A Novel Mental Health Crisis Service - Outcomes of Inpatient Data.

INTRODUCTION: Northern Ireland has high mental health needs and a rising suicide rate. Our area has suffered a 32% reduction of inpatient beds consistent with the national drive towards community based treatment. Taking these factors into account, a new Mental Health Crisis Service was developed incorporating a high fidelity Crisis Response Home Treatment Team (CRHTT), Acute Day Care facility and two inpatient wards. The aim was to provide alternatives to inpatient admission. The new service would facilitate transition between inpatient and community care while decreasing bed occupancy and increasing treatment in the community. METHODS: All services and processes were reviewed to assess deficiencies in current care. There was extensive consultation with internal and external stakeholders and process mapping using the COBRAs framework as a basis for the service improvement model. The project team set the service criteria and reviewed progress. RESULTS: In the original service model, the average inpatient occupancy rate was 106.6%, admission rate was 48 patients per month and total length of stay was 23.4 days. After introducing the inpatient consultant hospital model, the average occupancy rate decreased to 90%, admissions to 43 per month and total length of stay to 22 days. The results further decreased to 83% occupancy, 32 admissions per month and total length of stay 12 days after CRHTT initiation. DISCUSSION: The Crisis Service is still being evaluated but currently the model has provided safe alternatives to inpatient care. Involvement with patients, carers and all multidisciplinary teams is maximised to improve the quality and safety of care. Innovative ideas including structured weekly timetable and regular interface meetings have improved communication and allowed additional time for patient care.

Bimodal effect of humic acids on the LPS-induced TNF-alpha release from differentiated U937 cells.

Humic substances (HS) have been reported to possess anti-inflammatory as well as pro-inflammatory properties. The anti-inflammatory activity was demonstrated in the rat paw edema model and we found a preliminary explanation in the 5-lipoxygenase inhibitory effect of humic acids (HA). The pro-inflammatory activity is reflected by the production and release of pro-inflammatory cytokines in HA-treated neutrophilic granulocytes. With regard to the potential use of HA as antiviral and UV-protective agents it appears advisable to investigate the role of HS in the inflammation process in more detail. Hence we tested four different HS preparations - two naturally occurring HA from the Altteich peatland in Germany, one fulvic acid (FA) preparation from a Finnish spruce forest and a synthetic HA-like polymer (caffeic acid oxidation product, KOP) for their influence on the lipopolysaccharide (LPS)-induced TNF-alpha release in human U937 cells. In addition, the cytotoxicity of HS was determined. The results demonstrate a concentration-dependent bimodal effect of HA on the TNF-alpha release of differentiated LPS-stimulated U937 cells for both the natural black peat HA from the Altteich peatland and the HA-like polymer KOP. Low HA concentrations (10-80 microg/ml) enhanced the TNF-alpha release by up to threefold (pro-inflammatory activity), while HA concentrations >100 microg/ml reduced it about 10-fold (anti-inflammatory activity). FA failed to enhance TNF-alpha release, but reduced it at higher concentrations (>200 microg/ml) by the half. Brown water HA did not exert any significant effect on TNF-alpha release. No HS-stimulated TNF-alpha release was also observed in the absence of exogenously supplied LPS. This means that HS, unlike endotoxin, are no inflammation-causing agents for LPS-untreated cells. Differences in the effect of individual HS on TNF-alpha release are discussed in connection with the polyanionic character of HS, their molecular mass distribution and the hitherto imperfectly known chemical structure.

Adaptive upregulation of gastric and hypothalamic ghrelin receptors and increased plasma ghrelin in a model of cancer chemotherapy-induced dyspepsia.

Chemotherapy treatment can lead to delayed gastric emptying, early satiety, anorexia, nausea and vomiting, described collectively as the cancer-associated dyspepsia syndrome (CADS). Administration of ghrelin (GHRL), an endogenous orexigenic peptide known to stimulate gastric motility, has been shown to reduce the symptoms of CADS induced in relevant animal models with the potent chemotherapeutic agent, cisplatin. We examined the effects in the rat of cisplatin (6 mg/kg i.p.) treatment on the expression of GHRL and ghrelin receptor (GHSR) mRNAs in the hypothalamus and the stomach at a time-point (2 days) when the effects of cisplatin are pronounced. In addition, plasma levels of GHRL (acylated and total including des-acyl GHRL) were measured and the effect on these levels of treatment with the synthetic glucocorticoid dexamethasone (2 mg/kg s.c. bd.) was investigated. Cisplatin increased GHSR mRNA expression in the stomach (67%) and hypothalamus (52%) but not GHRL mRNA expression and increased the percentage of acylated GHRL (7.03+/-1.35% vs. 11.38+/-2.40%) in the plasma. Dexamethasone reduced the plasma level of acylated GHRL and the percentage of acylated GHRL to values below those in animals treated with saline alone (7.03+/-1.35% vs. 2.60+/-0.49%). Our findings support the hypothesis that an adaptive upregulation of the ghrelin receptor may occur during cancer chemotherapy-associated dyspepsia. This may have a role in defensive responses to toxic challenges to the gut. In addition, our results provide preliminary evidence for glucocorticoid modulation of plasma ghrelin levels.

Vagal nerve stimulation: adjustments to reduce painful side effects.

Vagal nerve stimulation is an approved adjunctive treatment for medically intractable epilepsy. Although it is generally well tolerated, some patients experience pain, coughing, or hoarseness during stimulation. Lowering the pulse width in these patients alleviates pain and reduces voice alteration without loss of efficacy. This allows more optimal programming of stimulation intensities.

Rapid ethnographic assessment of breastfeeding practices in periurban Mexico City.

Before carrying out a breastfeeding promotion programme in a periurban area of Mexico City, we conducted a rapid ethnographic study to determine the factors associated with absence of exclusive breastfeeding. The responses to pilot interviews were used to develop a standardized questionnaire regarding reasons for infant feeding choice, sources of advice, and barriers to breastfeeding. We interviewed a random sample of 150 mothers with a child < 5 years of age; 136 (91%) of them had initiated breastfeeding; but only 2% exclusively breastfed up to 4 months. The mothers consistently stated that the child's nutrition, health, growth, and hygiene were the main reasons for the type of feeding selected; cost, comfort, and the husband's opinion were less important. Physicians were ranked as the most important source of advice. Reduction or cessation of breastfeeding occurred on the doctor's advice (68%); or when the mothers encountered local folk illnesses such as "coraje" (52%) or "susto" (54%), which are associated with anger or fright; or had "not enough milk" (62%) or "bad milk" (56%); or because of illness of the mother (56%) or child (43%). During childhood illnesses and conditions, breastfeeding was reduced and the use of supplementary foods was increased. This study emphasizes the importance of cultural values in infant feeding choices, defines specific barriers to breastfeeding, and provides a basis for interventions to promote exclusive breastfeeding in the study population.

PIP: Prior to initiating a community-based intervention program to promote exclusive breast feeding in San Pedro Martir, Mexico, a 2-month (1994) rapid ethnographic assessment was conducted. 150 mothers whose youngest child was under 5 years of age were interviewed. 136 mothers (91%) had breast-fed their infant, for a median duration of 6 months, but only 2% exclusively breast-fed for up to 4 months. Mothers consistently described breast feeding as the best nutrition for their infant. However, the dominant feeding pattern was mixed breast and bottle-feeding. Formula, tea, and water were introduced during the first postpartum day. By the end of the third month, 63% of mothers had introduced solid food to promote growth. It was common practice to reduce breast feeding and increase feeding of supplementary foods when a child was ill. Physicians were the most respected source of knowledge on breast feeding. 42% of mothers reported that, at some point when they were breast feeding, a doctor had advised them to stop and half these mothers complied. The data collected in this rapid survey were used to guide a peer counseling program to promote exclusive breast feeding in the community.

Introducing quality management into primary health care services in Uganda.

In 1994, a national quality assurance programme was established in Uganda to strengthen district-level management of primary health care services. Within 18 months both objective and subjective improvements in the quality of services had been observed. In the examples documented here, there was a major reduction in maternal mortality among pregnant women referred to Jinja District Hospital, a reduction in waiting times and increased patient satisfaction at Masaka District Hospital, and a marked reduction in reported cases of measles in Arua District. Beyond these quantitative improvements, increased morale of district health team members, improved satisfaction among patients, and greater involvement of local government in the decisions of district health committees have been observed. At the central level, the increased coordination of activities has led to new guidelines for financial management and the procurement of supplies. District quality management workshops followed up by regular support visits from the Ministry of Health headquarters have led to a greater understanding by central staff of the issues faced at the district level. The quality assurance programme has also fostered improved coordination among national disease-control programmes. Difficulties encountered at the central level have included delays in carrying out district support visits and the failure to provide appropriate support. At the district level, some health teams tackled problems over which they had little control or which were overly complex; others lacked the management capacity for problem solving.

PIP: To strengthen district-level management of primary health care services in Uganda, a national quality assurance program was introduced in 1994. This approach includes the development and dissemination of standards and guidelines, determining the needs of patients and their families, strengthened communication between health care providers and users, and the use of data to identify gaps in service quality. Among the gains documented in the first 18 months of implementation of this strategy were a reduction in maternal mortality among pregnant women referred to Jinja District Hospital from 13.5% to 2.9%, elimination of lengthy waiting times and increased patient satisfaction at Masaka District Hospital, and a marked decrease in reported measles cases in Arua District. More subjective improvements have included increased morale among district health team members, improved patient satisfaction, and greater local government involvement in district health committee decision making. District quality management workshops, followed up with regular support visits from the Ministry of Health headquarters, have enhanced central staff understanding of district-level needs and issues. Implementation of this program has been achieved largely with existing resources. Difficulties encountered at the district level have included a tendency for some teams to select overly complex problems and a lack of management capacity for problem solving. Overall, however, the principles of quality management are highly applicable to the Ugandan context and can be easily mastered by health workers.

Potato growth in a porous tube water and nutrient delivery system.

Potato (Solanum tuberosum L.) cv. 'Norland', vegetative growth and tuber productivity grown in the porous water and nutrient delivery system (PTNDS) developed by the Wisconsin Center for Space Automation and Robotics were compared with the vegetative growth and tuber productivity of plants grown in a peat:vermiculite potting mixture (PT/VR). The plants were grown at 12, 16, and 24-h light periods, 18 degrees C constant temperature, 70% relative humidity, and 300 micromol m-2 s-1 photosynthetic photon flux. Canopy height of plants grown in the PT/VR system was taller than that of plants grown in the PTNDS system. Canopy height differences were greatest when the plants were grown under a 24-h photoperiod. Leaf and stem dry masses were similar for plants grown in the two systems under the 12-h photoperiod. Under the 24-h photoperiod, leaf and stem dry masses of plants grown in the PT/VR system were more than 3 times those of plants grown in the PTNDS system. Tuber dry masses were similar for plants grown in the two systems under the 12-h photoperiod. Under the 24 h-photoperiod, tuber dry weights of plants grown in the PT/VR system were more than twice those of plants grown in the PTNDS system. A slightly higher harvest index (ratio of tuber weight to leaf plus stem weight) was noted for the plants grown in the PTNDS than for the plants grown in the PT/VR system. Plants grown in the PTNDS system at the 24-h photoperiod matured earlier than plants grown at this photoperiod in the PT/VR system. Vegetative growth and tuber productivity of plants grown under the 16-h photoperiod generally were intermediate to those noted for plants grown under the 12 and 24-h photoperiods. These results indicate that potato plants grown in a PTNDS system may require less plant growing volume, mature in a shorter time, and likely produce more tubers per unit area compared with plants grown in the PT/VR system. These plant characteristics are a distinct advantage for a plant growing unit of a CELSS.

Utilization of white potatoes in CELSS.

Potatoes (Solanum tuberosum) have a strong potential as a useful crop species in a functioning CELSS. The cultivar Denali has produced 37.5 g m-2 d-1 when grown for 132 days with the first 40 days under a 12-h photoperiod and a light:dark temperature cycle of 20 degrees C:16 degrees C, and then 92 days under continuous irradiance and a temperature of 16 degrees C. Irradiance was at 725 micromoles m-2 s-1 PPF and carbon dioxide at 1000 micromoles mol-1. The dried tubers had 82% carbohydrates, 9% protein and 0.6% fat. Other studies have shown that carbon dioxide supplementation (1000 micromoles mol-1) is of significant benefit under 12-h irradiance but less benefit under 24 h irradiance. Irradiance cycles of 60 minutes light and 30 minutes dark caused a reduction of more than 50% in tuber weight compared to cycles of 16 h light and 8 h dark. A diurnal temperature change of 22 degrees C for the 12-h light period to 14 degrees C during the 12-h dark period gave increased yields of 30% and 10% for two separate cultivars, compared with plants grown under a constant 18 degrees C temperature. Cultivar screening under continuous irradiance and elevated temperatures (28 degrees C) for 8 weeks of growth indicated that the cvs Haig, Denali, Atlantic, Desiree and Rutt had the best potential for tolerance to these conditions. Harvesting of tubers from plants at weekly intervals, beginning at 8 weeks after planting, did not increase yield over a single final harvest. Spacing of plants on 0.055 centers produced greater yield per m2 than spacing at 0.11 or 0.22 m2. Plants maintained 0.33 meters apart (0.111 m2 per plant) in beds produced the same yields when separated by dividers in the root matrix as when no separation was made.

Umbilical and uterine artery blood flow velocities after vibratory acoustic stimulation.

Twelve healthy pregnant women between 37 and 41 weeks' gestational age were studied to determine the effects of external vibratory acoustic stimulation on the blood flow velocity waveform in the umbilical and uterine arteries. There was a significant decrease in umbilical peak-systolic/end-diastolic ratio during the first 5 minutes after stimulus after comparison with control ratios. Analysis of the frequency distribution of instantaneous fetal heart rate values during Doppler measurements suggested that the decrease in umbilical peak-systolic/end-diastolic ratio was due to fetal tachycardia rather than a change in the placental vascular resistance. The uterine artery peak-systolic/end-diastolic ratio was not altered after vibratory acoustic stimulation.

Cultural systems for growing potatoes in space.

Higher plants are being evaluated for life support to provide needed food, oxygen and water as well as removal of carbon dioxide from the atmosphere. The successful utilization of plants in space will require the development of not only highly productive growing systems but also highly efficient bioregenerative systems. It will be necessary to recycle all inedible plant parts and all human wastes so that the entire complement of elemental compounds can be reused. Potatoes have been proposed as one of the desirable crops because they are 1) extremely productive, yielding more than 100 metric tons per hectare from field plantings, 2) the edible tubers are high in digestible starch (70%) and protein (10%) on a dry weight basis, 3) up to 80% of the total plant production is in tubers and thus edible, 4) the plants are easily propagated either from tubers or from tissue culture plantlets, 5) the tubers can be utilized with a minimum of processing, and 6) potatoes can be prepared in a variety of different forms for the human diet (Tibbitts et al., 1982). However potatoes have a growth pattern that complicates the development of growing the plants in controlled systems. Tubers are borne on underground stems that are botanically termed 'rhizomes', but in common usage termed 'stolons'. The stolons must be maintained in a dark, moist area with sufficient provision for enlargement of tubers. Stems rapidly terminate in flowers forcing extensive branching and spreading of plants so that individual plants will cover 0.2 m2 or more area. Thus the growing system must be developed to provide an area that is darkened for tuber and root growth and of sufficient size for plant spread. A system developed for growing potatoes, or any plants, in space will have certain requirements that must be met to make them a useful part of a life support system. The system must 1) be constructed of materials, and involve media, that can be reused for many successive cycles of plant growth, 2) involve a minimum quantity of media, 3) contain media that is essentially inert and not oxidize or degrade with use, 4) utilize a recirculating nutrient solution to permit regulation of pH and nutrient concentrations, and 5) be capable of complete automation of all planting, maintenance and harvesting procedures.

Dental pathology of prehistoric residents of Oregon.

Dentitions of 208 prehistoric skeletal specimens from five geographic regions of Oregon were studied to describe their dental status. Comparisons were made of the incidence of specific pathologies among regions and between jaws. Maxillary premortem tooth losses were significantly higher than mandibular tooth loss. A relatively high caries incidence occurs in samples from the Willamette Valley and Klamath Basin, where plant foods were used aboriginally to a significant extent. A high frequency of abscesses was recorded in the Klamath Basin and the Lower Columbia River sample, which also showed the highest levels of attrition. Each of the five subsamples shows patterns of dental pathology consistent with former use of natural resources.