Multi parametric biophysical assessment of treatment effects on xerotic skin.

Background: Topical moisturizing products are widely used to alleviate the problems associated with xerotic skin. Their use affects many properties of the stratum corneum (SC) in a complex and interrelated manner. The range of measurement techniques available to the researcher has increased in recent years. However, few studies have looked for correlations between the different techniques for assessing how aspects of xerotic skin change over time as a result of topical moisturizer usage. Objectives: A 3-week in vivo study using an oil-in-water based moisturizing product and an untreated site was conducted to determine the clinical significance of and any correlations between a range of different approaches for the measurement of skin lipid content and also skin hydration and visual grading of dry skin. Methods: A range of traditional and more recently developed skin measurement techniques have been used to examine a variety of SC properties in normal and xerotic skin during topical moisturizer usage. Results: In vivo confocal Raman spectroscopy and analysis of SC lipids from tape strips both showed an increase in SC lipid level and organization after 3 weeks of moisturizer usage on xerotic skin. Hydration, measured both optically and electrically, also increased and skin barrier function improved, with strong correlations between the different measures of dryness being observed. Conclusions: Strong correlations were observed between the skin measurements for lipid assessment and skin hydration with regard to the assessment of xerotic skin, providing valuable new information for future in vivo clinical research into dry and atopic skin. Keywords biophysical assessment, skin barrier, skin hydration, topical moisturizers, Xerosis.

Measuring the effects of topical moisturizers on changes in stratum corneum thickness, water gradients and hydration in vivo.

BACKGROUND: Moisturizers are the most commonly used topically applied product for the treatment of dry skin conditions. They affect many properties and functions of the stratum corneum but some moisturizers have been reported to be detrimental to barrier function. Stratum corneum barrier function is a composite of its total structure and thickness but few studies have taken this into account. As a biosensor, the stratum corneum (SC) will change its structure in response to treatment and a swelling effect has been clearly demonstrated by skin hydration. Recently several moisturizing agents have been shown to have an effect on SC swelling behaviour with conflicting results. However, there is a paucity of data reported for measuring the effects of long-term usage of moisturizers on SC thickness in vivo as, until recently, traditional techniques did not have the resolution to measure the effects of moisturizers on nonpalmoplantar body sites. The development of confocal Raman spectroscopy for use in human subjects provides noninvasive, real-time, in vivo measurement of SC water concentration profiles and we have also used this state of the art equipment to measure the effect of the long-term use of moisturizers on SC thickness for the first time. OBJECTIVES: To validate the use of confocal Raman spectroscopy (CRS) to measure SC thickness and then use it to investigate the short- and long-term effects of moisturizers (one of which is known to improve SC barrier function) on SC thickness, water gradients and hydration. METHODS: Two studies were conducted: (i) to validate the use of CRS for measuring SC thickness through comparison with optical coherence tomography (OCT); and (ii) once validated to use CRS to measure the long-term effects of three commercially available moisturizers (A, B, C) on SC thickness and water gradients, together with total hydration, over a 3-week period (2 weeks of treatment and 1 week regression) and compare the spectroscopy-derived hydration value with instrumentally derived capacitance hydration values. RESULTS: (i) A strong, positive correlation in SC thickness was obtained between CRS and OCT (OCT-derived thickness = 0.96 x CRS-derived thickness, r(2) = 0.93; P <0.0001). OCT was shown, however, to have a lower resolution than CRS in distinguishing SC thickness on thinner nonpalmoplantar body sites. Using the CRS method, differences in SC thickness were readily apparent on different body sites (cheek 12.8 +/- 0.9 microm, volar forearm 18.0 +/- 3.9 microm, leg 22.0 +/- 6.9 microm). (ii) Examining the effects of moisturizers in a blinded, randomized 3-week study in human volunteers (n = 14) demonstrated that only one commercially available formulation (A) changed SC water gradients, thickness and hydration as measured by CRS. These hydration data did not directly correlate with capacitance hydration values. CONCLUSIONS: (i) In vivo CRS was validated as a technique to measure SC thickness on both palmoplantar and, particularly, on nonpalmoplantar skin sites. (ii) Moisturizers improve skin moisturization but in this study only formulation A improved SC thickness, water gradients and hydration as measured by CRS. We hypothesize that this was due to compositional differences between the products. We believe that niacinamide (nicotinamide, vitamin B(3)) is probably contributing significantly to this effect, as it has been proven to increase epidermal lipogenesis and SC barrier function in other studies. These results show that by using CRS, we were able for the first time to determine the effect of moisturizer on multiple SC barrier endpoints including SC thickness, and water content as a function of depth and total SC water content.

What determines patients' satisfaction with their mental health care and quality of life?

OBJECTIVES: This study investigated whether patients' satisfaction with their mental health care and quality of life is related to their age, gender, psychiatric diagnosis, and duration of mental disorder. METHOD: 120 adults of working age who were receiving input from a community mental health team in North Yorkshire were invited to complete the Carers' and User's Expectations of Services, User Version (CUES-U) questionnaire. This 16 item self rated outcome measure covers the issues that those using mental health services have identified as being their priorities. RESULTS: CUES-U ratings were lowest for "Social life" (49% satisfied) and highest for "Relationships with physical health workers" (88% satisfied). Satisfaction with psychiatric services correlated significantly with patients' age (Spearman's r = 0.444, p<0.001) and their satisfaction in other areas of their lives such as housing, money, and relationships (r = 0.575, p<0.001). Those with psychotic disorders rated their quality of life as higher than other respondents (median total satisfaction score 12 v 9, Mann-Whitney U = 377, p = 0.001). Gender and duration of disorder were unrelated to service satisfaction. CONCLUSIONS: Patient satisfaction ratings have been promoted as an outcome measure when evaluating the quality of their mental health services. Certain factors influencing an individual's satisfaction with the care provided (such as their age and general quality of life) are not directly under the control of professionals.

Do we manage deliberate self-harm appropriately? Characteristics of general hospital patients who are offered psychiatric aftercare.

BACKGROUND The appropriateness of psychiatric management decisions following an episode of deliberate self-harm is under-researched. AIM To determine whether the offer of follow-up or psychiatric admission by psychiatric doctors is related to known predictors of repetition of self-harm or completed suicide, and recognition of a depressive disorder. METHODS Prospective survey of 158 adult self-harm referrals from the general hospital. RESULTS Offer of aftercare was significantly associated with a definite wish to die at the time of the attempt (P<0.001), Beck's Suicide Intent score (P=0.001), Beck's Hopelessness score (P=0.001), age (P<0.01) and an ICD-10 diagnosis of depression (P<0.001). Psychiatric admission was more likely for men (P=0.01) and accommodation problems (P=0.04) and less likely for relationship problems (P=0.01). CONCLUSIONS Psychiatrists are selectively admitting or following up patients from established high-risk groups. Given the limitations of suicide prevention and mental health resources, their management is appropriate.

Coping with depression: a pilot study to assess the efficacy of a self-help audio cassette.

BACKGROUND: The self-help audio cassette 'Coping with Depression' was produced and widely distributed as part of the national Defeat Depression Campaign. A central aim was to improve public understanding and encourage the use of cognitive-behavioural techniques. AIM: To formally assess the ability of the audio cassette to change attitudes to depression in primary care and the degree to which patients are motivated to practice its recommended coping strategies. DESIGN OF STUDY: Comparison of Likert ratings of agreement completed by patients, before and after listening to the audio cassette at home. SETTING: General practitioners (GPs) in central Leeds chosen randomly from the 1998 West Yorkshire Practice Directory. METHOD: Fifty out of 71 patients aged over 16 diagnosed as depressed by their GP completed the hospital anxiety and depression (HAD) Scale and Likert ratings of agreement with key messages on the audio cassette. General practitioners provided feedback on the utility of the audio cassette in routine practice. RESULTS: A clinically significant improvement in overall attitudes and knowledge of 13% (95% confidence interval = 7-20%, P = 0.001) was seen. Negative attitudes decreased most among those not taking antidepressants (P = 0.007). Hearing a description of depressive symptoms and practical advice on coping were rated as the main benefits. Thirty (60%) patients stated that they had already begun to try out the cognitive-behavioural suggestions within the first week. CONCLUSIONS: Larger randomised controlled trials are needed to confirm the efficacy of self-help audio cassettes for depression. This tape may be most helpful to patients with negative attitudes towards treatment, especially those who initially decline antidepressant medication.

The timing of acts of deliberate self-harm: is there any relation with suicidal intent, mental disorder or psychiatric management?

OBJECTIVE: To investigate the common perception that more serious suicide attempts tend to occur earlier in the day. METHODS: Prospective study of 158 adults referred for psychiatric assessment from the general hospital following an episode of deliberate self-harm. The main outcome measures used were Beck's Suicide Intent score, ICD-10 psychiatric diagnosis, alcohol consumption at the time of the attempt, and follow-up decision recorded by the interviewing duty psychiatrist. The patient also completed a checklist of current precipitating problems. RESULTS: A marked circadian variation in timing of the act was found, peaking between 2200 and 2400 h. "Early" acts (0300-1459 h) were significantly less likely to involve alcohol consumption, more likely to lead to admission to a medical ward, and involved more patient-identified problems than "late" acts. People who took overdoses early in the day were more likely to have concerns about their own mental health. Compared to earlier acts of self-harm, late evening (2200-2359 h) cases were less likely to be diagnosed as depressed or offered psychiatric follow up. No relation was found between time of day of self-harm and Beck's Suicide Intent score. CONCLUSIONS: Implications arise regarding clinical risk assessment and current staffing levels in the accident and emergency department. The interviewing psychiatrist could concentrate on excluding depression and teaching problem solving to those who self-harm in the morning or afternoon, and on the detection and treatment of alcohol dependence for late evening cases.

Associations between perfectionism, mood, and fatigue in chronic fatigue syndrome: a pilot study.

This study investigated possible associations between perfectionistic personality traits, mood, and fatigue in chronic fatigue syndrome (CFS). Forty CFS sufferers referred to tertiary care and 31 control healthy subjects completed the Multidimensional Perfectionism Scale (MPS), Chalder Fatigue Questionnaire, and Hospital Anxiety and Depression (HAD) scale. Total perfectionism scores did not correlate with fatigue, anxiety, or depression in either group. Other-oriented MPS scores were significantly lower among CFS sufferers (p = .0019), especially women, and correlated negatively with physical fatigue levels overall (R = -0.27, p = .02). Total and socially prescribed MPS scores correlated with age for the CFS group alone (p = .05). Possible reasons why this study did not confirm a positive association between perfectionism and CFS are discussed. The finding that CFS sufferers set lower standards and have lower expectations for significant others may have implications for rehabilitation and recovery from this disorder.

Referral to a psychiatric clinic: what do patients expect?

Examines the knowledge and expectations of patients newly referred to one hospital psychiatric clinic. A total of 57 adults completed a structured questionnaire before their first outpatient appointment. The casenotes of all 45 non-anonymous respondents were reviewed six months later, to discover how their expectations regarding management compared with reality. Forty-four (77 per cent) referrals expected to see a doctor who dealt with mental health and emotional problems, 41 (72 per cent) anticipated that their problem was treatable, and 41 (72 per cent) wanted, primarily, a chance to talk. Thirty-four respondents (61 per cent) significantly underestimated their actual appointment duration. Patients received psychotropic medication or were referred to another mental health professional twice as often as they expected. Nevertheless, 25 out of 35 patients (71 per cent) correctly predicted their broad clinical management. Patients are becoming more informed users of mental health care services. Addressing their attitudes and expectations directly at the first outpatient attendance may help in predicting final clinical outcome, and assist in the efficient management of limited resources.

The elderly and their medication: understanding and compliance in a family practice.

Eighty patients aged 75 years and over were interviewed in the surgery or at home to assess their level of knowledge, degree of compliance, and problems with their medicines. Regular medication was prescribed to 59 patients, who took a total of 206 drugs. The correct purpose of medication was stated in 72% of cases, the dosage regimen recalled accurately for 75%, and the correct name given for 64% of drugs. The elderly rated their compliance as 'good' (never miss doses) for 77% of drugs prescribed. This correlated poorly for individual patients with the level of correct compliance as assessed on computer records of repeat prescriptions, which nevertheless was accurate for 80% of medicines taken. A significant difficulty for the elderly was the removal of tops from medicine containers, occurring in 18 cases (31% patients), including half of those taking analgesics or nonsteroidal anti-inflammatory drugs. The widespread, legally enforced, use of child-resistant containers for the elderly frequently seems inappropriate. Further improvements in comprehension and compliance may occur with regular explanation and rationalisation of medication by the family doctor, when visiting the elderly at home.