What can clinicians do to improve outcomes across psychiatric treatments: a conceptual review of non-specific components.

AIMS: Psychiatric treatments have specific and non-specific components. The latter has been addressed in an extensive literature on the placebo-effect in pharmacology and on common factors in psychotherapy. In the practice of mental health care, pharmacological, psychotherapeutic and social treatments are combined in complex interventions. This paper aims to review non-specific components across diverse psychiatric treatments and consider implications for practice and research. METHODS: We conducted a non-systematic review of non-specific components across psychiatric treatments, their impact on treatment processes and outcomes, and interventions to improve them. RESULTS: The identified research is heterogeneous, both in design and quality. All non-specific components capture aspects of how clinicians communicate with patients. They are grouped into general verbal communication - focusing on initial contacts, empathy, clarity of communication, and detecting cues about unspoken concerns - non-verbal communication, the framing of treatments and decision-making. The evidence is stronger for the impact of these components on process measures - i.e. therapeutic relationship, treatment satisfaction and adherence than on clinical outcomes - i.e. symptoms and relapse. A small number of trials suggest that brief training courses and simple methods for structuring parts of clinical consultations can improve communication and subsequently clinical outcomes. CONCLUSIONS: Methodologically, rigorous research advancing current understandings of non-specific components may increase effectiveness across different treatments, potentially benefitting large numbers of patients. Brief training for clinicians and structuring clinical communication should be used more widely in practice.

The same or different psychiatrists for in- and out-patient treatment? A multi-country natural experiment.

AIMS: A core question in the debate about how to organise mental healthcare is whether in- and out-patient treatment should be provided by the same (personal continuity) or different psychiatrists (specialisation). The controversial debate drives costly organisational changes in several European countries, which have gone in opposing directions. The existing evidence is based on small and low-quality studies which tend to favour whatever the new experimental organisation is.We compared 1-year clinical outcomes of personal continuity and specialisation in routine care in a large scale study across five European countries. METHODS: This is a 1-year prospective natural experiment conducted in Belgium, England, Germany, Italy and Poland. In all these countries, both personal continuity and specialisation exist in routine care. Eligible patients were admitted for psychiatric in-patient treatment (18 years of age), and clinically diagnosed with a psychotic, mood or anxiety/somatisation disorder.Outcomes were assessed 1 year after the index admission. The primary outcome was re-hospitalisation and analysed for the full sample and subgroups defined by country, and different socio-demographic and clinical criteria. Secondary outcomes were total number of inpatient days, involuntary re-admissions, adverse events and patients' social situation. Outcomes were compared through mixed regression models in intention-to-treat analyses. The study is registered (ISRCTN40256812). RESULTS: We consecutively recruited 7302 patients; 6369 (87.2%) were followed-up. No statistically significant differences were found in re-hospitalisation, neither overall (adjusted percentages: 38.9% in personal continuity, 37.1% in specialisation; odds ratio = 1.08; confidence interval 0.94-1.25; p = 0.28) nor for any of the considered subgroups. There were no significant differences in any of the secondary outcomes. CONCLUSIONS: Whether the same or different psychiatrists provide in- and out-patient treatment appears to have no substantial impact on patient outcomes over a 1-year period. Initiatives to improve long-term outcomes of psychiatric patients may focus on aspects other than the organisation of personal continuity v. specialisation.

In-patient treatment in functional and sectorised care: patient satisfaction and length of stay.

BACKGROUND: Debate exists as to whether functional care, in which different psychiatrists are responsible for in- and out-patient care, leads to better in-patient treatment as compared with sectorised care, in which the same psychiatrist is responsible for care across settings. Aims To compare patient satisfaction with in-patient treatment and length of stay in functional and sectorised care. METHOD: Patients with an ICD-10 diagnosis of psychotic, affective or anxiety/somatoform disorders consecutively admitted to an adult acute psychiatric ward in 23 hospitals across 11 National Health Service trusts in England were recruited. Patient satisfaction with in-patient care and length of stay (LoS) were compared (trial registration ISRCTN40256812). RESULTS: In total, 2709 patients were included, of which 1612 received functional and 1097 sectorised care. Patient satisfaction was significantly higher in sectorised care (ß = 0.54, 95% CI 0.35-0.73, P<0.001). This difference remained significant when adjusting for locality and patient characteristics. LoS was 6.9 days shorter for patients in sectorised care (ß = -6.89, 95% CI -11.76 to -2.02, P<0.001), but this difference did not remain significant when adjusting for clustering by hospital (ß = -4.89, 95% CI -13.34 to 3.56, P = 0.26). CONCLUSIONS: This is the first robust evidence that patient satisfaction with in-patient treatment is higher in sectorised care, whereas findings for LoS are less conclusive. If patient satisfaction is seen as a key criterion, sectorised care seems preferable. Declarations of interest None.

A new approach to disentangle genetic and epigenetic components on disease comorbidities: studying correlation between genotypic and phenotypic disease networks.

Disease comorbidity is a result of complex epigenetic interplay. A disease is rarely a consequence of an abnormality in a single gene; complex pathways to disease patterns emerge from gene-gene interactions and gene-environment interactions. Understanding these mechanisms of disease and comorbidity development, breaking down them into clusters and disentangling the epigenetic - actionable - components, is of utter importance from a public health perspective. With the increase in the average life expectancy, healthy aging becomes a primary objective, from both an individual (i.e. quality of life) and a societal (i.e. healthcare costs) standpoint. Many studies have analyzed disease networks based on common altered genes, on protein-protein interactions, or on shared disease comorbidites, i.e. phenotypic disease networks. In this work we aim at studying the relations between genotypic and phenotypic disease networks, using a large statewide cohort of individuals (100, 000+ from California, USA) with linked clinical and genotypic information, the Genetic Epidemiology Research on Adult Health and Aging (GERA). By comparing their phenotypic and genotypic networks, we try to disentangle the epigenetic component of disease comorbidity.

Recovery practice in community mental health teams: national survey.

BACKGROUND: There is consensus about the importance of 'recovery' in mental health services, but the link between recovery orientation of mental health teams and personal recovery of individuals has been underresearched. AIMS: To investigate differences in team leader, clinician and service user perspectives of recovery orientation of community adult mental health teams in England. METHOD: In six English mental health National Health Service (NHS) trusts, randomly chosen community adult mental health teams were surveyed. A random sample of ten patients, one team leader and a convenience sample of five clinicians were surveyed from each team. All respondents rated the recovery orientation of their team using parallel versions of the Recovery Self Assessment (RSA). In addition, service users also rated their own personal recovery using the Questionnaire about Processes of Recovery (QPR). RESULTS: Team leaders (n = 22) rated recovery orientation higher than clinicians (n = 109) or patients (n = 120) (Wald(2) = 7.0, P = 0.03), and both NHS trust and team type influenced RSA ratings. Patient-rated recovery orientation was a predictor of personal recovery (b = 0.58, 95% CI 0.31-0.85, P<0.001). Team leaders and clinicians with experience of mental illness (39%) or supporting a family member or friend with mental illness (76%) did not differ in their RSA ratings from other team leaders or clinicians. CONCLUSIONS: Compared with team leaders, frontline clinicians and service users have less positive views on recovery orientation. Increasing recovery orientation may support personal recovery.

A conceptual framework for improving well-being in people with a diagnosis of psychosis.

Background. Well-being is important for people with severe mental illness, such as psychosis. So far, no clear concept of well-being exists for this client group. A recent systematic review and narrative synthesis developed a static framework of well-being components. The present study aims to validate the static framework and to illuminate the processes by which well-being is experienced by people with psychosis. Methods. Semi-structured interviews were conducted with 23 service users with psychosis exploring their experience of well-being. Thematic analysis was used to analyse the data employing techniques taken from grounded theory to enhance the rigour of the analysis. Respondent validation was undertaken with 13 of the 23 participants. Results. Three superordinate categories of well-being were identified: current sense of self; transition to enhanced sense of self and enhanced sense of self. In the dynamic process of improving well-being the current sense of self undergoes a transition to an enhanced sense of self. The four factors influencing the transition are consistent with the static framework of well-being, hence validating the static framework. In addition, we identified three determinants of current sense of self and seven indicators of enhanced sense of self, which represent the achievement of improved well-being. Conclusions. This study provides an empirically defensible framework for understanding well-being in terms of determinants, influences and indicators. The influences are targets for interventions to improve well-being, and the indicators are outcome domains to assess the effectiveness of services in supporting well-being.

International differences in understanding recovery: systematic review.

AIMS: Mental health policy internationally varies in its support for recovery. The aims of this study were to validate an existing conceptual framework and then characterise by country the distribution, scientific foundations and emphasis in published recovery conceptualisations. METHODS: Update and modification of a previously published systematic review and narrative synthesis of recovery conceptualisations published in English. RESULTS: A total of 7431 studies were identified and 429 full papers reviewed, from which 105 conceptualisations in 115 papers were included and quality assessed using established rating scales. Recovery conceptualisations were identified from 11 individual countries, with 95 (91%) published in English-speaking countries, primarily the USA (47%) and the UK (25%). The scientific foundation was primarily qualitative research (53%), non-systematic literature reviews (24%) and position papers (12%). The conceptual framework was validated with the 18 new papers. Across the different countries, there was a relatively similar distribution of codings for each of five key recovery processes. CONCLUSIONS: Recovery as currently conceptualised in English-language publications is primarily based on qualitative studies and position papers from English-speaking countries. The conceptual framework was valid, but the development of recovery conceptualisations using a broader range of research designs within other cultures and non-majority populations is a research priority.

Measures of the recovery orientation of mental health services: systematic review.

PURPOSE: The review aimed to (1) identify measures that assess the recovery orientation of services; (2) discuss how these measures have conceptualised recovery, and (3) characterise their psychometric properties. METHODS: A systematic review was undertaken using seven sources. The conceptualisation of recovery within each measure was investigated by rating items against a conceptual framework of recovery comprising five recovery processes: connectedness; hope and optimism; identity; meaning and purpose; and empowerment. Psychometric properties of measures were evaluated using quality criteria. RESULTS: Thirteen recovery orientation measures were identified, of which six met eligibility criteria. No measure was a good fit with the conceptual framework. No measure had undergone extensive psychometric testing and none had data on test-retest reliability or sensitivity to change. CONCLUSIONS: Many measures have been developed to assess the recovery orientation of services. Comparisons between the measures were hampered by the different conceptualisations of recovery used and by the lack of uniformity on the level of organisation at which services were assessed. This situation makes it a challenge for services and researchers to make an informed choice on which measure to use. Further work is needed to produce measures with a transparent conceptual underpinning and demonstrated psychometric properties.

Technical modification for laparoscopic donor nephrectomy to minimize testicular pain: a complication with significant morbidity.

The laparoscopic approach to donor nephrectomy is becoming increasingly common. While it is felt that the recovery from laparoscopic nephrectomy is quicker and less painful, a number of complications have been reported. A rarely reported on complication in the literature with significant morbidity is ipsilateral orchalgia. From 1998 to 2008, 257 hand-assisted laparoscopic donor nephrectomies were performed at our institution. Eight of 129 (6.2%) men complained of de novo ipsilateral orchalgia postoperatively. The average duration of pain was 402 days. Patients reported significant morbidity related to this complication. None, however, required further treatment. Three patients reported that they would reconsider organ donation as a result of testicular pain. Our technique originally included dissection and ligation of the gonadal vein en bloc with the ureter at the level of the left common iliac artery. Since recognizing this complication, we have adopted a gonadal vein sparing approach so as not to disturb the vessel below its point of ligation at the renal vein. To date, 50 patients have undergone the modified technique without experiencing orchalgia. In conclusion, ipsilateral testicular pan is a relatively frequent complication of laparoscopic donor nephrectomy and may be a source of significant morbidity. Using a modified surgical technique, this complication can be reduced or eradicated.

Open or laparoscopic nephrectomy and extracoroporeal repair of complicated renal artery aneurysms: techniques for renal salvage.

Renal artery aneurysm is an infrequently seen disease. The most feared symptom is rupture, which is often rapidly fatal. Indications for intervention include size, intractable symptoms and pregnancy. Many cases are managed by endovascular techniques; however, very complex cases often are referred to the urologist. We report our experience with the rarely used technique of renal artery aneurysms repair comprised of nephrectomy, extracorporeal vascular reconstruction with aneurysmectomy, and autotransplant.

Nefrectomía abierta o laparoscópica y reparación extracorpórea de aneurismas de arteria renal complejos: técnicas para la recuperación renal / Open or laparoscopic nephrectomy and extracoroporeal repair of complicated renal artery aneurysms: techniques for renal salvage

El aneurisma de la arteria renal constituye una enfermedad infrecuentemente observada. Su síntoma más temido es la ruptura, que habitualmente suele ser fatal rápidamente. Las indicaciones para realizar su intervención incluyen su tamaño, la refractariedad de su sintomatología y la gestación. Muchos de los casos generalmente se tratan mediante técnicas endovasculares; sin embargo, los casos más complejos a veces se remiten al urólogo para su tratamiento. En este artículo comunicamos nuestra experiencia con la infrecuentemente empleada técnica de reparación de aneurismas que incluye la nefrectomía, la aneurismectomía con reconstrucción vascular extracorpórea y el autotransplante(AU)

Renal artery aneurysm is an infrequently seen disease. The most feared symptom is ruptu-re, which is often rapidly fatal. Indications for interven-tion include size, intractable symptoms and pregnancy. Many cases are managed by endovascular techniques; however, very complex cases often are referred to the urologist. We report our experience with the rarely used technique of renal artery aneurysms repair comprised of nephrectomy, extracorporeal vascular reconstruction with aneurysmectomy, and autotransplant(AU)

Outcome after radical prostatectomy with a pretreatment prostate biopsy Gleason score of >/=8.

OBJECTIVE: To determine the outcome and predictors of recurrence in patients with a pretreatment prostate biopsy Gleason score (GS) of >/= 8 and treated with radical prostatectomy (RP). PATIENTS AND METHODS: We retrospectively reviewed 1048 consecutive patients who underwent RP by one surgeon (M.S.S.); patients who had a pretreatment biopsy GS of >/= 8 were identified. Information was recorded on patient age, initial prostate specific antigen (PSA) level, clinical stage, biopsy GS, pathology GS, extraprostatic extension (EPE), tumour volume, surgical margin status, seminal vesicle invasion (SVI), and lymph node involvement. The results were assessed statistically using the Kaplan-Meier method, univariate log-rank tests and multivariate analysis using Cox's proportional hazards regression. RESULTS: In all, 123 patients met the initial selection criteria; 44 were excluded from further analyses (five salvage RP, 23 < 1 year follow-up and 16 adjuvant treatment). Thus 79 patients were included in the uni- and multivariate analyses; 25 (31%) patients had a GS of /= 8. The mean follow-up was 55 months, the age of the patients 63 years and the mean (sd) initial PSA level 13 (12) ng/mL. The overall biochemical failure rate was 38% (41% if the final GS was >/= 8 and 32% if it was /= 8 in the RP specimen, 20% (11/54) were organ-confined; two patients (2.5%) in this group developed local recurrence. If the final GS was /= 20 ng/mL, EPE, SVI, a positive surgical margin and tumour volume. Cox's proportional regression indicated that a PSA of >/= 20 ng/mL (hazard ratio 7.9, 95% confidence interval 2.6-24.2, P < 0.001), the presence of EPE (4.2, 1.6-10.9, P = 0.004) and a positive surgical margin (3.8, 1.5-9.7, P = 0.005) were significant independent predictors in a multivariate analysis. CONCLUSION: RP is a reasonable treatment option for patients with a prostate biopsy GS of >/=8 and clinical stage T1-2. These patients have a high chance of remaining disease-free if their PSA level is /= 8 should be counselled about the potential differences between the biopsy and the RP specimen GS.

Reflexes and somatic responses as predictors of ejaculation by penile vibratory stimulation in men with spinal cord injury.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To identify factors in addition to level of injury (LOI) that may predict ejaculation by penile vibratory stimulation (PVS) in spinal cord injured males. SETTING: Major urban medical school and teaching hospital. MATERIALS AND METHODS: Presence of a bulbocavernosus response (BCR) and a hip flexor response (HR) before PVS (n=123 patients), and somatic responses during PVS (n=204 trials performed on a subset of 44 patients) were evaluated for their frequency of occurrence on trials with and without ejaculation. RESULTS: Overall ejaculation success rates for cervical, T1-T6, and T7-T12 LOI were 71%, 73%, and 35%, respectively. Eighty per cent of patients who were positive for both BCR and HR ejaculated with PVS, while only 8% of patients who were negative for both BCR and HR ejaculated with PVS. For cervical injuries, BCR and HR were no more predictive of ejaculation by PVS than LOI alone. T1-T6 patients were more likely to ejaculate when at least one reflex was present. T7-T12 patients with no BCR were unlikely to ejaculate by PVS. Except for abdominal contractions, somatic responses were not present in the majority of PVS trials. When they were present, however, they occurred in a high percentage of ejaculation trials: withdrawal response (hip flexion, knee flexion and thigh adduction) (90%), piloerection (84%), extremity spasms (83%), thigh abduction (80%), and thigh adduction (72%). CONCLUSION: We recommend that patients with cervical injuries initially undergo PVS. Patients with T1-T6 LOI with at least one reflex present, and patients with T7-T12 LOI with both reflexes, or only BCR present, may undergo PVS. Certain somatic/autonomic responses, when seen, may help in deciding whether to continue with a given trial, or give a repeat trial, of PVS. SPONSORSHIP: The Miami Project to Cure Paralysis and the State of Florida Specific Appropriations.

MAG3-F0 scintigraphy in decision making for emergency intervention in renal colic after helical CT positive for a urolith.

UNLABELLED: Patients with renal colic are evaluated with clinical, laboratory, and imaging methods for stratification for emergency decompression, medical treatment, or discharge and follow up. The current standard practice is heavily based on unenhanced helical CT for detecting uroliths. However, the presence of a urolith does not necessarily mean that the kidney is obstructed and requires emergency decompression. In this study, technetium-mercaptoacetyltriglycine (MAG3) diuretic scintirenography was used to detect obstruction in patients with renal colic. The contribution of this test to patient management after positive findings from helical CT was also studied. METHODS: Diagnostic criteria were established on the basis of previous experience with 60 patients who had renal colic and had undergone radiography of the kidneys, ureters, and urinary bladder (KUB) and diuretic Tc-MAG3 scintirenography and were followed up to correlate scintigraphic findings with clinical outcome. Subsequently, 80 patients with renal colic underwent scintigraphy within 12 h of presentation in the emergency room, after abdominal helical CT showed findings positive for calculus and suggestive of obstruction. After therapeutic oral or intravenous hydration and analgesics, diuretic dynamic renal scintigraphy (flow, function, delayed imaging) was performed after intravenous injections of 10 mCi (370 MBq) 99mTc-MAG3 and 40 mg furosemide (at zero time, or F0). Results were available soon after completion of the study and were considered in patient management. Four characteristic patterns of scintirenography, essential in patient stratification and treatment, had been standardized and were used for interpretation of the studies: the unobstructed kidney; the partially obstructed kidney, proximally or distally obstructed, with mild to severe obstruction and impairment of function; the totally obstructed kidney, with arrested renal function; and the unobstructed but dysfunctioning kidney after decompression, or stunned kidney. RESULTS: Among the 80 patients with positive helical CT findings, 56.5% were found to have obstruction by scintigraphy (32.5% partially, 24% completely); the remaining 43.5% did not have obstruction (21% without an indication of recent obstruction and 22.5% with stunned kidneys after spontaneous decompression). Occasionally, findings of preexistent urine extravasation or infection were present. Patients who, by scintigraphy, never had obstruction or had experienced spontaneous decompression did not require admission or emergency intervention; those with complete or severe obstruction required admission and decompression for relief of pain or restoration of function, whereas those with mild obstruction were treated variably with forced fluids, analgesics, or, less frequently, elective surgery. Outcome information from clinical examination, imaging, and interventional findings indicated that this stratification was successful. The test caused no side effects. CONCLUSION: For renal colic, clinical selection, KUB radiography, and even positive helical CT findings were all found to have a low positive predictive value for obstruction (in this study, 35%, 32%, and 56% respectively). Anatomic studies, including helical CT, should be followed by diuretic MAG3-F0 scintirenography to diagnose and quantify or exclude obstruction, detect spontaneous decompression, and appropriately stratify patients for emergency intervention, observation and medical therapy, or further work-up and discharge with referral to the clinic.

A new tool to aid the urologist in the placement of stents for impacted ureteral stones or strictures: the glide catheter.

We describe a technique one can use when only a lubricious wire is able to pass an impacted stone that could otherwise not be passed, over which a new hydrophilic "Glide Catheter is then passed beyond the stone. The lubricious wire can then be exchanged for a stiffer wire that will aid the retrograde passage of a ureteral catheter, stent, or other endourologic device in both a safe and effective manner.

Traumatic thrombophlebitis of the superficial dorsal vein of the penis: an occupational hazard.

Several cases of thrombophlebitis of the superficial dorsal vein of the penis (TSDVP) have been reported in the literature. Etiologies may include any of the following: trauma associated with vigorous sexual intercourse; penile strangulation caused by a multitude of entities; penile injection; infection; neoplasm; or surgery. We report a rare case of traumatic TSDVP in a cab driver following repeated injury to the penis by a coin-filled pouch. We review the etiologies, mechanism, and treatment of traumatic TSDVP, and attempt to identify men who may be at similar occupational risk.

Substrate specificities of the insulin and insulin-like growth factor 1 receptor tyrosine kinase catalytic domains.

To compare the substrate specificities of the insulin and insulin-like growth factor 1 (IGF-1) receptor tyrosine kinases, the catalytic domains of the enzymes have been expressed in Escherichia coli as fusion proteins. The purified proteins have kinase activity, demonstrating that the catalytic domain of IGF-1 receptor, like that of insulin receptor, is active independent of its ligand-binding and transmembrane domains. The specificities of the two enzymes for the divalent cations Mg2+ and Mn2+ are indistinguishable. A series of peptides has been prepared that reproduces the major phosphorylation sites of insulin receptor substrate-1, a common substrate for the two receptor tyrosine kinases in vivo. Insulin and IGF-1 receptors show distinct preferences for these peptides; whereas insulin receptor prefers peptides based on Tyr-987 or Tyr-727 of insulin receptor substrate-1, the IGF-1 receptor preferentially recognizes the Tyr-895 site. The latter site, when phosphorylated, is a binding site for the SH2 domain-containing adapter protein Grb2. The ability of the two receptor tyrosine kinases to be phosphorylated and activated by v-Src has also been examined. The catalytic activity of IGF-1 receptor is stimulated approximately 3.4-fold by treatment with purified v-Src, while insulin receptor shows very little effect of Src phosphorylation under these conditions. This observation is relevant to recent findings of IGF-1 receptor activation in Src-transformed cells, and may represent one method by which Src amplifies its mitogenic signal. Collectively the data suggest that the catalytic domains of the two receptor kinases possess inherently different substrate specificities and signaling potentials.