Mental health pathways from a sexual assault centre: A review of the literature.

The recent long-term NHS plan calls for improvements to the mental health of those attending a Sexual Assault Referral Centre (SARCs). The assessment of mental health is currently the subject of a systematic review being undertaken as part of the MiMoS project. However, there is a literature that examines mental health outcomes following attendance at a SARC. We review these studies and consider the implications for SARCs in England.

Cognitive exposure versus avoidance in patients with chronic pain: adherence matters.

BACKGROUND: Behavioural exposure methods can reduce pain-avoidance behaviours, but outcomes vary. One possible explanation is that patients employ cognitive (experiential) avoidance during behavioural exposure. If so, reducing cognitive avoidance during behavioural exposure should help. One option is interoceptive exposure (IE), which involves sustained exposure (via attention) to pain sensations. In order to test if IE could improve outcomes from behavioural exposure, this study with mixed chronic pain patients compared outcomes from a cognitive behavioural therapy (CBT) pain management programme incorporating either IE or distraction from pain. METHODS: One hundred forty chronic pain patients were randomly assigned to CBT + IE or CBT + distraction. Outcome measures included pain, disability, depression and medication. Measures reflecting degree of threat of pain were also employed (catastrophizing, fear-avoidance, pain self-efficacy and pain acceptance). An intention-to-treat approach, using mixed-effects model repeated measures, as well as conventional inferential statistical tests, effect sizes and reliable change indices were employed to evaluate the outcomes up to 1-year post-treatment. RESULTS: Significant improvements were achieved by both treatment conditions on all outcome measures and on measures reflecting the threatening nature of pain, with no differences between treatment conditions. CONCLUSIONS: The addition of IE to behavioural exposure did not improve outcomes. However, higher adherence to either attentional strategy was associated with larger effect sizes on all measures, suggesting factors shared by the two treatments could have contributed to the outcomes. Taken as a whole, the results suggest that increasing adherence to treatment strategies, possibly by motivational measures, would improve the overall outcomes of these interventions.

Recommendations for patient selection in spinal cord stimulation.

Studies have shown that spinal cord stimulation (SCS) can reduce chronic pain by at least 50% over prolonged periods, improve function and quality-of-life, reduce requirements for healthcare resources and enable return to work in appropriately selected patients. However, SCS does not provide pain relief in all patients and is an expensive, labor intensive and invasive procedure with complications and ongoing management that requires specialists with specific skills and judgment. Multidisciplinary selection of appropriate patients for SCS is essential to achieve maximal benefit from the procedure. The aim of the article is to provide a clinical practice guide to the likely effectiveness of SCS in treating various types of chronic pain, as supported by the literature. The article will summarize indications and contraindications for SCS, provide guidance on the selection and timing for referral, and highlight the benefits and complications associated with the procedure.

The national continuous quality improvement tool for mental health education: results of targeted and supported implementation in England.

The national continuous quality assurance tool for mental health education and training has recently been developed. This paper describes the planned implementation of the tool across NHS Workforce Development Confederations (WDCs) in England. Large stakeholder groups in 15 WDCS were convened. The groups rated 29 programmes across a range of provisions including pre-qualifying programmes (social work and mental health nursing), post-qualifying programmes, new graduate mental health worker programmes and programmes run within NHS Trusts. Overall, the results indicate that the majority of rated programmes are relevant to the policy agenda and involve service users in a meaningful way. However, courses are less likely to engage with carers and to assess the impact of the programmes. Key factors are identified that promote the implementation of the new quality assurance tool and key barriers to implementation are also elicited. The paper concludes that the tool can provide a useful framework to assess the quality of a broad range of mental health education, furthermore, that it should be incorporated into existing quality assurance systems.

Working with a multidisciplinary team in secure psychiatric environments.

1. Research on working with a multidisciplinary team in inpatient mental health care is underdeveloped. 2. Knowledge of how to work as part of a team is taken for granted within the realm of professional training. 3. In effective teams, members value the support, knowledge, and professional development that membership offers. 4. Training teams to be more effective requires diverse educational strategies.

The Fourth Quinquennial National Community Mental Health Nursing Census of England and Wales.

Within an increasingly articulate policy framework, changes to the United Kingdom National Health Service have taken place and these have impacted on mental health service provision. They have particular implications for the work of community mental health nurses (CMHNs). Since 1980, a five-yearly national census of CMHNs has been conducted. Selected findings from the latest census, commissioned by the Department of Health, are set within the context of data derived from the three previous studies. Substantive implications which flow from the changes detected in the practice, organisation and management, and education of community mental health nurses in England and Wales, are discussed.

Differences in teaching about the acute sore throat within one medical faculty.

OBJECTIVES: To examine the consistency of teaching about the acute sore throat in four departments in one medical faculty, and to determine whether there is agreement between what is taught and the evidence-based literature. DESIGN: Cross-sectional study. SUBJECTS: 71 undergraduates and 15 postgraduate general practice registrars and four lecturers. RESULTS: Differences were identified in teaching about the diagnostic value of a throat swab, a full blood count and clinical scoring, as well as on the use of penicillin in suspected streptococcal pharyngitis. Only one department based their teaching on the evidence-based literature. No department discussed issues of cost-effectiveness. Half of the students identified discrepancies in the teaching about the sore throat and were initially confused by them. CONCLUSION: One method of resolving disagreement between teachers from different disciplines is to rely on the evidence-based literature. This type of study can be useful in curricular development and in correcting teaching inconsistencies within a faculty.

The views of nurses to the conduct of a randomised controlled trial of problem drinkers in an accident and emergency department.

The Trent Regional Health Authority funded a study in 1995 to train nurses in an accident and emergency (A&E) department to screen all adult attendees for alcohol problems with a view to identifying a sample of problem drinkers to participate in a randomised controlled trial (RCT). In the RCT identified drinkers were to be assigned either to health education plus brief counselling intervention or, as controls, to health education alone. Despite 16654 attendance's at A&E during the recruitment phase of the study only 20% of attendees were screened of whom a further 19% were identified as problem drinkers by the CAGE screening questionnaire. Less than half of the problem drinkers were, however, provided with feedback by the nurses, leaving a small group of 264 eligible for entry to the RCT. The great majority of this subgroup refused an initial appointment at the specialist clinic and so the trial was abandoned. A number of in-depth interviews were undertaken with the nurses in an attempt to understand ways in which the overall conduct of the study might have been improved. This paper outlines in some detail some of the reasons for the lack of success with the study which include; general environmental factors that undoubtedly led to stress and poor morale amongst the nursing team, the differences in perception between managers and clinical nurses concerning the value of research and the inadequacy of the initial training programme. The paper concludes that there are problems in the NHS which do not provide a helpful backcloth to the successful conduct of health services research.

Evaluating clinical outcome and staff morale in a rehabilitation team for people with serious mental health problems.

Tameside and Glossop rehabilitation team (in England) have developed a progressive and targeted service for people with serious mental health problems through the systematic implementation of research-based evidence in practice and service configuration. This study was undertaken to provide a method of auditing the clinical outcome of the service and monitoring staff morale in a manner which could be integrated in the day to day delivery of services, and which could inform future service developments. Changes in the functioning of the total population of rehabilitation team clients were assessed over a 1-year period by Health of the Nation Outcome Scales (HoNOS) ratings at 6-monthly intervals. Factors causing stress and stress levels among all staff were assessed using the Mental Health Stress Questionnaire. The findings give clear indications of areas of the service which needed improving or changing, and identify ways in which the ongoing process of data collection might be refined.

Kinetics of gentamicin uptake in the inner ear of Chinchilla langier after middle-ear administration in a sustained-release vehicle.

The search for a safe, effective treatment for the vertigo associated with Meniere's disease has long been an important topic in otolaryngology. In recent years many groups have begun using intratympanic gentamicin to treat this vertigo. Although reported cure rates are as high as 90%, many questions remain regarding this type of treatment. Current limitations are the necessity for repeated treatments and a lack of clear dosing guidelines. In addition, the gentamicin must be delivered in a manner that allows maximal vestibulotoxic effect without injury to hearing. Until investigators can control the exact amount of medicine that is placed in the ear and have an understanding of the kinetics of gentamicin absorption, adequate dosing guidelines will be difficult to establish, and therapy will continue to rely on empiric data. We describe the use of a fibrin-based sustained-release vehicle, impregnated with gentamicin, injected into the middle ear of chinchillas. This allows for a prolonged effect without repeated dosing. Using this model, we studied the absorption kinetics of gentamicin at time points ranging from 8 hours to 1 week after injection. We used our findings to create a kinetics curve of gentamicin absorption. We discuss the shape and characteristics of this kinetics curve and examine the effects of the fibrin-based sustained-release vehicle and gentamicin on the middle ear. We noted no absorption in the contralateral (untreated ear) or blood. Through better understanding of the actions of gentamicin in this animal model, we hope to facilitate safer use of intratympanic medicines in our patient population and initiate programs for the use of this sustained-release vehicle in human beings.

Problems encountered with opportunistic screening for alcohol-related problems in patients attending an accident and emergency department.

AIMS: To assess the value of opportunistic screening in Accident and Emergency (A&E) for patients with alcohol-related problems and provision of an intervention. DESIGN: Screening of A&E attendees for the purpose of recruitment to a randomized trial of a counselling intervention. SETTING: A General Hospital A&E department. PARTICIPANTS: All 17,000 adult A&E attendees, during a 6-month period and all nursing staff working within the department. MEASUREMENTS: Patients' self-reported alcohol consumption, responses to the CAGE questionnaire (four questions designed to identify problem drinking) and proportions offered, and taking up offer of help. FINDINGS: Only 4663 (28%) adult attendees at A&E were actually screened and of these 2% declined and 25% were judged unable to answer. Of the rest, 86% drank alcohol, with 22% drinking in excess of current guidelines or with two or more positive answers to CAGE. Only 41% (264) of those drinking to excess were offered help and 88% of these declined it. This left 13 patients to be included in the trial. CONCLUSION: There is a significant need for an effective intervention in this area but considerable barriers exist to testing the efficacy of potential screening strategies and interventions.

Sutureless cartilage graft laryngotracheal reconstruction using fibrin sealant.

OBJECTIVE: To determine whether fibrin sealant can replace suture as a means of holding a cartilage graft securely in the trachea. DESIGN: Randomized blinded control study comparing the use of fibrin sealant vs sutures in laryngotracheal reconstruction in ferrets. We compared results at 7 and 30 days. SUBJECTS: Forty ferrets randomized into 2 groups of 20: fibrin sealant and sutures. Within each group, half were studied at 7 days and the rest at 30 days. No ferrets were withdrawn from study because of adverse effects of the intervention. INTERVENTION: A carved costal cartilage graft was placed in the anterior cricoid split incision, and was secured with either fibrin sealant or sutures. All animals were extubated after recovery from anesthesia. Specimens were examined grossly and histologically. RESULTS: All animals survived until humanely killed. The pathologist, unaware of the groupings, measured lumen expansion in millimeters, cartilage graft migration, mucosal in-growth, degree of inflammation, graft integration, and graft viability. The fibrin sealant group had statistically significant (P<.05) better results in mucosal in-growth. In no categories was the suture group better than the fibrin sealant group. In comparing 7-day with 30-day results, the 30-day group had significantly better results in inflammation and graft viability. CONCLUSIONS: Fibrin sealant can be used in place of sutures with improvement in mucosal growth in costal cartilage laryngotracheal reconstruction in the experimental animal model. Use of fibrin sealant (instead of sutures) may result in less surgical trauma and edema, less surgical time, and faster recovery.

Cost effectiveness of community leg ulcer clinics: randomised controlled trial.

OBJECTIVES: To establish the relative cost effectiveness of community leg ulcer clinics that use four layer compression bandaging versus usual care provided by district nurses. DESIGN: Randomised controlled trial with 1 year of follow up. SETTING: Eight community based research clinics in four trusts in Trent. SUBJECTS: 233 patients with venous leg ulcers allocated at random to intervention (120) or control (113) group. INTERVENTIONS: Weekly treatment with four layer bandaging in a leg ulcer clinic (clinic group) or usual care at home by the district nursing service (control group). MAIN OUTCOME MEASURES: Time to complete ulcer healing, patient health status, and recurrence of ulcers. Satisfaction with care, use of services, and personal costs were also monitored. RESULTS: The ulcers of patients in the clinic group tended to heal sooner than those in the control group over the whole 12 month follow up (log rank P=0.03). At 12 weeks, 34% of patients in the clinic group were healed compared with 24% in the control. The crude initial healing rate of ulcers in intervention compared with control patients was 1.45 (95% confidence interval 1.04 to 2. 03). No significant differences were found between the groups in health status. Mean total NHS costs were 878.06 pounds per year for the clinic group and 859.34 pounds for the control (P=0.89). CONCLUSIONS: Community based leg ulcer clinics with trained nurses using four layer bandaging is more effective than traditional home based treatment. This benefit is achieved at a small additional cost and could be delivered at reduced cost if certain service configurations were used.

Difficulties in the measurement of outcome in people who have serious mental health problems.

In the present drive towards evidence-based health care it is essential for nurses to be able to define and measure their contribution in the health services and thereby ensure that resources are deployed to provide maximum improvement in the health of the population. Yet there exist few rigorous studies which examine the impact of the nursing contribution on patient health gain. One explanation for this is the sheer complexity of outcome measurement. This paper considers the multitude of factors which must be taken into account when designing studies to measure the impact of interventions for people with serious mental health problems. The heterogeneous nature of the population, the range of services these people might use, the composite of possible interventions and the paucity of adequate measurement tools are among the issues to be tackled. Although no single methodology can be prescribed, a number of principles are offered to guide study design.

Outcome after laparoscopic cholecystectomy for chronic acalculous cholecystitis.

Patients with typical symptoms of biliary tract disease but no gallstones on ultrasonography may benefit from cholecystectomy for presumed chronic acalculous cholecystitis. We retrospectively analyzed the outcome of 50 patients with a preoperative diagnosis of chronic acalculous cholecystitis based upon history (chronic or recurrent, postprandial right upper quadrant abdominal pain), the absence of acid-peptic disease, and normal biliary sonography treated with laparoscopic cholecystectomy (LC) and transcholecystic cholangiography from 1991 to 1996. All patients had preoperative cholecystokinin-stimulated hepatobiliary scintigraphy (CCK-HBS). There were 42 women and 8 men with a mean age of 43 years. CCK-HBS was abnormal in 45 patients (< or = 35 per cent gallbladder ejection fraction or nonfilling of the gallbladder). There was no postoperative mortality and one morbidity (urinary retention). All patients had microscopic evidence of chronic cholecystitis. At mean follow-up of 30 months, (range, 7-62 months) 39 patients (78%) were free of abdominal pain. Thirty-five of 45 patients with abnormal CCK-HBS were pain free (positive predictive value, 0.78). Four of five patients with normal CCK-HBS were pain free (negative predictive value, 0.20). The positive and negative likelihood ratios for CCK-HBS were 0.99 and 1.13, respectively, confirming that this test was not useful for predicting benefit from LC. Seven patients with persistent right upper quadrant pain had abnormal postoperative sphincter of Oddi manometry; they improved after endoscopic sphincterotomy. Patients with symptoms typical of biliary colic with normal gallbladder sonography and absence of acid-peptic disease benefit from LC in the majority of cases. Those who remain symptomatic after LC may benefit from endoscopic retrograde cholangiopancreatography with sphincter of Oddi manometry and endoscopic sphincterotomy when manometry is abnormal.

A new anesthetic system for microlaryngeal surgery.

Anesthesia for microlaryngeal surgery creates many obstacles for the anesthesiologist and otolaryngologist. Anesthetic techniques developed to improve surgical exposure have been met with significant limitations and are difficult for the anesthesiologist to monitor. A new subglottic jet ventilation anesthesia system is introduced that meets the needs of the otolaryngologist and the anesthesiologist. This new system is made up of two components: (1) The Hunsaker Mon-Jet tube is a laser-safe, subglottic jet ventilation tube constructed of a nonflammable fluoroplastic material. It allows monitoring of tracheal pressure and end tidal carbon dioxide, and it is designed with a basket-shaped distal extension to align the jet port away from the tracheal mucosa and to prevent trauma and submucosal injection of jetted gas. (2) An automatic jet ventilator, which has an adjustable respiratory rate, inspiratory/expiratory ratio, and flow rate, also monitors expiratory end peak airway pressures and has an automatic shutdown feature if either of these pressures are exceeded. This system was successfully used in 36 patients undergoing microlaryngeal surgery.

Propofol maintenance to reduce postoperative emesis in thyroidectomy patients: a group sequential comparison with isoflurane/nitrous oxide.

The clinical benefit of propofol anaesthesia in the prevention of postoperative nausea and vomiting (PONV) is still being elucidated despite many studies to date. In this study 64 adult female patients scheduled for thyroidectomy received, in a randomized double-blind fashion, propofol with air or isoflurane with nitrous oxide for maintenance of anaesthesia. The primary response variable was the presence or absence of vomiting in the first six hours. A group sequential design was used to allow interim analysis. After 64 patients, the fourth analysis showed that fewer patients receiving propofol vomited or required an anti-emetic during the first six hours (P < 0.05). There was no significant difference detected in the 6 to 24 hour interval. In this group of female patients, total intravenous anaesthesia (TIVA) with propofol is associated with an early reduction in early postoperative vomiting compared with standard inhalational techniques. This reduction in vomiting does not appear to persist beyond the first six hours.

Mapping the difficulties experienced by clinicians and managers in health and social care who are seeking to develop research skills.

In 1994 the Department of Health commissioned project work and reviews to inform the development of a National Strategy to enhance the capacity of the NHS workforce to contribute to Research and Development. This paper reports one aspect of this review: a preliminary study mapping the difficulties experienced by clinicians and managers who sought to develop their research skills. A range of professionals were included in the sample, all of whom had applied for funding to undertake research education or training through a variety of schemes offering differing levels of support. There was a remarkable degree of consistency between the professional groups in terms of their level of training, success in achieving funding and their perception of the difficulties they faced in pursuing funding for research training--which they ranked in the same order of importance. However, two major significant differences arose: nurses and therapists rated their managers as less helpful, and they felt that completing application forms for research training was a skill that they lacked. The ranking of areas of difficulty, and the additional comments made by all respondents highlight issues that need to be addressed within a coherent strategic framework to reduce the difficulties experienced by those professionals wishing to pursue funding for research training.