The impact of an epilepsy nurse competency framework on the costs of supporting adults with epilepsy and intellectual disability: findings from the EpAID study.

BACKGROUND: The development of a nurse-led approach to managing epilepsy in adults with an intellectual disability (ID) offers the potential of improved outcomes and lower costs of care. We undertook a cluster randomised trial to assess the impact on costs and outcomes of the provision of ID nurses working to a designated epilepsy nurse competency framework. Here, we report the impact of the intervention on costs. METHOD: Across the United Kingdom, eight sites randomly allocated to the intervention recruited 184 participants and nine sites allocated to treatment as usual recruited 128 participants. Cost and outcome data were collected mainly by telephone interview at baseline and after 6 months. Total costs at 6 months were compared from the perspective of health and social services and society, with adjustments for pre-specified participant and cluster characteristics at baseline including costs. Missing data were imputed using multiple imputation. Uncertainty was quantified by bootstrapping. RESULTS: The intervention was associated with lower per participant costs from a health and social services perspective of -£357 (2014/2015 GBP) (95% confidence interval -£986, £294) and from a societal perspective of -£631 (95% confidence interval -£1473, £181). Results were not sensitive to the exclusion of accommodation costs. CONCLUSIONS: Our findings suggest that the competency framework is unlikely to increase the cost of caring for people with epilepsy and ID and may reduce costs.

How people from Chinese backgrounds make sense of and respond to the experiences of mental distress: Thematic analysis.

RATIONALE FOR THE STUDY: Many Chinese people do not contact mental health services when they first develop mental health problems. It is therefore important to find out reasons for low uptake of services so that strategies can be identified to promote early intervention. WHAT IS ALREADY KNOWN ABOUT THE TOPIC?: Most Chinese people only come into contact with mental health services during crisis situations. Language difference, lack of knowledge of mainstream services and stigma attached to mental health problems are barriers to access and utilize mental health services. WHAT THE STUDY ADDS TO THE INTERNATIONAL EVIDENCE?: Chinese people apply both Western medication and traditional healing to manage distress caused by mental health problems. Because of the extreme stigma associated with mental health problems, Chinese people are reluctant to accept support from their own cultural groups outside their family. Family plays a major role in caring for relatives with mental health problems. Families are prepared to travel across the world in search of folk healing if not available in Western societies. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is important to recognize the different approaches to understanding and managing mental health problems among Chinese people, otherwise they will be dissuaded from engaging with mental health services if their beliefs are disregarded and invalidated. Services that involve Chinese speaking mental health workers can address the issue of language differences and sensitive mental health issues within the Chinese community. ABSTRACT: Introduction Late presentation and low utilization of mental health services are common among Chinese populations. An understanding of their journey towards mental health care helps to identify timely and appropriate intervention. Aim We aimed to examine how Chinese populations make sense of the experiences of mental distress, and how this understanding influences their pathways to mental health care. Method We undertook in-depth interviews with fourteen people with mental health problems (MHPs) and sixteen family members. Thematic analysis was used to analyse data. Results/Discussions Different conceptualization of mental distress and the stigma attached to MHPs explained why most participants accessed services at crisis points. Because of mental illness stigma, they were reluctant to seek help outside of the family. Participants used a pragmatic pluralistic approach to incorporate ritual healing and Western interventions to manage mental distress as they travelled further on the pathway journey. Families play a key role in the journey and are prepared to visit different parts of the world to seek traditional healers. Implications for practice Mental health nurses need to adopt a transcultural working approach to address mental health issues so that family will get the support needed to continue their caring role.

The physical health of the seriously mentally ill: an overview of the literature.

Despite the wealth of literature which attests to the relationship between serious mental illness (SMI) and physical ill health, the provision of optimum physical health care for mental health service users remains a challenge. In England the Department of Health has identified the evident health inequalities for people with SMI as a priority area for health improvement, publishing numerous policy directives aimed at addressing these inequalities. However, this is a highly complex process and little is known about why the rhetoric of holistic health care has proved unattainable thus far. In this paper we present an informed commentary of the contemporary literature with the aim of offering a more comprehensive understanding of the health inequalities faced by people with SMI. We searched relevant databases for publications related to: the causes of poor physical health among the mentally ill, strategies to address these health needs and the impact which professional education, culture and services structure has on this facet of service delivery. This enabled us to identify potential strategies that can be adopted by health care practitioners wishing to improve the health of this vulnerable group, and by educationalists to advance professionals' knowledge of this important and ostensibly neglected area.

Determination of immunoglobulin G in bovine colostrum and milk powders, and in dietary supplements of bovine origin by protein G affinity liquid chromatography: collaborative study.

An AOAC collaborative study was conducted to evaluate an affinity LC procedure for measuring immunoglobulin G (IgG) in selected dairy powders. The powders were extracted with 0.15 M sodium chloride solution and the pH was adjusted to 4.6 to precipitate caseins, which would otherwise lead to an overestimation of IgG. The analyte was then bound to a commercially available Protein G affinity cartridge and selectively eluted with a glycine buffer at pH 2.5. Detection was at 280 nm and quantification was made against a calibration curve prepared from bovine serum IgG. The samples analyzed included the likely matrixes for which this assay will find commercial use, namely, high- and low-protein-content colostrum powders, tablets containing colostrum powder, and some IgG-containing dairy powders; milk protein isolate, whey protein concentrate, and skim milk powder. Eleven laboratories provided data for the study and assayed blind duplicates of six materials. The repeatability RSD values ranged from 2.1 to 4.2% and the reproducibility RSD values ranged from 6.4 to 18.5%. The Protein G method with casein removal has adequate reproducibility for measuring IgG in colostrum-derived powders that are traded on the basis of IgG content as a colostral marker.

A technique for reconstruction of upper lid marginal defects.

BACKGROUND/AIMS: Reconstruction of large full thickness upper lid defects that cannot be closed directly often rely on utilising the lower lid. An example is the Cutler Beard procedure. A one stage technique for repair of large horizontal upper lid defects utilising local posterior and anterior lamella advancement flaps is described and the results reported. METHOD: Eight cases with upper lid defects repaired utilising this technique were reviewed retrospectively. The procedures were carried out by one surgeon. The upper lid lesions were removed under frozen section control. The mean follow up time was 35 months. RESULTS: All patients had a good cosmetic result. One patient had a recurrence of the upper lid lesion. Two patients complained of corneal irritation from lanugo hairs. The technique was modified to prevent this complication. CONCLUSIONS: Large upper lid marginal defects can be readily repaired using the technique described with local advancement flaps with no significant complications.

Retinal vasoproliferative tumors: surgical management and histological findings.

Vascular masses occurring in the peripheral retina have been described extensively in the literature. Many terms, including "presumed acquired hemangiomas," "hemangioma-like," "angiomatous masses," "angioma-like," "peripheral retinal telangiectasis," and "vasoproliferative tumors," have been suggested that reflect the lack of the known histological features and the potentially variable causes. We describe the histological features of 2 patients who underwent transcleral local resection as management for suspected choroidal melanoma. Pathological examination of these tumors reveals the constituents to be primarily benign glial cell proliferation with secondary vasoproliferation. The weight of the literature agrees with a reactionary process. We therefore suggest the term "reactionary retinal glioangiosis." Transcleral resection has a place where diagnosis is difficult. It prevents an unnecessary enucleation and allows accurate tissue diagnosis.

Extracellular calcium modulates insulin's action on enzymes controlling cyclic AMP metabolism in intact hepatocytes.

Absence of physiological concentrations of extracellular Ca2+ in the Krebs-Henseleit incubation buffer did not affect the ability of 10 nM glucagon (< 5%) to increase hepatocyte intracellular cyclic AMP concentrations, but severely ablated (by approximately 70%) the ability of 10 nM insulin to decrease these elevated concentrations. Cyclic AMP metabolism is determined by production by adenylate cyclase and degradation by cyclic AMP phosphodiesterase (PDE). In the absence of added extracellular Ca2+ (2.5 mM), insulin's ability to activate PDE activity was selectively compromised, showing a failure of insulin to activate two of the three insulin-stimulated activities, namely the 'dense-vesicle' and peripheral plasma-membrane (PPM) PDEs. In the absence of added Ca2+, insulin's ability to inhibit adenylate cyclase activity in intact hepatocytes was decreased dramatically. Vasopressin and adrenaline (+ propranolol) failed to elicit the activation of either the 'dense-vesicle' or the PPM-PDEs. The presence of physiological concentrations of extracellular Ca2+ in the incubation medium is shown to be important for the appropriate generation of insulin's actions on cyclic AMP metabolism.

Long-term follow-up of lichen planus.

Several large series of patients with lichen planus were reported some 30 years ago but no recent large surveys have been published. In this study, detailed enquiry was made into the natural history of the disease in 214 patients followed up 8 to 12 years after presentation to the Dermatology Department. The key findings from this study showed that the mean age of onset of lichen planus in males was significantly lower than in females (40.3 years in males compared with 46.4 years in females, p less than 0.05). The main eruption of lichen planus cleared within one year in 68% of the patients but we found a higher recurrence rate than in previous series at 49%. Many patients suffered from persistent brown staining many years after the rash had cleared.

Treatment of intact hepatocytes with the calcium ionophore A23187 perturbs both the synthesis and the degradation of the second messenger cyclic AMP. Actions on adenylate cyclase and cyclic AMP phosphodiesterase activities.

The presence of the calcium ionophore A23187 augmented glucagon's ability to elevate intracellular cyclic AMP concentrations in intact hepatocytes. However, when the cyclic AMP phosphodiesterase inhibitor 1-isobutyl-3-methylxanthine (IBMX) was added to prevent the degradation of cyclic AMP then the presence of A23187 attenuated the ability of glucagon to increase intracellular cyclic AMP concentrations. Treatment of intact hepatocytes with A23187 led to a dose-dependent persistent inhibition of the glucagon-stimulated adenylate cyclase activity expressed by a membrane fraction isolated from such ionophore-treated hepatocytes. In hepatocytes where glucagon-stimulated adenylate cyclase activity was desensitized then A23187-treatment of hepatocytes failed to exert any inhibitory action on adenylate cyclase. Treatment of isolated membranes directly with A23187 did not elicit any changes in glucagon-stimulated adenylate cyclase activity. Such actions of A23187 were blunted when Ca2+ (2.5 mM) was not added to the extracellular medium. It is suggested that treatment of hepatocytes with A23187 leads to the functional uncoupling of glucagon-stimulated adenylate cyclase activity in a manner which appears to mimic the desensitization process. A23187-treatment also exerted an overall inhibitory effect on the cyclic AMP phosphodiesterase activity displayed by intact hepatocytes. Thus treatment of hepatocytes with A23187 exerted a profound effect on cyclic AMP metabolism in these cells.

Insulin and glucagon attenuate the ability of cholera toxin to activate adenylate cyclase in intact hepatocytes.

Treatment of intact hepatocytes with cholera toxin at 37 degrees C caused a stable activation of adenylate cyclase activity after a lag period of around 10 min. The presence of either insulin (10 nM) or glucagon (10 nM) in the incubation medium had little effect on this lag period; however, these hormones markedly attenuated the maximal activation of adenylate cyclase activity that could be achieved by treatment with cholera toxin. Such actions of insulin and glucagon were dose-dependent, with EC50 values (concn. giving 50% inhibition) of 0.20 nM for insulin and 0.49 nM for glucagon, and were not additive. Treatment of intact hepatocytes with either glucagon or insulin did not affect the ability of cholera toxin to cause the ADP-ribosylation of the 45 kDa alpha-subunit of the stimulatory guanine nucleotide regulatory protein, Gs, in intact hepatocytes. It is suggested that treatment of intact hepatocytes with either insulin or glucagon attenuates the stimulatory action of ADP-ribosylated Gs on adenylate cyclase.

The phorbol ester TPA inhibits cyclic AMP phosphodiesterase activity in intact hepatocytes.

Treatment of intact hepatocytes with the phorbol ester 12-O-tetradecanoyl phorbol 13-acetate (TPA) potentiated the ability of glucagon to increase intracellular cyclic AMP concentrations. This effect was dose-dependent upon TPA, exhibiting an EC50 of 0.39 ng/ml and such activation was observed at both saturating and sub-saturating concentrations of glucagon. However, this stimulatory effect of TPA was completely abolished by the presence of the cyclic AMP phosphodiesterase inhibitor 1-isobutyl-3-methylxanthine, when TPA now inhibited the glucagon-stimulated increase in intracellular cyclic AMP concentrations. It is suggested that, as well as inhibiting glucagon-stimulated adenylate cyclase activity, TPA also inhibits cyclic AMP phosphodiesterase activity in intact hepatocytes. Treatment of either hepatocyte homogenates or purified cyclic AMP phosphodiesterase with TPA failed to show any direct inhibitory effect of TPA on activity showing that TPA did not exert any direct inhibitory action on phosphodiesterase activity. However, homogenates made from hepatocytes that had been pre-treated with TPA did show a reduced cyclic AMP phosphodiesterase activity. It is suggested that TPA might inhibit cyclic AMP phosphodiesterase activity through phosphorylation by C-kinase.