Markov models for clinical decision-making in radiation oncology: A systematic review.

The intrinsic stochasticity of patients' response to treatment is a major consideration for clinical decision-making in radiation therapy. Markov models are powerful tools to capture this stochasticity and render effective treatment decisions. This paper provides an overview of the Markov models for clinical decision analysis in radiation oncology. A comprehensive literature search was conducted within MEDLINE using PubMed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only studies published from 2000 to 2023 were considered. Selected publications were summarized in two categories: (i) studies that compare two (or more) fixed treatment policies using Monte Carlo simulation and (ii) studies that seek an optimal treatment policy through Markov Decision Processes (MDPs). Relevant to the scope of this study, 61 publications were selected for detailed review. The majority of these publications (n = 56) focused on comparative analysis of two or more fixed treatment policies using Monte Carlo simulation. Classifications based on cancer site, utility measures and the type of sensitivity analysis are presented. Five publications considered MDPs with the aim of computing an optimal treatment policy; a detailed statement of the analysis and results is provided for each work. As an extension of Markov model-based simulation analysis, MDP offers a flexible framework to identify an optimal treatment policy among a possibly large set of treatment policies. However, the applications of MDPs to oncological decision-making have been understudied, and the full capacity of this framework to render complex optimal treatment decisions warrants further consideration.

Skin assessment in congenital untreated isolated GH deficiency.

PURPOSE: The separation between the inside and outside through the skin was fundamental for the evolution of prevertebrates, which grow through extrapituitary circuits, to vertebrates, which grow through the somatotrophic axis, namely pituitary growth hormone (GH). and circulating IGF1.Individuals with untreated isolated growth hormone (GH) deficiency (IGHD) due to a mutation in the GH-releasing hormone receptor (GHRH) gene, residing in Itabaianinha, Brazil, are vulnerable to skin cancer and have reduced sweating. However other aspects of their skin physiology are still unknown. Our objectives were to evaluate the number of skin cancers, skin aging, and functional aspects of the skin in this IGHD cohort. METHODS: Twenty-six IGHD individuals and 26 controls matched by age, sex, ethnicity, and occupation were submitted to a biochemical, dermatological and a functional skin assessment by the Multi Probe Adapter Cutometer® MPA 580. RESULTS: There was no difference in the number of skin cancers and in the degrees of photodamage between the groups. The melanin content in the forearm was similar between the groups but was lower in the buttocks (p = 0.005), as well as skin resistance (p < 0.0001) and elasticity (p = 0.003), lower in the IGHD. There was no difference in hydration and sebum content between the two groups. CONCLUSION: IGHD is apparently associated with a neutral profile in terms of skin cancer and photodamage, with similar melanin on the forearm and lower buttocks, lower skin resistance and elasticity, with hydration and sebum similar to controls.

Pencil beam kernel-based dose calculations on CT data for a mixed neutron-gamma fission field applying tissue correction factors.

Objective.For fast neutron therapy with mixed neutron and gamma radiation at the fission neutron therapy facility MEDAPP at the research reactor FRM II in Garching, no clinical dose calculation software was available in the past. Here, we present a customized solution for research purposes to overcome this lack of three-dimensional dose calculation.Approach.The applied dose calculation method is based on two sets of decomposed pencil beam kernels for neutron and gamma radiation. The decomposition was performed using measured output factors and simulated depth dose curves and beam profiles in water as reference medium. While measurements were performed by applying the two-chamber dosimetry method, simulated data was generated using the Monte Carlo code MCNP. For the calculation of neutron dose deposition on CT data, tissue-specific correction factors were generated for soft tissue, bone, and lung tissue for the MEDAPP neutron spectrum. The pencil beam calculations were evaluated with reference to Monte Carlo calculations regarding accuracy and time efficiency.Main results.In water, dose distributions calculated using the pencil beam approach reproduced the input from Monte Carlo simulations. For heterogeneous media, an assessment of the tissue-specific correction factors with reference to Monte Carlo simulations for different tissue configurations showed promising results. Especially for scenarios where no lung tissue is present, the dose calculation could be highly improved by the applied correction method.Significance.With the presented approach, time-efficient dose calculations on CT data and treatment plan evaluations for research purposes are now available for MEDAPP.

Energy expenditure of red-footed tortoises (Chelonoidis carbonaria) fed kibble diets with high levels of fibre, starch, or fat.

Knowledge of energy requirements is necessary to optimise the nutritional management of animals. For tortoises, very little is known about their nutrient and energy requirements. Data on substrate oxidation and the implications of starch or fat intake on the energy metabolism are lacking. The present study compared the daily energy expenditures (DEE) of red-footed tortoises (Chelonoidis carbonaria) that were fed three extruded diets: a control diet high in fibre and two test diets, one with high starch content and another with high fat content. A total of 18 tortoises (5.5 ± 1.18 kg) were used in a completely randomised design, with 6 animals per diet. After 14 months of experimental diet intake and 48 h of preliminary fasting, the animals were kept for 12 h in 70-l respiratory chambers. An open "push mode" system was used to determine the carbon dioxide production and oxygen consumption levels for the subsequent calculations of DEE. The data were analysed with ANOVA, and the means were compared by using Tukey's test (p < 0.05). The body weights, chamber temperatures and food intakes of the tortoises were similar among the treatments (p > 0.05). There were no significant differences in oxygen consumption (21.7 ± 3.16 ml · kg-1 · h-1), carbon dioxide production (18.1 ± 1.96 ml · kg-1 · h-1), or DEE (9.7 ± 1.04 kJ · kg-1 d-1) between diets or sex (p > 0.05). The respiratory quotients (0.84 ± 0.11) were also similar among the diets (p > 0.05). The DEE of red footed tortoises did not differ after a long-term starch or fat intake.

Malpractice and socioeconomic aspects in neurosurgery: a developing-country reality.

OBJECTIVE: Neurosurgery occupies a prominent place in medical malpractice, but cases are still underreported in Brazil. This study describes the socioeconomic issues of medical malpractice in neurosurgery procedures and how they culminate in unfavorable outcomes in a developing country. METHODS: The authors analyzed 112 neurosurgical procedures listed in the Brazilian Hospital Information System (Sistema de Informações Hospitalares do Sistema Único de Saúde [SIHSUS]) records in the DATASUS (Departamento de Informática do SUS) database between January 2008 and February 2020. Malpractice data were collected using the JusBrasil platform, with the authors searching the name of each of the 112 neurosurgical procedures plus "medical malpractice" among the jurisprudence records for January 2008 to February 2020. A simple linear regression analysis was performed using appropriate software. Analyses were considered statistically significant at p < 0.05. RESULTS: According to DATASUS, 842,041 neurosurgical procedures were performed by the Brazilian Unified Health System between January 2008 and February 2020. The mean hospitalization cost for neurosurgical procedures was $714.06, and the average amount paid to professionals per procedure was $145.28 with variations according to the type of practice (public or private) in which they were performed, the complexity of the procedure, and the Brazilian region. The mortality rate and mean length of stay for neurosurgical procedures were 11.37% and 10.15 days, respectively. There were 79 medical malpractice lawsuits in the studied period. In these lawsuits, 26.58% of the court decisions were unfavorable to the neurosurgeons, with a mean compensation per procedure 15 times higher than the median value paid for all professionals in a neurosurgical procedure. The spine subspecialty had more lawsuits, and the brain tumor subspecialty had the most expensive compensation.A lack of resources in public healthcare negatively impacts inpatient care. The mortality rate was 1.5 times higher in public practice than in private practice and was inversely proportional to the MTCs paid for the neurosurgical procedure. Patients with the lower educational levels associated with limited access to good medical care could reflect the lower plaintiff motivation in regions with a low gross domestic product and Human Development Index. In most cases, there is no understanding from either the patient or his family about the health-disease process, nor that there was medical malpractice committed by the physician to be sued. CONCLUSIONS: The socioeconomic inequalities and the population's low awareness of their rights could explain the few malpractice cases reported in Brazil. The authors recommend better decisions regarding the investments to be made in neurosurgical procedures to reduce malpractice lawsuits.

Quality improvement initiative for improved patient communication in an ED rapid assessment zone.

INTRODUCTION: Patient-clinician communication in the Emergency Department (ED) faces challenges of time and interruptions, resulting in negative effects on patient satisfaction with communication and failure to relieve anxiety. Our aim was to improve patient satisfaction with communication and to decrease related patient anxiety. METHODS: A multistage quality improvement (QI) initiative was conducted in the ED of Toronto General Hospital, a quaternary care centre in Ontario, Canada, from January to May 2018. We engaged stakeholders widely including clinicians, allied health and patients. We developed a 5-point Likert scale survey to measure patient and clinician rating of their communication experience, along with open-ended questions, and a patient focus group. Inductive analyses yielded interventions that were introduced through three Plan-Do-Study-Act (PDSA) cycles: (1) a clinician communication tool called Acknowledge-Empathize-Inform; (2) patient information pamphlets; and (3) a multimedia solution displaying patient-directed material. Our primary outcome was to improve patient satisfaction with communication and decrease anxiety by at least one Likert scale point over 6 months. Our secondary outcome was clinician-perceived interruptions by patients. We used statistical process control (SPC) charts to identify special cause variation and two-tailed Mann-Whitney U tests to compare means (statistical significance p<0.05). RESULTS: A total of 232 patients and 104 clinicians were surveyed over baseline and three PDSA cycles. Communication about wait times, ED process, timing of next steps and directions to patient areas were the most frequently identified gaps, which informed our interventions. Measurements at baseline and during PDSA 3 showed: patient satisfaction increased from 3.28 (5 being best; n=65) to 4.15 (n=59, p<0.0001). Patient anxiety decreased from 2.96 (1 being best; n=65) to 2.31 (n=59, p<0.001). Clinician-perceived interruptions by patients changed from 4.33 (5 being highest; n=30) to 4.18 (n=11, p=0.98) and did not meet significance. SPC charts showed special cause variation temporally associated with our interventions. CONCLUSIONS: Our pragmatic low-cost QI initiative led to statistically significant improvement in patient satisfaction with communication and decreased patient anxiety while narrowly missing our a priori improvement aim of one full Likert scale point.

Budgets of Organic Carbon Composition and Oxidation in Indoor Air.

The chemical composition of indoor air at the University of Colorado, Boulder art museum was measured by a suite of gas- and particle-phase instruments. Over 80% of the total observed organic carbon (TOOC) mass (100 µg m-3) consisted of reduced compounds (carbon oxidation state, OSC < -0.5) with high volatility (log10 C* > 7) and low carbon number (nC < 6). The museum TOOC was compared to other indoor and outdoor locations, which increased according to the following trend: remote < rural ≤ urban < indoor ≤ megacity. The museum TOOC was comparable to a university classroom and 3× less than residential environments. Trends in the total reactive flux were remote < indoor < rural < urban < megacity. High volatile organic compound (VOC) concentrations compensated low oxidant concentrations indoors to result in an appreciable reactive flux. Total hydroxyl radical (OH), ozone (O3), nitrate radical (NO3), and chlorine atom (Cl) reactivities for each location followed a similar trend to TOOC. High human occupancy events increased all oxidant reactivities in the museum by 65-125%. The lifetimes of O3, NO3, OH, and Cl reactivities were 13 h, 15 h, 23 days, and 189 days, respectively, corresponding to over 88% of indoor VOC oxidant reactivity being consumed outdoors after ventilation.

How do emergency departments and emergency leaders catalyze positive change through quality improvement collaborations?

OBJECTIVES: Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration. METHODS: An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback. RESULTS: Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program. CONCLUSION: A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.

OBJECTIF: L'amélioration de la qualité et la sécurité des patients (AQSP) joue un rôle important dans la correction des lacunes observées dans la prestation optimale de soins. Toutefois, les équipes de soins au service des urgences (SU) disposent de peu de documentation sur la conception de leurs propres programmes d'AQSP. L'étude avait donc pour objectif l'élaboration de recommandations conçues à l'intention des chefs de file, nouveaux ou confirmés, au SU, et présentées comme une voie à emprunter pour améliorer les soins aux patients, par l'application d'activités programmatiques d'AQSP, tout d'abord au sein du service, puis entre services, grâce à la collaboration. MÉTHODE: Un groupe d'experts composé de 10 cliniciens en médecine d'urgence, ayant des compétences particulières en AQSP et en pouvoir d'influence, a été mis sur pied. Un examen de cadrage a été entrepris à la recherche de publications sur l'établissement de programmes d'AQSP et de cadres de travail s'y rapportant, en soins de santé. Des consultations ont été menées avec les parties intéressées parmi les chefs de file en soins de santé au Canada, et le groupe d'experts a rédigé une version préliminaire de recommandations fondées sur l'ensemble de l'information recueillie. Celles-ci ont été examinées et améliorées durant le Symposium sur les affaires universitaires 2018 de l'ACMU, à Calgary, à la suite de rétroactions communiquées en personne ou par voie électronique. RÉSULTATS: Les recommandations portaient sur : l'éveil d'un sentiment d'urgence à l'égard de l'amélioration; la mobilisation d'intervenants et de chefs de file compétents; la mise sur pied d'un comité local structuré d'AQSP; l'obtention de financement et de ressources; la disponibilité de données locales pour orienter le travail; le soutien de la formation des membres d'équipe en AQSP; la promotion de la collaboration entre professions, entre services et avec les patients; l'utilisation d'un cadre de travail d'AQSP déjà établi afin d'orienter le travail; l'élaboration d'un système de récompenses et de structures incitatives; la possibilité d'entreprendre, au début, des initiatives à petite échelle, soit des projets plutôt que des programmes. CONCLUSION: Les dix recommandations ont été présentées à titre de principes directeurs en vue de l'élaboration d'activités d'AQSP et de leur mise en œuvre durable dans les SU, au Canada et ailleurs dans le monde. Les chefs de file dans les SU sont invités à appliquer ces recommandations dans le but d'améliorer les soins aux patients.

Mitigating environmental impacts using Life Cycle Assessment in Brazilian companies: A stakeholders' perspective.

The increase in environmental problems in recent decades has required the evolution of the tools used to mitigate environmental impacts, such as Life Cycle Assessment (LCA). The aim of the present study was to evaluate the use of LCA in Brazilian companies. Data collection involved a questionnaire administrated to companies addressing attitudes related to environmental management, enabling the following three classifications: (1) Does not use Life Cycle Thinking (LCT), (2) Uses LCT and (3) Uses LCA. The results were categorized and submitted to both descriptive and multivariate analyses. Most companies investigated do not yet use LCA. The main obstacles were difficulties involved in implementing LCA, the lack of an external demand, a lack of available background data and difficulty applying the results to the environmental improvement of products. In contrast, the main reasons that led companies to use LCA were the possibility of reducing environmental impact, achieving improvements in the production process, the creation of a differentiated product for the market and the improvement of environmental management. The findings underscore the need for greater governmental support with regard to environmental labeling (mainly type III) and greater dissemination of information on LCA within industries, since the lack of knowledge of the tool is perceived as one of the greatest obstacles. This research is pioneering in Brazil. Further studies should identify the evolution in LCA use in Brazilian companies, which should reflect an improvement in environmental management on the national level.

Gender-related outcomes after open repair of descending thoracic and thoracoabdominal aortic aneurysms.

OBJECTIVE: Female sex has been associated with greater morbidity and mortality for a variety of major cardiovascular procedures. We sought to determine the influence of female sex on early and late outcomes after open descending thoracic aortic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: We searched our aortic surgery database to identify patients having open DTA or TAAA repair. Logistic regression and Cox regression analyses were used to assess the effect of sex on perioperative and long-term outcomes. RESULTS: From 1997 until 2017, there were 783 patients who underwent DTA or TAAA repair. There were 462 male patients and 321 female patients. Female patients were significantly older (67.6 ± 13.9 years vs 62.6 ± 14.7 years; P < .001), had more chronic pulmonary disease (47.0% vs 35.7%; P = .001) and forced expiratory volume in 1 second <50% (28.3% vs 18.2%; P < .001), and were more likely to have degenerative aneurysms (61.7% vs 41.6%; P < .001). Operative mortality was not different between women and men (5.6% vs 6.2%; P = .536). However, women were more likely to require a tracheostomy after surgery (10.6% vs 5.0%; P = .003) despite a reduced incidence of left recurrent nerve palsy (3.4% vs 7.8%; P = .012). Logistic regression found female sex to be an independent risk factor for a composite of major adverse events (odds ratio, 2.68; confidence interval, 1.41-5.11) and need for tracheostomy (odds ratio, 3.73; confidence interval, 1.53-9.10). Women also had significantly lower 5-year survival. CONCLUSIONS: Women undergoing open DTA or TAAA repair are not at greater risk for operative mortality than their male counterparts are. Reduced preoperative pulmonary function may contribute to an increased risk for respiratory failure in the perioperative period.

Promoter Activity Buffering Reduces the Fitness Cost of Misregulation.

Organisms regulate gene expression through changes in the activity of transcription factors (TFs). In yeast, the response of genes to changes in TF activity is generally assumed to be encoded in the promoter. To directly test this assumption, we chose 42 genes and, for each, replaced the promoter with a synthetic inducible promoter and measured how protein expression changes as a function of TF activity. Most genes exhibited gene-specific TF dose-response curves not due to differences in mRNA stability, translation, or protein stability. Instead, most genes have an intrinsic ability to buffer the effects of promoter activity. This can be encoded in the open reading frame and the 3' end of genes and can be implemented by both autoregulatory feedback and by titration of limiting trans regulators. We show experimentally and computationally that, when misexpression of a gene is deleterious, this buffering insulates cells from fitness defects due to misregulation.

Ideal cardiovascular health score at the ELSA-Brasil baseline and its association with sociodemographic characteristics.

BACKGROUND: The American Heart Association's ideal cardiovascular health (ICH) define criteria for seven metrics, four classified as lifestyle factors (diet, physical activity, smoking and body-mass index) and four classified as health factors (smoking, blood pressure, fasting plasma glucose and total cholesterol). We aimed to analyze ICH scores at the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline assessment and the associations with sociodemographic characteristics (age, sex, race, educational level, and family income). METHODS: We analyzed 13,356 ELSA-Brasil participants without cardiovascular disease using quasi-Poisson regression models to study the association between the ICH score and sociodemographic characteristics. RESULTS: Mean ICH scores were 2.5±1.3. Only 1047 (7.8%) participants had 5 or more ICH metrics. In adjusted models, age 65-74years was associated with lower ICH scores (-35.4%; 95% confidence interval [CI]: -37.6% to -33.1%) compared to age 35-44years. Women had higher ICH scores compared to men (+13.8%; 95%CI: +11.8% to +15.7%), mainly due to differences in the health factor ICH metrics. Participants of Black race had lower ICH scores compared to those of White race (-9.4%; 95%CI: -11.8% to -7.0%). Individuals with less than high school education had lower ICH scores than college-educated individuals (-17.2%; 95%CI: -20.0% to -14.2%). Low (<1245 USD) family income was also associated with lower ICH scores compared to those with high (≥3320 USD) family income (-4.4%, 95%CI: -7.2% to -1.6%). CONCLUSIONS: We found a low proportion of individuals with 5 or more ICH metrics. Age, sex, race, educational level and income were associated with ICH scores.

Techniques for intraoperative graft assessment in coronary artery bypass surgery.

Early graft patency is a major determinant of morbidity and mortality following coronary artery bypass surgery. Long-term graft failure is caused by intimal hyperplasia and atherosclerosis, while early failure, especially in the first year, has been attributed, in part, to surgical error. The need for intraoperative graft evaluation is paramount to determine need for revision and ensure future functioning grafts. Transit time flowmetry (TTFM) is the most commonly used intraoperative modality, however, only about 20% of cardiac surgeons in North America use TTFM. When combined with high resolution epicardial ultrasonography, TTFM provides high diagnostic yield. Fluorescence imaging can provide excellent visualization of the coronary and graft vasculature; however, data on this subject is limited. We herein examine the literature and discuss the available techniques for graft assessment along with their limitations.

Melt-and-mold fabrication (MnM-Fab) of reconfigurable low-cost devices for use in resource-limited settings.

Interest in low-cost analytical devices (especially for diagnostics) has recently increased; however, concomitant translation to the field has been slow, in part due to personnel and supply-chain challenges in resource-limited settings. Overcoming some of these challenges require the development of a method that takes advantage of locally available resources and/or skills. We report a Melt-and-mold fabrication (MnM Fab) approach to low-cost and simple devices that has the potential to be adapted locally since it requires a single material that is recyclable and simple skills to access multiple devices. We demonstrated this potential by fabricating entry level bio-analytical devices using an affordable low-melting metal alloy, Field's metal, with molds produced from known materials such as plastic (acrylonitrile-butadiene-styrene (ABS)), glass, and paper. We fabricated optical gratings then 4×4 well plates using the same recycled piece of metal. We then reconfigured the well plates into rapid prototype microfluidic devices with which we demonstrated laminar flow, droplet generation, and bubble formation from T-shaped channels. We conclude that this MnM-Fab method is capable of addressing some challenges typically encountered with device translation, such as technical know-how or material supply, and that it can be applied to other devices, as needed in the field, using a single moldable material.

Needs for and barriers to correctional mental health services: inmate perceptions.

OBJECTIVES: Because of increasing numbers of mentally ill offenders without concomitant increases in mental health staffing, issues of service utilization and priority populations have become paramount. The aim of this study was to expand upon previous studies of correctional mental health service utilization by examining the underlying factor structure of problems for which inmates may seek services and by examining the barriers hindering inmates' willingness to seek services. Additionally, this study investigated whether previous treatment experiences had an impact on inmates' willingness to seek services or barriers to seeking services. METHODS: Participants consisted of 418 incarcerated adult males who voluntarily participated in this study and were from three security levels (that is, reception and diagnostic unit, minimum security, and maximum security). Participants completed a three-page survey inquiring about use of mental health services before and during incarceration. RESULTS: Factor analysis indicated five types of problems for which inmates may request mental health services (behavioral dyscontrol, physical health concerns, negative affect, interpersonal relationships, and institutional relations) and four types of potential barriers to service utilization (self-preservation concerns, procedural concerns, self-reliance, and professional service provider concerns). Inmates with no prior history of mental health service use were more likely to present with self-preservation concerns about services and present as self-reliant. CONCLUSIONS: Results of this study provide an overarching conceptualization of barriers hindering inmates' willingness to seek services, as well as the types of problems for which they are likely to seek services. Also, inmates' mental health treatment history affected their current perceptions of services.

Mental health nurse supplementary prescribing: experiences of mental health nurses, psychiatrists and patients.

AIM: This paper is a report of a study to explore the views of patients, mental health nurses and psychiatrists involved in mental health nurse supplementary prescribing. BACKGROUND: Medication prescribing by mental health nurses in the United Kingdom is controversial. However, the experience of mental health patients suggests that increasing prescribing capacity could be one strategy to provide a person-centred prescribing approach. METHOD: A qualitative study was carried out in 2005. Semi-structured interviews were conducted with 12 psychiatrists, 11 mental health nurses with prescribing authority, and 12 patients who had been prescribed psychiatric medication by a mental health nurse. Participants were interviewed about positive aspects of supplementary prescribing including the extent of it being evidence-based, person-centred and clinically focussed. FINDINGS: Participants from all three groups had a positive reaction to nurse supplementary prescribing. Mental health nurse prescribing was viewed as evidence-based, person-centred and with an additional focus on physical health. Mental health nurses worked within their levels of competency. Barriers to the implementation of mental health nurse prescribing were nurses' lack of prescribing experience, shortfalls in supervision, insufficient focus on redesigning the service to support the role of the mental health nurse, and preparation for the role. CONCLUSION: Mental health nurse prescribing seems potentially beneficial. However, more rigorous audit and evaluation are needed to confirm its safety, patient satisfaction and health outcomes. Mental health nurse prescribing will require service redesign to ensure that is becomes embedded in the service organizational culture.

Pharmacological management of akathisia in combination with psychological interventions by a mental health nurse consultant.

The article describes the management of akathisia by a mental health nurse (MHN) prescriber, working in partnership with the patient. A single-case design was used to evaluate this. It highlights three features: first, MHN can safely prescribe psychiatric medication in combination with concordance therapy. Second, the value base underpinning prescribing practice is partnership, honesty and choice for the patient. Finally, the pharmacological mechanism of antipsychotic medication, which contributes towards akathisia, requires further analysis.

Heavy users of acute psychiatric beds: randomized controlled trial of enhanced community management in an outer London borough.

BACKGROUND: Heavy users of psychiatric services, often defined as the population that uses the most beds, consume a large part of the resources used by the whole service, despite being relatively small in number. Any intervention that reduces heavy use is therefore likely to lead to significant savings, and enhancement of standard care using a form of intensive case management akin to assertive community treatment was thought to be a pragmatic strategy for testing in this group. METHODS: The effectiveness of enhanced community management (ECM) was compared with standard care alone in heavy users, who represented the 10% of patients with the highest number of hospital admissions and occupied bed days over the previous 6.5 years in an outer London borough. One hundred and ninety-three patients were randomly assigned to ECM or standard care and their use of services was determined after 1 and 2 years, with assessments of costs, clinical symptoms, needs, and social function made before entry into the study and after 1 and 2 years. RESULTS: Despite a 24 fold increase in community contacts in the study group, there were no significant differences between the two groups in any of the main outcome measures. Small savings on in-patient and day-hospital service costs were counterbalanced by the increased costs of outpatient and community care for the subjects assigned to ECM. Clinical outcome data derived from interviews in two-thirds of the subjects were similar in both groups. CONCLUSIONS: Providing additional intensive community focused care to a group of heavy users of psychiatric in-patient services in an outer London borough does not lead to any important clinical gains or reduced costs of psychiatric care.