Proactive and integrated consultation-liaison psychiatry for older medical inpatients: A mixed methods description of training, care provided and clinician experience in the HOME study.

OBJECTIVES: To describe the practical experience of delivering a proactive and integrated consultation-liaison (C-L) psychiatry service model (PICLP). PICLP is designed for older medical inpatients and is explicitly biopsychosocial and discharge-focused. In this paper we report: (a) observations on the training of 15 clinicians (seven senior C-L psychiatrists and eight assisting clinicians) to deliver PICLP; (b) the care they provided to 1359 patients; (c) their experiences of working in this new way. METHOD: A mixed methods observational study using quantitative and qualitative data, collected prospectively over two years as part of The HOME Study (a randomized trial comparing PICLP with usual care). RESULTS: The clinicians were successfully trained to deliver PICLP according to the service manual. They proactively assessed all patients and found that most had multiple biopsychosocial problems impeding their timely discharge from hospital. They integrated with ward teams to provide a range of interventions aimed at addressing these problems. Delivering PICLP took a modest amount of clinical time, and the clinicians experienced it as both clinically valuable and professionally rewarding. CONCLUSION: The experience of delivering PICLP highlights the special role that C-L psychiatry clinicians, working in a proactive and integrated way, can play in medical care.

The Use of Immersive Virtual Reality in Sensory Sessions on a Specialist Dementia Unit: Service Evaluation of Feasibility and Acceptability.

This service evaluation reviewed inclusion of Immersive Virtual Reality (iVR) relaxation activities as part of routine occupational therapy sensory sessions on a specialist dementia unit. Twenty-five sessions were completed over 13 wk with 14 participants. Nine participants chose to engage in multiple sessions. Feasibility was assessed through participant engagement and tolerability. Modal first session length was in the range 30 s to 2 min. This increased to over 2 min on second sessions. There was a lack of significant adverse effects measured by direct questioning, neuropsychiatric assessment before vs. after sessions and adverse incident reporting. Acceptability was assessed via structured review of user and staff feedback which noted positive experiences such as relaxation, openness to discussion, reminiscence, wider engagement and interest in future use. Further work is required to explore efficacy and use in other settings.

Narrative Matters: 'Who decides what a meaningful life is?' Life, Animated - a refreshing insight into an autistic person's life.

Life, Animated (2016), directed by Roger Ross Williams is a documentary that centres around the life of Owen Suskind; an autistic person. In recent decades, the media has become a powerful tool that has been used to typify and inform public opinion surrounding autism. This article analyses the portrayal of autism in Life, Animated and draws out important learning points for clinicians, families, service users and the public.

The effectiveness of inpatient consultation-liaison psychiatry service models: A systematic review of randomized trials.

OBJECTIVE: To systematically review randomized trials of the effectiveness of inpatient Consultation-Liaison (C-L) Psychiatry service models in improving patient outcomes, reducing length of hospital stay and decreasing healthcare costs. METHOD: We searched databases including Ovid Medline, Ovid Embase, Ovid PsycINFO and EBSCO CINAHL for relevant trials. Two independent reviewers assessed articles and extracted data. The review is registered with PROSPERO, number CRD42019120827. RESULTS: Eight trials were eligible for inclusion. All had methodological limitations and all were published more than ten years ago. None reported clear evidence that the C-L Psychiatry service model evaluated was more effective than usual medical care alone. All the service models tested focused on providing a consultation for patients identified by screening. Clinical heterogeneity precluded meta-analysis. CONCLUSION: Whilst we found no evidence that any of the inpatient C-L Psychiatry service models evaluated is effective, the sparseness of the literature and its methodological limitations preclude strong conclusions. The trials do, however, suggest that purely consultation-based service models may not be effective. A new generation of robust clinical trials of a wider range of C-L Psychiatry service models is now required to inform future service developments.

Use of Immersive Virtual Reality in the Assessment and Treatment of Alzheimer's Disease: A Systematic Review.

BACKGROUND: Immersive virtual reality (iVR) allows seamless interaction with simulated environments and is becoming an established tool in clinical research. It is unclear whether iVR is acceptable to people with Alzheimer's disease (AD) dementia or useful in their care. We explore whether iVR is a viable research tool that may aid the detection and treatment of AD. OBJECTIVES: This review examines the use of iVR in people with AD or mild cognitive impairment (MCI). METHODS: Medline, PsycINFO, Embase, CINAHL, and Web of Science databases were searched from inception. PRISMA guidelines were used with studies selected by at least two researchers. RESULTS: Nine studies were eligible for inclusion. None reported any issues with iVR tolerability in participants with MCI and AD on assessment or treatment tasks. One study demonstrated capability for detecting prodromal AD and correlated with neuroanatomical substrates. Two studies showed iVR to have high accuracy in differentiating participants with AD from controls but were not hypothesis driven or with adequate controls measures. In a small validation study and two longitudinal case studies, iVR cognitive training was positively rated but did not demonstrate reliable benefit. CONCLUSION: iVR is emerging as a viable method of assessing older adults and people with AD. Strongest benefits were seen when closely integrated with theoretical models of neurodegeneration and existing screening methods. Further randomized controlled trials integrated with clinical populations are required. This will consolidate the power of iVR for assessment of MCI and clarify treatment efficacy beyond current applications in physical rehabilitation.

Early Intervention in Psychosis Treatment Components Utilization in Patients Aged Over 35.

Early Intervention in Psychosis (EIP) services have been youth-focused since their inception. In England, recent National Institute for Health and Care Excellence (NICE) guidelines and new National Health Service (NHS) Standards for EIP recommend the expansion of the age acceptability criterion from 14-35 to 14-65. In the Cambridgeshire and Peterborough EIP service (CAMEO), we ran a service evaluation to assess the initial impact of this policy change. It aimed to elicit EIP treatment components utilization by patients with first-episode psychosis (FEP) aged over 35, in comparison with those under 35. We found that the over-35s required more contacts from EIP healthcare professionals, especially from care coordinators (coefficient = .239; Robust SE = .102; Z = 6.42; p = 0.019) and social workers (coefficient = 18.462; Robust SE = .692; Z = .016; p < 0.001). These findings indicate that FEP patients aged over 35 may present with more complex and sustained clinical/social needs. This may have implications for EIP service development and commissioning.

The over-35s: early intervention in psychosis services entering uncharted territory.

Aims and methodFollowing the introduction of new standards for early intervention in psychosis (EIP) in England, EIP services are accepting referrals for people aged 35-65. The Cambridgeshire and Peterborough EIP service (CAMEO) aimed to explore the immediate implications for the service, especially with regards to referral numbers and sources. Data were collected from April 2016 to June 2017. RESULTS: Referrals for over-35s represented 25.7% of all new referrals. Fifty per cent of referrals for over-35s were accepted onto caseload (40.2% for under-35s). The over-35s were more likely to be referred from acute and secondary mental health services (P < 0.01) and had longer durations of untreated psychosis than the under-35s (P = 0.02).Clinical implicationsCAMEO has received a significantly higher number of referrals as a result of age inclusivity, with an increased proportion of patients suffering from severe, acute psychotic presentations and existing mental health difficulties. This has implications for service planning.Declaration of interestNone.

Systematic Review Investigating Multi-disciplinary Team Approaches to Screening and Early Diagnosis of Dementia in Primary Care - What are the Positive and Negative Effects and Who Should Deliver It?

BACKGROUND: Primary care services frequently provide the initial contact between people with dementia and health service providers. Early diagnosis and screening programmes have been suggested as a possible strategy to improve the identification of such individuals and treatment and planning health and social care support. OBJECTIVE: To determine what early diagnostic and screening programmes have been adopted in primary care practice, to explore who should deliver these and to determine the possible positive and negative effects of an early diagnostic and screening programme for people with dementia in primary care. METHODS: A systematic review of the literature was undertaken using published and unpublished research databases. All papers answering our research objectives were included. A narrative analysis of the literature was undertaken, with the CASP tools used appropriately to assess study quality. RESULTS: Thirty-three papers were identified of moderate to high quality. The limited therapeutic options for those diagnosed with dementia means that even if such a programme was instigated, the clinical value remains questionable. Furthermore, accuracy of the diagnosis remains difficult to assess due to poor evidence and this raises questions regarding whether people could be over- or under-diagnosed. Given the negative social and psychological consequences of such a diagnosis, this could be devastating for individuals. CONCLUSION: Early diagnostic and screening programmes have not been widely adopted into primary care. Until there is rigorous evidence assessing the clinical and cost-effectiveness of such programmes, there remains insufficient evidence to support the adoption of these programmes in practice.

Staples vs subcuticular sutures for skin closure at cesarean delivery: a metaanalysis of randomized controlled trials.

Recently published randomized trials examining skin closure technique on postcesarean wound complications have produced conflicting results. We performed a metaanalysis of trials comparing staples and subcuticular sutures for skin closure at cesarean section (CS). Pooled outcome measures were calculated using random effects models. Primary outcomes were rates of wound dehiscence (separation) and a composite wound complication rate. Secondary outcomes were patient satisfaction, operating time, and postoperative pain. A total of 877 women from 5 trials were included. Both wound separation (pooled odds ratio, 4.01; P < .0001) and composite wound complication (pooled odds ratio, 2.11; P = .003) rates were higher with staples. The use of staples reduced operating time (weighted mean difference, -5.05 minutes; P = .021). Data on postoperative pain and patient satisfaction were insufficient for metaanalysis. Our findings suggest a possible benefit with subcuticular sutures compared to skin staples for skin closure at CS. However, the optimal skin closure technique at CS demands further study.

Teaching adults new words: the role of practice and consolidation.

Semantic and orthographic learning of new words was investigated with the help of the picture-word interference (PWI) task. In this version of the Stroop task, picture naming is delayed by the simultaneous presentation of a semantically related as opposed to an unrelated distractor word (a specific PWI effect), as well as by an unrelated word compared with a nonword (a general PWI effect). This interference is taken to reflect automatic orthographic and semantic processing. The authors observed that participants showed both types of PWI effects for newly learned words following a single study session. Interestingly, specific PWI effects were not obtained immediately after testing but did emerge a week later without additional practice. This suggests that a period of consolidation is involved in the establishment of word representations. In addition, identical PWI effects were obtained when the study and test words were presented in either the same or different letter case. This provides evidence that the newly acquired orthographic representations are coded in an abstract format.