation of solid lipids, nanostructured lipid carriers (NLC), can reduce some of the drawbacks of SLN, such as its restricted capacity for drug loading and drug expulsion during storage. NLC are controlled nanostructured lipid particles that enhance drug loading. This review covers a brief introduction of solid lipid nanoparticles, manufacturing techniques, benefits, limitations, and their characterization tests.

Vesicular approach of cubosomes, its components, preparation techniques, evaluation and their appraisal for targeting cancer cells.

Cancer has been characterized by abnormal and uncontrolled proliferation of cells. Majority of drugs given through chemotherapy produce unwanted and adverse effects of chemotherapeutic agents to the other healthy cells and tissues of body. Various nanocarriers have now been considered for treatment of cancer. Among various nanocarriers, cubosomes are the nano sized dispersions that have drawn interest of researchers recently. Cubosomes are defined as dispersions of colloidal nature containing cubic crystalline liquid formations in aqueous medium in presence of suitable surfactant molecules. The unique capacity to encapsulate lipophilic, hydrophilic, and amphiphilic compounds inside their structure distinguishes them among others. Top- down method and hydrotrope method are most often employed methods for cubosomes preparation. Cubosomes can be characterized by Polarized light microscopy Photon correlation spectroscopy X-ray scattering (SAXS), Transmission electron microscopy and various stability studies. Cubic lipid nanoparticles have a very stable cubic structure that enables slower dissociation rate, increased retention and site-specific delivery of drugs. Cubosomes containing extracts of cornelian cherry for boosting anti-cancerous effects in cancer of colorectal cells by preventing against GIT destruction. When applied for skin cancer, cubosomes have shown to be having enhanced permeation of the drug. In liver cancer, increased bioavailability of drug was observed via cubosomes. This current review elaborates the advancement of cubosomes and their effective role in the treatment of cancer. This review aims to describe vesicular approach of cubosomes, its composition and method of preparation, characterization tests as well as elaborates various applications of cubosomes in cancer.

Evaluation of postgraduate family medicine trainee's knowledge and attitude following an online Educational Module in Palliative Care: A descriptive study.

Objectives: To identify improvement in knowledge and attitude of Family Medicine (FM) postgraduate trainees (PGT) towards Palliative care (PC) in order to provide effective care to the patients with advanced disease. Methods: A cross-sectional study was conducted over eight weeks from 1st July till 3rd September 2021 at Family Medicine Department, Aga Khan University Hospital (AKUH). PGT who willingly signed the written informed consent were enrolled in the study. Descriptive analysis, frequencies, proportions and thematic approach were used for data analysis. Data was analyzed using SPSS version 23. Results: FM-PGT were included in the study. Improvement in knowledge was observed in posttest scores along with positive change in their attitude and improved perception of level of confidence for managing PC patients. Overall assessment of PCM was positive. Conclusion: This PCM seems to be a useful tool for PC training in postgraduate medical education (PGME). This highlights some useful aspects for future applications in PC education and training.

Confronted With Death: Factors Affecting End of Life Decisions in the Intensive Care Unit.

To determine how often care is limited at the end of life and the factors that are associated with this decision, we reviewed the medical records of all patients that passed away in the intensive care units (ICU) of Aga Khan University. We found that a majority of patients had Do-Not-Resuscitate orders in place at the time of death. Our analysis yielded 6 variables that were associated with the decision to limit care. These are patient age, sex, duration of mechanical ventilation, Glasgow Coma Scale (GCS) ≤8 at any point during ICU stay, GCS ≤8 in the first 24 hours following ICU admission, and mean arterial pressure <65 mm of Hg while on vasopressors in the first 24 hours following ICU admission. These variables require further study and should be carefully considered during end of life discussions to allow for optimal management at the end of life.

Formulation of Aloe vera based curcumin topical gel and its in-vitro evaluation.

Curcumin is a polyphenolic compound obtained from the rhizome of plant. Curcuma longa possesses antioxidant, anti-inflammatory and wound-healing properties. The current study was designed to formulate an Aloe vera-based curcumin topical gel. To enhance curcumin's solubility, it was first complexed with ß-cyclodextrin, given its hydrophobic nature. While Carbopol, carboxy methyl cellulose and guar gum were used in various concentrations as gelling agents for preparation of the formulations. The effect of propylene glycol as a permeation enhancer was also observed. The prepared formulations were tested for different parameters such as physical appearance, spreadability, drug content, pH, viscosity and in-vitro permeation. All the formulations were found to be stable. All formulations consisting of propylene glycol showed permeation within the range of 80-90%. The maximum percentage of drug release was observed in the formulation containing 1% Carbopol 940 as the gelling agent which also exhibited good spreadability. In comparison to gels formulated with carboxymethyl cellulose and guar gum, Carbopol 940 gels appeared more translucent. Consequently, it was concluded that curcumin's permeation improved following its complexation with ß-cyclodextrin. This complex when further used for the formation of an aloe vera based topical gel with 1% Carbopol 940 and 10% propylene glycol demonstrated maximum efficacy.

IGWO-IVNet3: DL-Based Automatic Diagnosis of Lung Nodules Using an Improved Gray Wolf Optimization and InceptionNet-V3.

Artificial intelligence plays an essential role in diagnosing lung cancer. Lung cancer is notoriously difficult to diagnose until it has progressed to a late stage, making it a leading cause of cancer-related mortality. Lung cancer is fatal if not treated early, making this a significant issue. Initial diagnosis of malignant nodules is often made using chest radiography (X-ray) and computed tomography (CT) scans; nevertheless, the possibility of benign nodules leads to wrong choices. In their first phases, benign and malignant nodules seem very similar. Additionally, radiologists have a hard time viewing and categorizing lung abnormalities. Lung cancer screenings performed by radiologists are often performed with the use of computer-aided diagnostic technologies. Computer scientists have presented many methods for identifying lung cancer in recent years. Low-quality images compromise the segmentation process, rendering traditional lung cancer prediction algorithms inaccurate. This article suggests a highly effective strategy for identifying and categorizing lung cancer. Noise in the pictures was reduced using a weighted filter, and the improved Gray Wolf Optimization method was performed before segmentation with watershed modification and dilation operations. We used InceptionNet-V3 to classify lung cancer into three groups, and it performed well compared to prior studies: 98.96% accuracy, 94.74% specificity, as well as 100% sensitivity.

Tanneries impact on groundwater quality: a case study of Kasur city in Pakistan.

Leather industry is the second largest export-earning sector of Pakistan. However, because of poor waste management, this industry has been continuously polluting the environment. In this paper, the impact of tanneries on the groundwater quality of Kasur city (i.e., the second largest leather producing city) is examined. The study is conducted in the following three phases: (I) water samples collection, (II) determination of physio-chemical properties, and (III) application of data mining techniques. In phase I, groundwater samples were collected from various sources such as hand pumps, motor pumps, and tube wells. In phase II, several physio-chemical properties such as (i) total dissolved solids (TDS), (ii) pH, (iii) turbidity, (iv) electrical conductivity (EC), (v) total hardness (TH), (vi) total alkalinity (TA), (vii) nitrates, (viii) chromium, (ix) fluoride, and (x) chloride were estimated. The estimated values of all these foregoing parameters are then compared with the Punjab Environmental Quality Standards for Drinking Water (PEQSDW). In phase III, principle component analysis and cluster analysis of the estimated parameters were performed to elucidate the relation between various parameters and to highlight the highly vulnerable sites, respectively. The results exhibit that most of the sampling collections sites are at the threshold of losing quality water. Moreover, it is also found that Mangal Mandi carries the worst groundwater quality among all sampling locations. Overall, it is concluded that serious attention is due from the water and wastewater authorities to further investigate and monitor the groundwater quality of Kasur before the country strikes with another pandemic after COVID-19.

Contact-Free Pulse Signal Extraction from Human Face Videos: A Review and New Optimized Filtering Approach.

In this chapter, we review methods for video-based heart monitoring, from classical signal processing approaches to modern deep learning methods. In addition, we propose a new method for learning an optimal filter that can overcome many of the problems that can affect classical approaches, such as light reflection and subject's movements, at a fraction of the training cost of deep learning approaches. Following the usual procedures for region of interest extraction and tracking, robust skin color estimation and signal pre-processing, we introduce a least-squares error optimal filter, learnt using an established training dataset to estimate the photoplethysmographic (PPG) signal more accurately from the measured color changes over time. This method not only improves the accuracy of heart rate measurement but also resulted in the extraction of a cleaner pulse signal, which could be integrated into many other useful applications such as human biometric recognition or recognition of emotional state. The method was tested on the DEAP dataset and showed improved performance over the best previous classical method on that dataset. The results obtained show that our proposed contact-free heart rate measurement method has significantly improved on existing methods.

Treatment outcomes of patients with tuberculosis in war affected region of Khyber Pakhtunkhwa, Pakistan.

BACKGROUND: Globally, tuberculosis (TB) remains the leading cause of death from a single infectious disease. TB treatment outcome is an important indicator for the effectiveness of a national TB control program. This study aimed to assess treatment outcomes of TB patients and its determinants in Batkhela, Khyber Pakhtunkhwa, Pakistan. METHODS: A retrospective cohort study was designed using all TB patients who were enrolled at District Head Quarter (DHQ) Hospital Batkhela, Pakistan, from January 2011 to December 2014. A binary logistic regression models were used to identify factors associated with successful TB treatment outcomes defined as the sum of cure and completed treatment. RESULTS: A total of 515 TB patients were registered, of which 237 (46%) were males and 278 (53.98%) females. Of all patients, 234 (45.44%) were cured and 210 (40.77%) completed treatment. The overall treatment success rate was 444 (86.21%). Age 0-20 years (adjusted odds ratio, AOR = 3.47; 95% confidence interval, CI) = 1.54-7.81; P = 0.003), smear-positive pulmonary TB (AOR) = 3.58; 95% CI = 1.89-6.78; P = < 0.001), treatment category (AOR = 4.71; 95% CI = 1.17-18.97; P = 0.029), and year of enrollment 2012 (AOR = 6.26; 95% CI = 2.52-15.59; P = < 0.001) were significantly associated with successful treatment outcome. CONCLUSIONS: The overall treatment success rate is satisfactory but still need to be improved to achieve the international targeted treatment outcome. Type of TB, age, treatment category, and year of enrollment were significantly associated with successful treatment outcomes.

Prevalence of thyroid stimulating hormone dysfunction among sofosbuvir-treated HCV-infected patients: A real-world clinical experience.

Thyroid dysfunctions occur frequently among hepatitis C virus (HCV)-infected patients. Accumulating evidence has shown the higher incidence of thyroid dysfunctions in interferon-treated patients that was previously the standard of care therapy. However, the prevalence of thyroid disorders has not been studied in the recently developed interferon-free regimens or direct-acting antiviral (DAA) drugs-treated patients. We recruited 37 patients who had just completed 6 months long sofosbuvir-based treatment, and 26 interferon-treated patients were also included in the study. Serum thyrotropin level of all participants was measured using VIDAS. We observed thyroid dysfunctions in both pegylated interferon-experienced and DAA drug-experienced patients but the prevalence of hyperthyroidism was found significantly higher in patients treated with interferon-based regimen as compared with interferon-free regimens. This high prevalence of hypothyroidism in patients with HCV posttreatment highlights the need for regular periodic screening of patients during the treatment.

Inequalities and outcomes: end stage kidney disease in ethnic minorities.

BACKGROUND: The international evidence about outcomes of End Stage Kidney Disease (ESKD) for ethnic minorities was reviewed to identify gaps and make recommendations for researchers and policy makers. METHODS: Nine databases were searched systematically with 112 studies from 14 different countries included and analysed to produce a thematic map of the literature. RESULTS: Reviews (n = 26) highlighted different mortality rates and specific causes between ethnic groups and by stage of kidney disease associated with individual, genetic, social and environmental factors. Primary studies focussing on uptake of treatment modalities (n = 19) found ethnic differences in access. Research evaluating intermediate outcomes and quality of care in different treatment phases (n = 35) e.g. dialysis adequacy, transplant evaluation and immunosuppression showed ethnic minorities were disadvantaged. This is despite a survival paradox for some ethnic minorities on dialysis seen in studies of longer term outcomes (n = 29) e.g. in survival time post-transplant and mortality. There were few studies which focussed on end of life care (n = 3) and ethnicity. Gaps identified were: limited evidence from all stages of the ESKD pathway, particularly end of life care; a lack of system oriented studies with a reliance on national routine datasets which are limited in scope; a dearth of qualitative studies; and a lack studies from many countries with limited cross country comparison and learning. CONCLUSIONS: Differences between ethnic groups occur at various points and in a variety of outcomes throughout the kidney care system. The combination of individual factors and system related variables affect ethnic groups differently indicating a need for culturally intelligent policy informed by research to prevent disadvantage.

Role of altered immune cells in liver diseases: a review.

Immune cells play an important role in controlling liver tumorigenesis, viral hepatitis, liver fibrosis and contribute to pathogenesis of liver inflammation and injury. Accumulating evidence suggests the effectiveness of natural killer (NK) cells and Kupffer cells (KCs) against viral hepatitis, hepatocellular damage, liver fibrosis, and carcinogenesis. Activation of natural killer cells provides a novel therapeutic strategy to cure liver related diseases. This review discusses the emerging roles of immune cells in liver disorders and it will provide baseline data to scientists to design better therapies for treatment.

Exploring end-of-life care for South Asian kidney patients: interviewer reflections.

The reduction of inequalities in access to quality care has been a central tenet of UK health policy. Ethnic minorities may experience additional inequalities because of language and other cultural barriers. This article reports interviewer reflections of conducting interviews with South Asian kidney patients about their experiences of end-of-life care. It explores themes which emerged from the analysis of a focus group held with eight bilingual research interviewers. The relevance of these themes to understanding inequalities and access to end-of-life care is discussed; together with the potential for the research process to contribute to service improvement.

Delayed nausea and vomiting from carboplatin doublet chemotherapy.

BACKGROUND: Delayed nausea and vomiting following administration of carboplatin containing chemotherapy regimen remains a clinically significant problem for patients with cancer despite administration of standard antiemetic prophylaxis comprising of a 5-HT3 antagonist and dexamethasone. We performed a prospective study to define the incidence and risk factors for delayed chemotherapy-induced nausea and vomiting (CINV). METHODS: Previously untreated patients with newly diagnosed cancer scheduled to receive carboplatin containing chemotherapy (AUC 5 or above), but no prophylactic aprepitant were enrolled in the study. The primary endpoint was the incidence of delayed CINV after Cycle 1 of chemotherapy. Secondary endpoints included the incidence of CINV with the third chemotherapy cycle and gender differences in incidence of CINV. Patients completed the Functional Living Index Emesis (FLIE) questionnaires 24, 48, 72 and 96 hours after receiving chemotherapy. Telephone interviews were conducted 24-48 hours following chemotherapy to assess the severity and need for breakthrough medications for CINV. RESULTS: Between December 2006 and July 2009, 105 patients were enrolled onto this study. Delayed emesis following Cycle 1 of carboplatin was observed in 30% of patients. Of these, 14.1%, 22.4% and 23.5% of patients described CINV at 48, 72, and 96 hours, respectively. The incidence of delayed CINV following Cycle 3 dropped to 12.8%, 14.6% and 16% of patients at 48, 72 and 96 hours, respectively. No differences were observed in the incidence of CINV between men and women. A total of 20% of patients required use of breakthrough antiemetics with Cycle 1. CONCLUSIONS: Without prophylactic aprepitant administration, 30% of patients receiving carboplatin containing regimen had moderate to severe delayed CINV.

Crisis intervention for people with severe mental illnesses.

BACKGROUND: A particularly difficult challenge for community treatment of people with serious mental illnesses is the delivery of an acceptable level of care during the acute phases of severe mental illness. Crisis-intervention models of care were developed as a possible solution. OBJECTIVES: To review the effects of crisis-intervention models for anyone with serious mental illness experiencing an acute episode compared to the standard care they would normally receive. If possible, to compare the effects of mobile crisis teams visiting patients' homes with crisis units based in home-like residential houses. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials. There is no language, time, document type, or publication status limitations for inclusion of records in the register. This search was undertaken in 1998 and then updated 2003, 2006, 2010 and September 29, 2014. SELECTION CRITERIA: We included all randomised controlled trials of crisis-intervention models versus standard care for people with severe mental illnesses that met our inclusion criteria. DATA COLLECTION AND ANALYSIS: We independently extracted data from these trials and we estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CI). We assessed risk of bias for included studies and used GRADE to create a 'Summary of findings' table. MAIN RESULTS: The update search September 2014 found no further new studies for inclusion, the number of studies included in this review remains eight with a total of 1144 participants. Our main outcomes of interest are hospital use, global state, mental state, quality of life, participant satisfaction and family burden. With the exception of mental state, it was not possible to pool data for these outcomes.Crisis intervention may reduce repeat admissions to hospital (excluding index admissions) at six months (1 RCT, n = 369, RR 0.75 CI 0.50 to 1.13, high quality evidence), but does appear to reduce family burden (at six months: 1 RCT, n = 120, RR 0.34 CI 0.20 to 0.59, low quality evidence), improve mental state (Brief Psychiatric Rating Scale (BPRS) three months: 2 RCTs, n = 248, MD -4.03 CI -8.18 to 0.12, low quality evidence), and improve global state (Global Assessment Scale (GAS) 20 months; 1 RCT, n = 142, MD 5.70, -0.26 to 11.66, moderate quality evidence). Participants in the crisis-intervention group were more satisfied with their care 20 months after crisis (Client Satisfaction Questionnaire (CSQ-8): 1 RCT, n = 137, MD 5.40 CI 3.91 to 6.89, moderate quality evidence). However, quality of life scores at six months were similar between treatment groups (Manchester Short Assessment of quality of life (MANSA); 1 RCT, n = 226, MD -1.50 CI -5.15 to 2.15, low quality evidence). Favourable results for crisis intervention were also found for leaving the study early and family satisfaction. No differences in death rates were found. Some studies suggested crisis intervention to be more cost-effective than hospital care but all numerical data were either skewed or unusable. We identified no data on staff satisfaction, carer input, complications with medication or number of relapses. AUTHORS' CONCLUSIONS: Care based on crisis-intervention principles, with or without an ongoing homecare package, appears to be a viable and acceptable way of treating people with serious mental illnesses. However only eight small studies with unclear blinding, reporting and attrition bias could be included and evidence for the main outcomes of interest is low to moderate quality. If this approach is to be widely implemented it would seem that more evaluative studies are still needed.