Acceptability and face validity of two mental health screening tools for use in the routine surgical setting.

BACKGROUND: Preoperative assessment of mental health rarely occurs within routine surgery. Any screening tool selected to form part of this process must be deemed practical, acceptable and valid by clinicians and consumers alike. This study aims to assess the acceptability and face validity of two existing mental health screening tools to select one for further development and use in the routine surgical setting. METHODS: A survey of clinicians and consumers was conducted from October 2020 to March 2021 at a tertiary hospital in Sydney, Australia. Using a Likert scale (1-5, lowest to highest rating), the clinicians evaluated four domains for acceptability and two for validity (six overall) and the consumers four domains for acceptability and one for validity (five overall) on the preoperative use of the amended Kessler Psychological Distress Scale (K10) and the Somatic and Psychological Health Report-12 (SPHERE-12). Consensus was achieved through a rating of 4 or 5 being given by 70% or more of participants with domains able to remain unchanged. Free text responses were analysed into themes. RESULTS: A total of 73 participants (51 clinicians; 22 consumers) were included. The K10 received consensus scores (≥ 70%) in four out of six domains for clinicians (4/4 acceptability; 0/2 validity), and all five domains for consumers (4/4 acceptability; 1/1 validity). The SPHERE-12 received consensus scores (≥ 70%) in three domains for clinicians (3/4 acceptability; 0/2 validity), and three domains for consumers (3/4 acceptability; 0/1 validity). Six qualitative themes were described including (1) amendments to tool structure and language; (2) scale response options; (3) difficulty with somatic questions; (4) practicality and familiarity with K10; (5) challenges for specific patient cohorts and (6) timing considerations for patients. CONCLUSION: Adequate acceptability was established for the K10. However further development is required to strengthen its validity for this specific surgical cohort and purpose. Future research to determine the feasibility and acceptability of implementing and using the K10 in the routine surgical setting is now needed.

Surgical experience for patients with serious mental illness: a qualitative study.

BACKGROUND: People with serious mental illness (SMI) have significantly worse surgical outcomes compared to the general population. There are many contributing factors to this complex issue, however consideration of the surgical experience from the patient's own perspective has never been undertaken. This lack of understanding prevents the provision of truly patient centred care and may limit the impact of potential improvement initiatives. Therefore this study aims to describe and better understand the surgical experience from the perspective of patients with SMI. METHODS: Within this qualitative study, semi-structured, audio-recorded interviews were conducted between August 2019 - June 2020, with 10 consenting participants with SMI who had surgery in the previous 2 years. A thematic analysis approach was used to explore both the positive and negative aspects of the participant's surgical experience commencing from pre-operative consultation to hospital discharge and follow-up. RESULTS: Four main themes and related subthemes emerged including i) the perceived lack of mental ill health recognition, ii) highly variable patient and clinician interactions, iii) the impact of healthcare services, and iv) strategies for improvement. CONCLUSION: Surgical patients with SMI want to be treated like everyone else whilst still having their mental ill health acknowledged and proactively managed despite this rarely occurring, which is valuable information for all surgical teams to consider and learn from. Participants were able to describe several readily implementable strategies to potentially improve their care and overall surgical experience, and as such highlight considerable opportunities for these to be tested and evaluated for this underserved patient group.

The evaluation of e-learning resources as an adjunct to otolaryngology teaching: a pilot study.

BACKGROUND: The concept of e-Learning has been rapidly accepted as an important component of medical education and is especially adept at teaching clinical skills. However, their impact on learning, particularly in Otolaryngology Head and Neck Surgery (OHNS) medical school curriculum, has yet to be adequately explored. The aim of this pilot study is to develop interactive e-Learning resources and evaluate their impact in enhancing OHNS teaching in medical school. METHODS: This pilot study is a randomized controlled trial assessing the effectiveness of e-Learning resources in enhancing the current traditional lecture and tutorial-based teaching of OHNS in medical school. Nineteen final-year medical students from the University of Sydney were recruited for this study, who were randomly allocated into intervention group with additional e-Learning resources (Group A) and control group (Group B). Student knowledge was assessed through objective structured clinical examinations (OSCE) with use of standardized forms for objective scoring. Assessors were blinded to student randomization status. A post-study questionnaire was distributed to assess student feedback on the e-Learning resources. RESULTS: Eight students were allocated to Group A and 11 students to Group B. Group A performed significantly better than Group B in the overall examination scores (78.50 ± 13.88 v. 55.82 ± 8.23; P = < 0.01). With the minimum pass mark of 65%, the majority of students in Group A was able to pass the OSCE assessments, while the majority of students in Group B failed (87.50% v. 9.10%; P = 0.01). The post-test questionnaire on the e-Learning resources showed very favorable feedback from the students' perspective. CONCLUSION: Results from our pilot study suggests that the use of interactive online e-Learning resources can be a valuable adjunct in supplementing OHNS teaching in medical school, as they are readily accessible and allow flexible on-demand learning. Future studies involving large numbers of medical students are needed to validate these results.

Impact of serious mental illness on surgical patient outcomes.

BACKGROUND: People with comorbid mental illness have poorer health status and disparate access to healthcare. Several studies internationally have reported mixed findings regarding the association between mental illness and surgical patient outcomes. This study examines the surgical outcomes in people with decompensated serious mental illness (SMI) within the setting of the Australian universal healthcare system. METHODS: Retrospective cohort study involving elective overnight surgical patients aged 18 years and above who attended a large public tertiary referral hospital in Sydney, Australia, between 2010 and 2014. Patients were identified using ICD-10-AM diagnosis codes. Outcomes measure including in-hospital mortality, post-operative complications, morbidity, admission and time in intensive care, length and cost of hospitalization, discharge destination and 28-day re-admission rates were examined. RESULTS: Of 23 343 surgical patient admissions, 451 (2%) patients had decompensated comorbid SMI with a subset of 47 (0.2%) having a specific psychotic illness. Patients with SMI comorbidity had significantly higher in-hospital mortality (2% versus 0%), post-operative complications (22% versus 8%), total comorbidity (7.6 versus 3.4 secondary codes), admissions (29% versus 9%) and time in intensive care (34.6 h versus 5.0 h), stay in hospital (12.2 days versus 4.6 days), admission costs ($24 162 versus $12 336), re-admission within 28 days (14% versus 10%) and discharges to another facility (11% versus 3%). CONCLUSION: Patients with comorbid SMI had significantly worse surgical outcomes and incur much higher costs compared with the general surgical population. These results strongly highlight that specific perioperative interventions are needed to proactively improve the identification, management and outcomes for these disadvantaged patients.

Cardiovascular disease in patients with schizophrenia.

Patients with schizophrenia die on average 25 years earlier than the general population, and this gap appears to be increasing. Most of the excess mortality is due to premature cardiovascular deaths rather than suicide. Many psychotropic agents are orexigenic and can increase weight and promote dyslipidaemia. Traditional cardiac risk factors are undertreated among patients with schizophrenia, and they are less likely to receive cardiac revascularisation than those without a mental illness. Clozapine is an atypical antipsychotic medication effective for treatment of refractory schizophrenia, but is associated with the risk of myocarditis and cardiomyopathy. Established protocols in Australia screen for myocarditis for patients who are initiating clozapine therapy and for long term monitoring for cardiomyopathy with echocardiography. Coordinated care between tertiary providers, general practitioners and primary health care professionals should monitor the physical health of people with psychosis or schizophrenia at least annually and treatment should be offered accordingly.

The Sydney Mental Health Client Mortality Audit: what does it tell us and what are we to do?

OBJECTIVES: To examine the characteristics of those mental health clients of an Australian metropolitan health service who died during a 6 year period, 2005 - 2010. METHODS: The medical records, and where available, coronial post-mortem examinations were audited for 109 people with schizophrenia who died while they were clients of the mental health service. RESULTS: The mean age of death for men was 45 years and for women, 47 years, compared to the general population's male and female life expectancy of 79 and 84 years, respectively. About one-half of the deaths were due to suicide (n = 55), followed by natural causes (n = 42; 39%), undetermined causes (n = 7), and accidents or acts of violence (n = 5). Smoking rates, diagnosed diabetes and hypertension were higher in the group that died from natural causes. Morbid obesity (body mass index (BMI) > 35 kg/m(2)) rates were higher in the group that died of natural causes (38%), compared with the suicide group (5%). CONCLUSIONS: While suicide accounts for the majority of those dying prematurely in this study cohort, it appears that for those who survive the risk of suicide in the earlier period of a chronic psychotic illness, there is yet another threat to life expectancy: death from preventable cardiorespiratory disorders, due to a poor lifestyle and social deprivation.

Are cardiometabolic and endocrine abnormalities linked to sleep difficulties in schizophrenia? A hypothesis driven review.

Schizophrenia is a psychiatric disorder that includes symptoms such as hallucinations, disordered thoughts, disorganized or catatonic behaviour, cognitive dysfunction and sleep-wake disturbance. In addition to these symptoms, cardiometabolic dysfunction is common in patients with schizophrenia. While previously it has been thought that cardiometabolic symptoms in patients with schizophrenia were associated with medications used to manage this disorder, more recently it has been demonstrated that these symptoms are present in drug naive and unmedicated patients. Sleep-wake disturbance, resulting in chronic sleep loss has also been demonstrated to induce changes in cardiometabolic function. Chronic sleep loss has been associated with an increased risk for weight gain, obesity and cardiac and metabolic disorders, independent of other potentially contributing factors, such as smoking and body mass index. We hypothesise that the sleep-wake disturbance comorbid with schizophrenia may play a significant role in the high prevalence of cardiometabolic dysfunction observed in this patient population. Here we present a critical review of the evidence that supports this hypothesis.

An inter-ethnic comparison study of clozapine dosage, clinical response and plasma levels.

The present study investigated clozapine dosage, plasma clozapine and metabolite levels, clinical and side-effect profiles in Asian versus Caucasian patients with chronic schizophrenia who were on stable maintenance treatment. Twenty Asian patients from Singapore and 20 Caucasian patients from Australia were systematically evaluated with the following rating scales: Positive and Negative Syndrome Scale for Schizophrenia, drug attitude scale (DAI-10), drug adverse reaction profile (Liverpool University Neuroleptic Side-effect Rating Scale), extrapyramidal side-effects scales (Abnormal Involuntary Movement Scale, Simpson and Angus Scale). Cigarette and caffeine consumption were recorded and steady-state plasma clozapine and metabolites levels were measured. Although Asian patients received a significantly lower mean clozapine dose (176 mg/day) than the Caucasian group (433 mg/day, P<0.001), plasma clozapine levels were similar between the groups. As a result, Asian patients had more than twice the effective clozapine concentration to dose ratio (P<0.001). The findings remained significant even after controlling for gender, body mass index, cigarette, alcohol and caffeine use. Conversely, the plasma metabolites (desmethylclozapine and clozapine N-oxide) to clozapine ratios were higher in the Caucasian patients (P<0.01). Compared to Caucasian patients, Asian patients appeared to have a lower dosage requirement for clinical efficacy. Hence, appropriate dose adjustment should be considered in Asian patients receiving maintenance clozapine therapy in clinical practice.

An audit of outpatient antipsychotic usage in the three health sectors of Auckland, New Zealand.

OBJECTIVE: To examine antipsychotic usage in outpatients in three community mental health centres. METHOD: A retrospective chart review was conducted for all outpatient files that were active in March 2000 at all community mental health services in Auckland (population 1.3 million). All patients prescribed an antipsychotic had information entered into a specifically designed computer software program. The antipsychotic, dose and route of administration were recorded. The diagnosis, number of hospitalizations, ethnicity and gender were also collected. RESULTS: 6558 community files were audited and 3254 people were prescribed antipsychotics; 3178 (97.6%) files had adequate information for study inclusion. The mean antipsychotic daily dose in chlorpromazine equivalents (CPZe) was 360 mg. Most of the population (76.6%) was prescribed an oral antipsychotic alone, 14.9% were prescribed depot antipsychotic only and 8.4% were on a depot and oral antipsychotic. The average daily dose prescribed for people on antipsychotic polypharmacy was 601 mg CPZe compared with 312 mg CPZe for those on a single antipsychotic. There were 2300 patients with schizophrenia (72.5% of cohort) and 585 patients with bipolar affective disorder (18.5%). The mean total daily dose in CPZe was significantly higher for schizophrenia than any other psychotic diagnoses. Regional analysis showed differences in the doses and type of antipsychotics prescribed; one health sector had significantly higher daily doses while another was significantly more likely to prescribe atypical antipsychotics and correspondingly fewer depot antipsychotics. CONCLUSIONS: There is a significant variation in the prescribing of antipsychotics across the three Auckland health sectors. The variation relates to dosage used, type of antipsychotics prescribed and effect of multiple antipsychotic prescribing. Combination therapy of more than one oral antipsychotic or a combination of oral and depot antipsychotics leads to a significant trend of higher doses in excess of best practice guidelines.

A three-dimensional fractal model of tumour vasculature.

We constructed a three-dimensional fractal model of the vascular network in a tumour periphery. We model the highly disorganised structure of the neoplastic vasculature by using a high degree of variation in segment properties such as length, diameter and branching angle. The overall appearance of the vascular tree is subjectively similar to that of the disorganised vascular network which encapsulates tumours. The fractal dimension of the model is within the range of clinically measured values.