[Community mental health approaches for avoidance of patient placement in closed psychiatric facilities-a positioning]. / Gemeindepsychiatrische Ansätze zur Vermeidung der Unterbringung in geschlossenen Heimen ­ eine Positionsbestimmung.

BACKGROUND: In many cases the placement of people with mental disorders in closed residential homes is an expression of the lack of alternative care options. In the area of tension between the need for security in the case of chronically self-endangering behavior, recurrent acute psychiatric crisis interventions and a lack of perspective to establish a permanent therapy, in many places a placement in a closed facility approved under care law is carried out. OBJECTIVE: What alternatives are there to closed institutional care in the psychiatric care system in Germany? METHODS: A trialogical discussion process was carried out in an expert panel taking the relevant literature into consideration and with the participation of organizations of those affected and their relatives. RESULTS: The community psychiatric care system in Germany is extremely heterogeneous. The fragmented sociolegal and financing systems makes cross-sectoral and continuous care planning and service provision difficult. Precisely tailored and individualized services that could prevent the persons concerned from being placed in a closed home exist in Germany only at a few locations and in the form of individual model projects. CONCLUSION: The structural and sociolegal deficits addressed require a reform of the institutional framework and a redirection of all actors involved, including the clinics. Alternative approaches to the care of people with severe mental disorders are outlined. These include the Wedding model, binding community psychiatric structures, the basic functional model and assistance services under the German Social Code IX following the revision of the Federal Participation Act.

["Treatment at Home" in Lengerich (Westfalia) - A Model of Community-Based Mental Health Care]. / "HT ­ Behandlung zu Hause" in Lengerich (Westfalen) ­ ein Modellprojekt gemeindenaher, psychiatrischer Versorgung.

We examined the effectiveness of a new homebased integrated care intervention model for patients with multiple-episode psychosis in a rural area in Germany, which combines elements of 2 other well-defined interventions: Assertive Community Treatment and Home Treatment. The pilot evaluation was conducted in 2 steps, using a quantitative and a qualitative design. In a 24-month follow-up period, patients showed significant improvement in symptoms, illness severity, global functioning and quality of life, as well as larger reduction in the number of days of inpatient treatment needed. The results of the qualitative survey indicate a high level of satisfaction with the care offered. The results are in agreement with other German studies. Home Treatment in Lengerich seems to be a model, which can address the fragmentation of the German healthcare system and provide effective care to long-term patients in a setting outside of psychiatric hospitals.

[Influence of staffing levels on conflicts in inpatient psychiatric care]. / Einfluss der Personalbesetzung auf Konflikte auf psychiatrischen Stationen.

Acute psychiatric wards are an important element in the mental healthcare of people at risk for acute harm to others or self-harm. Unfortunately, aggression, violence (conflict) and the use of coercion (containment) are still part of psychiatric care. The decisive factor for the correct handling of these situations is the quantity as well as the quality of the employees. Therefore, the present study dealt with the care situation on acute psychiatric wards. The hypothesis is that both the number of beds on the acute psychiatric ward and the number of caregivers have an impact on the occurrence of conflict and containment. For this purpose, data were collected in 6 clinics on a total of 12 acute psychiatric wards. The Patient Staff Conflict Checklist - Shift Report (PCC-SR) was used as the data entry tool. A total of 2026 shifts (early, late and night shifts) were recorded and evaluated. The staffing of the wards with nursing personnel varied considerably. The results show that both the size of the ward and also the number of caregivers on acute psychiatric wards have a significant impact on the occurrence of conflicts. The results also show that the incidence of conflicting behavior of patients differs both in terms of the wards of the hospitals involved and in the type of service considered. In addition, it can be seen that the extent of closure of an acute ward (i. e. the closed ward or entrance door) and the size of a ward (i. e. the number of beds) have a negative impact on the incidence of inpatient acute psychiatric contexts. The occurrence of conflict behavior can lead to alien or self-endangerment and to a variety of de-escalating and containment measures. This requires appropriate human resources.

['NischE - Nicht von schlechten Eltern' - Evaluation of a Multidisciplinary Teamwork Approach to Support Children in Families with Mentally Ill Parents]. / "NischE ­ Nicht von schlechten Eltern" ­ Evaluation eines Kooperationsprojektes zur Unterstützung von Kindern in Familien mit psychisch- oder suchtbelasteten Eltern.

Objective: Evaluation of a project offering low-threshold anonymous counseling services jointly by mental health services and child and youth services to support children in families with mentally ill parents Methods: Evaluating performance data and completed questionnaires returned by parents included in the project. Results: Between 2011-2014, 150 families received up to 10 sessions of family-oriented counseling. The survey results indicate a high level of satisfaction with the services of the cooperation project. The vast majority of respondents said that they would recommend this service to others or would themselves take advantage of the services again. Conclusion: A collaboration of service providers from psychiatry and child and youth welfare department resulting in continuous availability of counseling with a common family medical perspective represents a forward-looking model for families with a mentally ill parent.

[Personnel resources for psychiatric institutions. Needs assessment exemplified by the nursing profession in Germany]. / Personalressourcen für psychiatrische Einrichtungen. Bedarfsermittlung am Beispiel der Pflegefachberufe in Deutschland.

BACKGROUND: The Psychiatry Personnel Act (Psych-PV) as the basis for personnel assessment in psychiatry becomes invalid on 1 January 2019. Because the Psych-PV previously coupled the personnel quota with the intensity of services provided, current efforts are required to develop an instrument to adapt the extent of financed personnel resources to the manifold new legal requirements and advances in treatment in terms of guideline-based care. OBJECTIVES: Based on a literature search and the additional use of a databank of routine data, an example of a calculation was made to estimate the additional personnel resources which would be necessary for psychoeducation and fulfill the legal requirements from 2019 onwards. An investigation was also carried out to identify which psychiatry guidelines contain time values which can be used for calculation of personnel requirements. MATERIAL AND METHODS: A three-step approach was used: (1) screening of the current guidelines and determination of the average intervention times with respect to nursing staff, (2) exemplary comparison between the times for guideline-based psychoeducation for patients in the diagnosis groups F32-F33 with the times allocated by the Psych-PV and (3) determination of times between education measures prescribed by law and necessary training for which no (sufficient) time contingents are provided in the Psych-PV. RESULTS: Times for individual activities (e.g. psychoeducation), which are also appropriate for nursing personnel can be found in the primary literature on guidelines; however, these include only a small proportion of tasks undertaken by nursing personnel. For psychoeducation it could be shown that additional time contingents would be necessary in the Psych-PV. Furthermore, there are new mandatory but disregarded schooling measures and instructions for nursing staff, the duration of which can be conservatively calculated as 21 min per case per hospital stay. CONCLUSION: The empirical approach presented in this study shows the possibility to identify time resources needed for nursing personnel to provide guideline-based interventions; however, these represent only partial aspects of nursing activities. Further research and analytical methods are needed to calculate the currently needed personnel resources for all nursing activities and other professional groups involved in treatment in inpatient psychiatry.

Comorbidity in context: Part 2. Ethicolegal considerations around HIV and tuberculosis during the COVID-19 pandemic in South Africa.

The COVID-19 pandemic has brought discussions around the appropriate and fair rationing of scare resources to the forefront. This is of special importance in a country such as South Africa (SA), where scarce resources interface with high levels of need. A large proportion of the SA population has risk factors associated with worse COVID-19 outcomes. Many people are also potentially medically and socially vulnerable secondary to the high levels of infection with HIV and tuberculosis (TB) in the country. This is the second of two articles. The first examined the clinical evidence regarding the inclusion of HIV and TB as comorbidities relevant to intensive care unit (ICU) admission triage criteria. Given the fact that patients with HIV or TB may potentially be excluded from admission to an ICU on the basis of an assumption of lack of clinical suitability for critical care, in this article we explore the ethicolegal implications of limiting ICU access of persons living with HIV or TB. We argue that all allocation and rationing decisions must be in terms of SA law, which prohibits unfair discrimination. In addition, ethical decision-making demands accurate and evidence-based strategies for the fair distribution of limited resources. Rationing decisions and processes should be fair and based on visible and consistent criteria that can be subjected to objective scrutiny, with the ultimate aim of ensuring accountability, equity and fairness.

Comorbidity in context: Part 1. Medical considerations around HIV and tuberculosis during the COVID-19 pandemic in South Africa.

Infectious diseases pandemics have devastating health, social and economic consequences, especially in developing countries such as South Africa. Scarce medical resources must often be rationed effectively to contain the disease outbreak. In the case of COVID-19, even the best-resourced countries will have inadequate intensive care facilities for the large number of patients needing admission and ventilation. The scarcity of medical resources creates the need for national governments to establish admission criteria that are evidence-based and fair. Questions have been raised whether infection with HIV or tuberculosis (TB) may amplify the risk of adverse COVID-19 outcomes and therefore whether these conditions should be factored in when deciding on the rationing of intensive care facilities. In light of these questions, clinical evidence regarding inclusion of these infections as comorbidities relevant to intensive care unit admission triage criteria is investigated in the first of a two-part series of articles. There is currently no evidence to indicate that HIV or TB infection on their own predispose to an increased risk of infection with SARS-CoV-2 or worse outcomes for COVID-19. It is recommended that, as for other medical conditions, validated scoring systems for poor prognostic factors should be applied. A subsequent article examines the ethicolegal implications of limiting intensive care access of persons living with HIV or TB.

Protecting participants in health research: The South African Material Transfer Agreement.

The need to transfer human biological materials (HBMs) across national boundaries has become increasingly important in view of increased biobank and commercial activities globally. In light of South Africa (SA)'s history of colonisation and racial discrimination, coupled with well-known instances of exploitation of research participants in the developing world, it is critical that the management of HBMs from and to other jurisdictions is explored and regulated. Material transfer agreements (MTAs) represent an important point of departure in such a process. This article explores the need for a uniform MTA in SA and discusses some aspects of the recently gazetted national MTA, which provides a framework that can serve as a safeguard for cross-border transfer of HBMs in the absence of the National Health Act's chapter 8 regulations in this regard.

The effect of different intervention programmes on the self-concept and motor proficiency of 7- to 9-year-old children with DCD.

BACKGROUND: The self-concept of children is influenced by developmental co-ordination disorder (DCD). The aim was to determine the most effective method in enhancing motor proficiency and self-concept of 7- to 9-year-old children with DCD. METHODS: Teachers at nine different schools identified 201 possible DCD candidates. The Movement Assessment Battery for Children identified 58 with DCD (36 boys and 22 girls). Self-concept and anxiety were determined by the Tennessee Self-Concept Scale (Child Form) and Child Anxiety Scale respectively. The children were randomly grouped into four experimental groups [motor intervention (MI), self-concept (SC) enhancing intervention, psycho-motor intervention (P-MI) and a control group (CG)]. A two-way analysis of variance (anova) with a group factor and a repeated measures over time followed by a Bonferroni post hoc analysis and separate one-way anovas followed by a Tukey post hoc analysis were conducted to determine between-group and within-group differences at the pre-, post- and re-tests. Effect sizes (d) were calculated to determine the practical significance of statistical differences (P < 0.05). RESULTS: After completion of the intervention programmes, no significant improvement in motor proficiency was found in the SC group, while the MI, P-MI and CG groups improved significantly (P < 0.01). No further improvements were found after the retention period in all the groups. From the pre-test to retest 2, the MI, P-MI and CG improved (P < 0.01), while the SC showed lower (P > 0.05) motor proficiency. A tendency of lower anxiety (P > 0.05) was found in the SC, while the total self-concept of the P-MI showed the biggest improvement (P < 0.05). CONCLUSION: Motor proficiency and self-concept of children with DCD benefit from intervention, but both should be addressed for optimal benefits.

Discovery of a haem uptake system in the soil bacterium Bradyrhizobium japonicum.

In Bradyrhizobium japonicum, the nitrogen-fixing symbiont of soybeans, we have identified a haem uptake system, Hmu, that comprises a cluster of nine open reading frames. Predicted products of these genes include: HmuR, a TonB-dependent haem receptor in the outer membrane; HmuT, a periplasmic haem-binding protein; and HmuUV, an ABC transporter in the inner membrane. Furthermore, we identified homologues of ExbBD and TonB, that are required for energy transduction from the inner to the outer membrane. Mutant analysis and complementation tests indicated that HmuR and the ExbBD-TonB system, but not the HmuTUV transporter, are essential for haem uptake or haem acquisition from haemoglobin and leghaemoglobin. The TonB system seems to be specific for haem uptake as it is dispensable for siderophore uptake. Therefore, we propose the existence of a second TonB homologue functioning in the uptake of Fe-chelates. When tested on soybean host plants, hmuT-hmuR and exbD-tonB mutants exhibited wild-type symbiotic properties. Thus, haem uptake is not essential for symbiotic nitrogen fixation but it may enable B. japonicum to have access to alternative iron sources in its non-symbiotic state. Transcript analysis and expression studies with lacZ fusions showed that expression of hmuT and hmuR is induced under low iron supply. The same was observed in fur and irr mutant backgrounds although maximal induction levels were decreased. We conclude either that both regulators, Fur and Irr, independently mediate transcriptional control by iron or that a yet unknown iron regulatory system activates gene expression under iron deprivation. An A/T-rich cis-acting element, located in the promoter region of the divergently transcribed hmuTUV and hmuR genes, is possibly required for this type of iron control.

Three new NifA-regulated genes in the Bradyrhizobium japonicum symbiotic gene region discovered by competitive DNA-RNA hybridization.

The so-called symbiotic region of the Bradyrhizobium japonicum chromosome (C. Kündig, H. Hennecke, and M. Göttfert, J. Bacteriol. 175:613-622, 1993) was screened for the presence of genes controlled by the nitrogen fixation regulatory protein NifA. Southern blots of restriction enzyme-digested cosmids that represent an ordered, overlapping library of the symbiotic region were competitively hybridized with in vitro-labeled RNA from anaerobically grown wild-type cells and an excess of RNA isolated either from anaerobically grown nifA and rpoN mutant cells or from aerobically grown wild-type cells. In addition to the previously characterized nif and fix gene clusters, we identified three new NifA-regulated genes that were named nrgA, nrgB, and nrgC (nrg stands for NifA-regulated gene). The latter two probably form an operon, nrgBC. The proteins encoded by nrgC and nrgA exhibited amino acid sequence similarity to bacterial hydroxylases and N-acetyltransferases, respectively. The product of nrgB showed no significant similarity to any protein with a database entry. Primer extension experiments and expression studies with translational lacZ fusions revealed the presence of a functional -24/-12-type promoter upstream of nrgA and nrgBC and proved the NifA- and RpoN (sigma(54))-dependent transcription of the respective genes. Null mutations introduced into nrgA and nrgBC resulted in mutant strains that exhibited wild-type-like symbiotic properties, including nitrogen fixation, when tested on soybean, cowpea, or mung bean host plants. Thus, the discovery of nrgA and nrgBC further emphasizes the previously suggested role of NifA as an activator of anaerobically induced genes other than the classical nitrogen fixation genes.