Gravity complexes as a focus of seafloor fluid seepage: the Rio Grande Cone, SE Brazil.

Seafloor methane emissions can affect Earth's climate and ocean chemistry. Vast quantities of methane formed by microbial decomposition of organic matter are locked within gas hydrate and free gas on continental slopes, particularly in large areas with high sediment accumulations such as deep-sea fans. The release of methane in slope environments has frequently been associated with dissociation of gas hydrates near the edge of the gas hydrate stability zone on the upper slope, with discharges in greater water depths less understood. Here we show, using data from the Rio Grande Cone (western South Atlantic), that the intrinsic, gravity-induced downslope collapse of thick slope sediment accumulations creates structures that serve as pathways for gas migration, unlocking methane and causing seafloor emissions via giant gas flares in the water column. The observed emissions in the study region (up to 310 Mg year-1) are three times greater than estimates for the entire US North Atlantic margin and reveal the importance of collapsing sediment accumulations for ocean carbon cycling. Similar outgassing systems on the Amazon and Niger fans suggest that gravity tectonics on passive margins is a common yet overlooked mechanism driving massive seafloor methane emissions in sediment-laden continental slopes.

Systematic review of studies of mental health nurses' experience of anger and of its relationships with their attitudes and practice.

WHAT IS KNOWN ON THE SUBJECT?: It is generally felt that it is helpful for mental health nurses to control their emotions during their work. There are different approaches, but there is growing acceptance that different emotions may need different coping strategies. There is lots of evidence that nurses sometimes feel anger in a number of situations, but the research about anger in mental health nurses has never been examined as a whole. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: We have systematically identified all previous research where nurses completed measures that tried to measure their anger in certain situations, compared it to other people or investigated how it affected them or what its relationship was with their practice. Only a few studies have measured nurses' anger. However, it seems that while nurses are not generally angrier than any other group, they do often feel anger in relation to management of patient aggression and their job situation more generally. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Anger is the most commonly reported problematic emotion for mental health nurses. It may influence their practice and affect their well-being. This has implications for staff support and training. ABSTRACT: Introduction Emotional regulation is important in mental health nursing practice, but individual emotions may require different regulation strategies. There is ample evidence that nurses experience anger specifically during their work, for example when experiencing patient aggression. It is, therefore, important to consolidate what is known about how anger manifests in mental health nursing practice. AIM: We aimed to systematically identify, evaluate and synthesize results from studies about mental health nurses and anger, where anger was measured objectively. METHODS: Systematic literature review based on PRISMA guidelines. RESULTS: We identified 12 studies. A range of validated and nonvalidated instruments was used. Mental health nurses may have lower levels of anger than normative samples, but anger is commonly reported as an issue for them. Anger was studied in relation to its links with (1) clinical management of patients, notably violence containment; and (2) employment issues more generally, notably job motivation. Anger is related to nurses' attitudes about the acceptability of coercion, but there is no evidence that it results in more coercion. IMPLICATIONS FOR PRACTICE: Nurses should be aware of the potential influence of anger on their practice. Anger, specifically, should be considered when supporting mental health nurses, for example in clinical supervision. Emotional regulation training should target anger.

Should we advocate neutering for all pet rabbits?

The neutering of pet rabbits has become more common in recent years due to recognition of the importance of species-specific social contact and the perceived risk of reproductive malignancies in unspayed older females. Here, GUEN BRADBURY: and GREG DICKENS: argue that the benefits of neutering singly housed rabbits (still the majority in the UK) may not outweigh the adverse effects of the procedure.

Appropriate handling of pet rabbits: a literature review.

Many rabbits show fear behaviours when lifted off the ground. Estimates from owner surveys suggest that around 60% of pet rabbits struggle when lifted and fear-related aggression is common. This article integrates information from both laboratory and pet rabbit studies to formulate a list of recommendations for appropriate handling of rabbits. Reduction of the frequency of the stressor can be achieved by educating owners on alternative management practices to reduce the need to carry their rabbits. However, in some situations, it is unavoidable that a rabbit is lifted. Amelioration of the stress in these instances can be achieved by a 2 pronged strategy. First, the population of rabbits can be made more resilient to infrequent stressors by selectively breeding for confident rabbits and by better socialisation of unweaned kits, and, where possible, training of individual animals to permit handling. Secondly, any unavoidable lifting can be made less stressful by educating veterinary staff in appropriate methods of holding rabbits during both consultations and inpatient care. Better understanding of appropriate interactions with rabbits will improve welfare.

How short should short-term risk assessment be? Determining the optimum interval for START reassessment in a secure mental health service.

ACCESSIBLE SUMMARY: The Short-Term Assessment of Risk and Treatability (START) is a tool used in some mental health services to assess patients to see if they are at risk of violence, self-harm, self-neglect or victimization. The recommended time between assessments is 3 months but there is currently no evidence to show that this is best practice. We have investigated whether assessing at 1- or 2-month intervals would be more accurate and therefore facilitate more individualized risk management interventions. We found that many patients who were rated as low risk had been involved in risk behaviours before 3 months had passed; some patients who were rated at increased risk did not get involved in risk behaviours at all. Results are mixed for different outcomes but on balance, we think that the recommendation to conduct START assessment every 3 months is supported by the evidence. However, reassessment should be considered if risk behaviours are not prevented and teams should always consider whether risk management practices are too restrictive. ABSTRACT: The Short-Term Assessment of Risk and Treatability (START) guides assessment of potential adverse outcomes. Assessment is recommended every 3 months but there is no evidence for this interval. We aimed to inform whether earlier reassessment was warranted. We collated START assessments for N = 217 adults in a secure mental health hospital, and subsequent aggressive, self-harm, self-neglect and victimization incidents. We used receiver operating characteristic analysis to assess predictive validity; survival function analysis to examine differences between low-, medium-, and high-risk groups; and hazard function analysis to determine the optimum interval for reassessment. The START predicted aggression and self-harm at 1, 2 and 3 months. At-risk individuals engaged in adverse outcomes earlier than low-risk patients. About half warranted reassessment before 3 months due to engagement in risk behaviour before that point despite a low-risk rating, or because of non-engagement by that point despite an elevated risk rating. Risk assessment should occur at appropriate intervals so that management strategies can be individually tailored. Assessment at 3-month intervals is supported by the evidence. START assessments should be revisited earlier if risk behaviours are not prevented; teams should constantly re-evaluate the need for restrictive practices.

Predictive validity of the HCR-20 for inpatient aggression: the effect of intellectual disability on accuracy.

BACKGROUND: People with intellectual disability (ID) account for a large proportion of aggressive incidents in secure and forensic psychiatric services. Although the Historical, Clinical, Risk Management 20 (HCR-20) has good predictive validity in inpatient settings, it does not perform equally in all groups and there is little evidence for its efficacy in those with ID. METHOD: A pseudo-prospective cohort study of the predictive efficacy of the HCR-20 for those with ID (n = 109) was conducted in a UK secure mental health setting using routinely collected risk data. Performance of the HCR-20 in the ID group was compared with a comparison group of adult inpatients without an ID (n = 504). Analysis controlled for potential covariates including security level, length of stay, gender and diagnosis. RESULTS: The HCR-20 total score was a significant predictor of any aggression and of physical aggression for both groups, although the area under the curve values did not reach the threshold for a large effect size. The clinical subscale performed significantly better in those without an ID compared with those with. The ID group had a greater number of relevant historical and risk management items. The clinicians' summary judgment significantly predicted both types of aggressive outcomes in the ID group, but did not predict either in those without an ID. CONCLUSIONS: This study demonstrates that, after controlling for a range of potential covariates, the HCR-20 is a significant predictor of inpatient aggression in people with an ID and performs as well as for a comparison group of mentally disordered individuals without ID. The potency of HCR-20 subscales and items varied between the ID and comparison groups suggesting important target areas for improved prediction and risk management interventions in those with ID.

Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital.

ACCESSIBLE SUMMARY: Medication administration errors and near misses are common including in mental health settings. Nurses should report all errors and near misses so that lessons can be learned and future mistakes avoided. We interviewed 50 nurses to find out if they would report an error that a colleague had made or if they would report a near-miss that they had. Less than half of nurses said they would report an error made by a colleague or a near-miss involving themselves. Nurses commonly said they would not report the errors or near misses because there was a good excuse for the error/near miss, because they lacked knowledge about whether it was an error/near miss or how to report it, because they feared the consequences of reporting it, or because reporting it was too much work. Mental health nurses mostly report similar reasons for not reporting errors and near misses as nurses working in general medical settings. We have not seen another study where nurses would not report an error or near miss because they thought there was a good excuse for it. Training programmes and policies should address all the reasons that prevent reporting of errors and near misses. Medication errors are a common and preventable cause of patient harm. Guidance for nurses indicates that all errors and near misses should be immediately reported in order to facilitate the development of a learning culture. However, medication errors and near misses have been under-researched in mental health settings. This study explored the reasons given by psychiatric nurses for not reporting a medication error made by a colleague, and the perceived barriers to near-miss reporting. We presented 50 nurses with clinical vignettes about error and near-miss reporting and interviewed them about their likely actions and about their views and perceptions. Less than half of participants would report an error made by a colleague (48%) or a near-miss involving themselves (40%). Thematic analysis revealed common themes for both not reporting an error or a near-miss were knowledge, fear, burden of work, and excusing the error. The first three themes are similar to results obtained from research in general medical settings, but the fourth appears to be novel. Many mental health nurses are not yet fully convinced of the need to report all errors and near misses, and that improvements could be made by increasing knowledge while reducing fear, burden of work, and excusing of errors.

Smoking behaviour, motives, motivation to quit and self-efficacy among patients in a secure mental health service: comparison with staff controls.

People with mental disorder account for a disproportionately large amount of smokers, and the problem is greatest in inpatient settings. 'Stop smoking' services should be tailored to the needs of individual patient groups. It is important therefore to investigate factors relevant to different groups in order to inform future quit smoking interventions. We compared 50 patients and 50 staff in a secure mental health hospital on measures of smoking and smoking motives, nicotine dependence, craving, previous cessation attempts, motivation to quit and quit smoking-related self-efficacy. Patients were significantly more dependent on nicotine with higher levels of craving; were more likely to smoke to cope with stress, for something to do when bored, for enjoyment and pleasure; and reported significantly less readiness to quit smoking. Staff were more likely to cite health concerns as reasons for quitting. Future pre-intervention work with inpatients should focus on increasing their readiness to quit smoking. Once motivation is increased, interventions should include advice on reducing cravings, finding alternative methods for coping with stress and boredom and achieving enjoyment and pleasure from alternative sources.

Potential severity of aggressive behaviour after acquired brain injury: implications for recording.

Aggression is a consequence of acquired brain injury that may necessitate admission to neurobehavioural services. The 'Overt Aggression Scale - Modified for Neurorehabilitation' (OAS-MNR) is a valid, reliable means of capturing this. A criticism of observational rating scales is they do not reflect factors like intent to harm which results in recording anomalies. 'Attacks' has been proposed as a measure which achieves this within psychiatric settings. Principal goals of this study are to determine the usefulness of measuring similar concepts in neurobehavioural services and further validating both scales. A total of 1066 physical assaults were recorded in 6 weeks by 25 patients in an inpatient neurobehavioural programme using the OAS-MNR. Fifty incidents were also rated on Attacks. Convergent validity for using both measures in neurobehavioural services was found. Modifying OAS-MNR severity scores using one of two factors found to underlie Attacks produced an index that successfully discriminated incidents whose risk necessitated more intrusive intervention, which was not evident otherwise. Modifying scores that objectively reflect severity of physical assaults using measures of perceived intent should be a feature of observational recording scales such as the OAS-MNR. Ensuring robust inter-rater reliability will be essential in any development work.

An audit of the use of breakaway techniques in a large psychiatric hospital: a replication study.

This paper describes an audit study of the effectiveness of breakaway training conducted in a specialist inpatient mental health hospital. Breakaway techniques comprise a set of physical skills to help separate or break away from an aggressor in a safe manner, but do not involve the use of restraint. Staff (n= 147) were assessed on their ability to break away from simulations of potentially life-threatening scenarios in a timely manner, and using the techniques taught in annual breakaway or refresher training. We found that only 14% (21/147) of participants correctly used the taught techniques to break away within 10 s. However, 80% of people were able to break away from the scenarios within 10 s but did not use the techniques taught to them. This audit reinforces questions about breakaway training raised in a previous study. It further demonstrates the need for a national curriculum for physical intervention training and development of the evidence base for the content of such training as a priority.

Smoking in a forensic psychiatric service: a survey of inpatients' views.

Smoking in a forensic psychiatric service: a survey of inpatients' views Very little is known concerning the views and beliefs of psychiatric inpatients about smoking in hospital. We conducted a survey of inpatients from the forensic wards of a large independent psychiatric hospital using a structured interview to collect data about their views on smoking. Of 102 patients eligible to participate, 45 (44.1%) agreed to do so. Most participants (34, 75.6%) were current smokers. Most smokers thought it was just too difficult to give up smoking (25, 73.5%). They cited seeing staff and other patients smoking, as well as the smoky atmosphere on the ward, as barriers to quitting. The majority of participants (35, 77.8%) thought that staff should be allowed to smoke with patients. Smokers held more liberal views about smoking than non-smokers. A smaller proportion of non-smokers than smokers were happy with the hospital smoking policy, as reflected in the ward rules about smoking. The results of this survey suggest that a change in attitude and culture towards smoking may be needed in psychiatric units. Smokers should be regularly offered help and encouragement to quit. Psychiatric care staff should carefully consider whether their own smoking behaviour undermines their patients' attempts to stop smoking. More attention should be given to the views and needs of non-smokers.

Nurses' perceptions of the working environment: a UK independent sector study.

The working environment is an important determinant of employee well-being. Previous UK studies report registered nurses' perception of the working environment using the Work Environment Scale (WES), but surprisingly few include data for nurses working in mental health or learning disability settings. One hundred and sixty-one (58.8%) registered nurses working day shifts in five specialist divisions (forensic adult mental health, adolescent mental health, elderly continuing care, adult and adolescent learning disability and brain injury rehabilitation) of a large charitable hospital comprising mostly secure (i.e. 'locked') wards completed the WES. Nurses working in separate clinical divisions differed only on the 'physical comfort' subscale. These results are discussed in the context of previous UK research: this sample of nurses scored differently on a number of subscales, with the working environment characterized by relatively high levels of support, cohesion and managerial control and slightly lower levels of autonomy. It is unclear whether the differences reflect the organizational (i.e. non-NHS) context, or a secure environment effect. Previous studies of mental health nurses are now 10 years old and we present data that may provide a benchmark of perceptions of the working environment held by nurses working in mental health and learning disability settings.

Smoking and mental health nurses: a survey of clinical staff in a psychiatric hospital.

There is a lack of evidence on the prevalence of smoking among mental health nurses, and the beliefs and attitudes they hold about smoking at work. This paper describes results from a cross-sectional survey of clinical staff working in a UK specialist charitable-status psychiatric hospital and focuses on the responses of registered mental health nurses. Questionnaires specifically developed for this study were sent to all 1371 clinical employees. Completed questionnaires were returned by 167 of 429 (38.9%) registered nurses (RNs), 300 of 842 (35.6%) nursing assistants (NAs), and 123 of 200 (61.5%) other health professionals (OHPs). Twenty-nine (17.4%) RNs, 93 (31%) NAs and eight (6.5%) OHPs reported themselves as current smokers. Differences in response to attitudinal questions between groups could not be attributed to age. RN smokers were significantly more likely than RN non-smokers to state that staff should be allowed to smoke with patients, and to report therapeutic value for patients in this activity. RN smokers were less likely than RN non-smokers to report that patients should be encouraged to stop smoking. RNs were significantly more likely than OHPs to report therapeutic value for patients in smoking with staff, even after controlling for the possible confounding effect of smoking status. Implications of the survey are discussed in the context of the international literature, including the disproportionately high smoking prevalence among patients living in psychiatric institutions and current guidelines to move towards no 'smoking allowed' areas for staff working in them.

Absconding of patients from an independent UK psychiatric hospital: a 3-year retrospective analysis of events and characteristics of absconders.

The need for accurate local information on the scale, nature and outcome of absconding or Absence Without Leave (AWOL) from an independent UK psychiatric hospital led to this 3-year (1997-1999) retrospective analysis of of AWOL data. One hundred and forty-eight AWOL incidents involving 88 patients were identified. Absconders were found to be significantly younger, more likely to be detained upon admission and more likely to be unmarried than a control group (n = 1378) of non-absconders. There were no significant differences for sex, length of admission or ethnicity. Descriptive data on the circumstances surrounding AWOL events are given, with at least 24 (16.2%) incidents having serious adverse outcomes. Baseline absconding rates are presented for the specialist clinical divisions within the hospital. There is a need for more detailed studies of absconding by patients within the Adolescent Mental Health Service subgroup where the absconding rate was relatively high and engagement in risk activity whilst AWOL relatively frequent.

Pharmacokinetics of flunisolide administered via metered dose inhaler with and without a spacer device and following oral administration.

BACKGROUND: After inhalation of a glucocorticoid from a meter dose inhaler (MDI), a certain portion of the delivered dose is deposited in the lungs, and the remainder is deposited in the oropharynx. OBJECTIVE: To examine the absolute bioavailability of flunisolide given orally via metered dose inhaler, and metered dose inhaler with a commercially available spacer device as well as to determine the fraction of drug deposited in the lungs following inhalation. METHODS: Twenty-four healthy volunteers were enrolled in the study; twenty-two completed the study. The IRB approved the study protocol, and informed consent was obtained. Volunteers received four treatments: treatment A (MDI), 1.0 mg inhaled flunisolide; treatment B (MDI-S), 1.0 mg inhaled flunisolide with a spacer device; treatment C, 1.0 mg of orally administered flunisolide with 240 mL of water; and treatment D, 1.0 mg intravenous flunisolide by IV push in the antecubital vein over 60 seconds. Plasma and urine flunisolide were quantified by HPLC/mass spectrometry/mass spectrometry. RESULTS: Flunisolide is a corticosteroid with low oral bioavailability (6.7%), which was found to be lower than previously reported. Similar AUCs were observed between the MDI and MDI-S groups, but by using mass balance equations, it appears that more flunisolide was delivered to the lungs in the MDI-S group (410 microg versus 280 microg). Oropharyngeal deposition was an important difference between the two inhaler groups. Approximately an 11-fold reduction in the oropharyngeal deposition of flunisolide through use of the spacer device was observed. CONCLUSIONS: Use of a spacer device improved pulmonary delivery of flunisolide by almost 50% and significantly decreased the oropharyngeal exposure to drug.

A pilot study of estrogen's effects on bronchial myocyte adhesion molecule expression.

We examined the effects of estrogen on tumor necrosis factor alpha (TNF-alpha)-induced expression of intracellular adhesion molecule (ICAM-1) and vascular adhesion molecule (VCAM-1) in cultured human bronchial smooth muscle cells (BSMC). Experiments were performed in triplicate in T-75 tissue culture flasks containing normal human BSMC. Four experiments were carried out: untreated BSMC cells (control); TNF-alpha 1000 U/ml stimulation of BSMC; forskolin 5 microM before TNF-alpha stimulation of BSMC; and estradiol 30 microM before TNF-alpha stimulation of BSMC. Cyclic adenosine monophosphate was measured by a commercially available radioimmunoassay kit. Cell expression of ICAM-1 and VCAM-1 was quantified by flow cytometry Incubation of cells with TNF-alpha 1000 U/ml for 24 hours elicited a 27-fold increase in basal expression of ICAM-1 and a 2-fold increase in VCAM-1 (p>0.05). Incubation of BSMC with forskolin 5 microM, for 1 hour before TNF-alpha, decreased TNF-alpha-induced expression of ICAM-1 by 62% and VCAM-1 slightly by 17%. The BSMC incubated with estradiol 30 microM, 1 hour before TNF-alpha, decreased TNF-alpha-induced expression of ICAM-1 by 21%; VCAM-1 remained unchanged (p>0.05). We found a trend toward inhibition of TNF-alpha-stimulated ICAM-1 expression in cultured BSMC with pretreatment with estradiol. However, due to large variability within the cell culture model, statistical significance was not reached.