Restrictive interventions on a psychiatric admission ward before and after COVID-19.

OBJECTIVES: Restrictive interventions (seclusion, restraint and special observations) are used on psychiatric wards when there are no other means available to keep a patient or others safe. These measures can be traumatic, and the Mental Health Commission and the Health Service Executive are focused on minimising their use. We set out to determine whether, following a COVID related reduction in bed numbers on a high dependency psychiatric ward in St John of God Hospital in Dublin, there was a change in their incidence. METHODS: Data on restrictive interventions and challenging behaviours were gathered for 9-month periods before and after March 2020 when COVID related ward changes took place. Figures were also collected on seclusion and restraint for the previous 18 months for a longer-term view. Ward and hospital occupancy levels were also recorded. RESULTS: Between the two time periods, episodes of seclusion fell by 53% and episodes of restraint by 56%. The hours devoted to special observation declined by 30% and incidents of challenging behaviours fell by 26%. Ward occupancy levels fell by only 5%. The longer-term comparison of figures for seclusion and restraint point towards a downward trend from mid-2019 that was accentuated in the post-COVID period. CONCLUSIONS: The changes found may relate to reduced crowding on the ward or other COVID related factors such as the emphasis on social distancing and a shared sense of purpose on the ward. The longer-term trend points towards an emerging cultural shift. The challenge now is to sustain and build upon these changes.

COVID-19 from the perspective of urban and rural general adult mental health services.

COVID-19 has presented society with one of the greatest challenges in living memory. Community Mental Health Teams (CMHTs)have needed to adapt quickly to a rapidly developing situation which has had a dramatic impact on society. In this piece, we describe some of the early challenges for CMHTs within two mental health services based in Dublin and Wicklow. We also discuss ongoing developments and anticipate the need for further vigilance as the COVID-19 pandemic continues to evolve.

Changing prescribing patterns in an Irish community mental health service.

OBJECTIVES: Medication is an important component of the treatment of many mental illnesses. Very little information is available about the particular medications that are being prescribed by community mental health services and how this has changed over time. We set out to obtain details of psychiatric medications being prescribed by one Irish community mental health service. METHOD: All prescribing by the Cluain Mhuire Community Mental Health Service became electronic during 2004. Using Business Intelligence software, we obtained details of all psychiatric medications prescribed from 2005 to 2016. We compared numbers of prescriptions written in the first 6 years (2005-2010) with the following 6 (2011-2016). RESULTS: Olanzapine was the most commonly prescribed medication throughout but its use declined by one-quarter over the study period. Clozapine, quetiapine, aripiprazole and haloperidol prescribing increased. Prescriptions for mood stabilisers and antidepressants fell by 25%. Sedative prescriptions declined by almost 50%. Absolute numbers of prescriptions written for methylphenidate and pregabalin were small but increased dramatically over the time period. CONCLUSIONS: This community mental health service prescribed less of most psychiatric medications in 2016, than had been the case in 2005. This is despite an increase in the numbers of patients seen over the same period. It is not clear if this pattern is echoed in other services.

Should all community mental health teams be sectorised?

OBJECTIVES: Sectorised catchment areas have characterised Irish mental health service delivery since the devolution of institutional care. Unlike other catchment areas, the Cluain Mhuire Community Mental Health Service (CMCMHS) never sectorised. With the development of Community Health Networks (CHNs) and Primary Care Centres, the CMCMHS has come under renewed pressure for structural change. We aimed to consider the implications of these proposed changes on staff and service users. METHOD: We obtained demographic information comparing the CHNs with respect to attendee numbers, new referrals and admissions over a 1- year period. Secondly, we conducted an anonymous survey seeking opinions on the proposals to switch to a sector-based model and/or specialist inpatient care. RESULTS: Referral and admission rates differed across CHNs, broadly consistent with populations. About 36% of staff and 33% of service users supported changing to a sector-based system. In the event of a sector-based system of care being implemented, 66% of service users felt that existing service users should remain under the care of their current team. There was little support among any group for the development of specialist inpatient teams. CONCLUSIONS: We discuss the benefits and drawbacks of sectorisation of mental health service provision. Most patients did not want to change teams either as current service users or as re-referrals (indicating it will take a significant time to transition to a sector-based system). Without clear pathways towards integration with primary care teams, the advantages of sectorisation may not outweigh the challenges associated with its implementation.

Snap-valve cerebral shunt design for intracranial pressure operation and ultrasound visualization.

Cerebral spinal fluid (CSF) shunts are the main treatment for hydrocephalus. They divert excess CSF from the ventricular system to the abdominal, pleural, or intravascular space where it is absorbed. The shunt valve regulates flow based on intracranial pressure (ICP) to maintain a physiologically stable and safe ICP. Shunt malfunction is difficult to detect, life-threatening and common. The present study demonstrates that snap-though buckling (STB) shells can be transformed into pressure-relief valves that act in the normal physiological range of ICP. Three different shell designs in this preliminary experiment were found to have opening and closing pressures that fall within the physiologically normal range of ICP of 6 to 25 cm H2O. Furthermore, these STB shells demonstrate a valve actuation that is visible by ultrasound and have an implantable form-factor that is similar to currently available shunt valves. The unique characteristics of STB shell valves have potential clinical applications for shunt monitoring using ultrasound imaging and can be fabricated from antibiotic-impregnated materials to mitigate shunt infection. These characteristics make STB valves attractive for future use in cerebral shunt systems.

An established practice in new surroundings: concepts, challenges, pitfalls and guidelines for NCHD Balint Groups.

Balint groups are now mandatory for psychiatry trainees. Balint groups have been in existence in General Practice for several decades. Providing Balint groups for Psychiatry Non Consultant Hospital Doctors brings with it challenges for the group leader and participants. Many of these challenges are common place in any form of group work, while others are unique to this cohort. This article describes these challenges. Guidelines which offer the the group the best chance of success, in the face of these common challenges, are discussed.

Service users' perspective of their admission: a report of study findings.

OBJECTIVES: The 'Service Users' Perspective of their Admission' study examined voluntarily and involuntarily admitted services users' perception of coercion during the admission process and whether this was associated with factors such as the therapeutic alliance, satisfaction with services, functioning and quality of life. This report aims to collate the findings of the study. METHODS: The study was undertaken across three community mental health services in Ireland. Participants were interviewed before discharge and at 1 year using the MacArthur Admission Experience. Caregivers of participants were interviewed about their perception of coercion during the admission. RESULTS: A total of 161 service users were interviewed and of those admitted involuntarily, 42% experienced at least one form of physical coercion. Service users admitted involuntarily reported higher levels of perceived coercion and less procedural justice than those admitted voluntarily. A total of 22% of voluntarily admitted service users reported levels of perceived coercion comparable with involuntarily admitted service users and this was associated with treatment in a secure ward or being brought to hospital initially under mental health legislation. In comparison with the service user, caregivers tended to underestimate the level of perceived coercion. The level of procedural justice was moderately associated with the therapeutic relationship and satisfaction with services. After 1 year, 70% experienced an improvement in functioning and this was not associated with the accumulated level of coercive events, when controlled for confounders. CONCLUSIONS: This study has provided valuable insights into the perceptions of coercion and can help inform future interventional studies aimed at reducing coercion in mental health services.

Thirty years of referrals to a community mental health service.

OBJECTIVES: In recent decades mental health services have become increasingly community based and multidisciplinary. However, it is unclear if referrals have changed over this period. The aim of this study was to compare referrals to a community mental health service over a 30-year period. METHOD: New referrals to a community mental health service were randomly sampled from 4 time points over a 30-year period, 1983, 1993, 2003 and 2013, using a mental health information system. Original referral letters were retrieved and anonymised. Referrals were compared with regard to referral sources, demographics, reason for referral, psychotherapy requests, urgency, risk concerns and subsequent hospital admission. RESULTS: There was a 20-fold increase in the number of new referrals between 1983 and 2013. Over the 30 years there was a significant decrease in the proportion of referrals expressing concern about psychosis, but an increase in the proportion that were deemed urgent and which were concerned with suicidal risk. Referrals in 2013 were longer and more likely to contain requests for psychotherapy. CONCLUSIONS: The work of community mental health teams is increasingly concerned with emotional crises. Although services are now more multidisciplinary, they have not been adequately resourced to meet these changing demands.

Physical coercion, perceived pressures and procedural justice in the involuntary admission and future engagement with mental health services.

OBJECTIVES: We sought to determine the level of procedural justice experienced by individuals at the time of involuntary admission and whether this influenced future engagement with the mental health services. METHODS: Over a 15-month period, individuals admitted involuntarily were interviewed prior to discharge and at one-year follow-up. RESULTS: Eighty-one people participated in the study and 81% were interviewed at one-year follow-up. At the time of involuntary admission, over half of individuals experienced at least one form of physical coercion and it was found that the level of procedural justice experienced was unrelated to the use of physical coercive measures. A total of 20% of participants intended not to voluntarily engage with the mental health services upon discharge and they were more likely to have experienced lower levels of procedural justice at the time of admission. At one year following discharge, 65% of participants were adherent with outpatient appointments and 18% had been readmitted involuntarily. Insight was associated with future engagement with the mental health services; however, the level of procedural justice experienced at admission did not influence engagement. CONCLUSIONS: This study demonstrates that the use of physical coercive measures is a separate entity from procedural justice and perceived pressures.

Effects of endurance exercise training on markers of cholesterol absorption and synthesis.

Abnormal cholesterol metabolism, including low intestinal cholesterol absorption and elevated synthesis, is prevalent in diabetes, obesity, hyperlipidemia, and the metabolic syndrome. Diet-induced weight loss improves cholesterol absorption in these populations, but it is not known if endurance exercise training also improves cholesterol homeostasis. To examine this, we measured circulating levels of campesterol, sitosterol, and lathosterol in 65 sedentary subjects (average age 59 years; with at least one metabolic syndrome risk factor) before and after 6 months of endurance exercise training. Campesterol and sitosterol are plant sterols that correlate with intestinal cholesterol absorption, while lathosterol is a marker of whole body cholesterol synthesis. Following the intervention, plant sterol levels were increased by 10% (p<0.05), but there was no change in plasma lathosterol. In addition, total and LDL-cholesterol were reduced by 0.16 mmol and 0.10 mmol, respectively (p<0.05), while HDL-C levels increased by 0.09 mmol (p<0.05). Furthermore, the change in plant sterols was positively correlated with the change in VO2max (r=0.310, p=0.004), independent of other metabolic syndrome risk factors. These data indicate that exercise training reduces plasma cholesterol despite increasing cholesterol absorption in subjects with metabolic syndrome risk factors.

A description of the new technologies used in transforming dental education.

Information and communications technology (ICT) is a universal term describing the use of technology and media to disseminate and share knowledge and information. Educational media provide a means by which information can be communicated between teacher and learner. In this context, the aim of this digest is to summarise and describe the spectrum of tools available. All technologies used in education have their strengths and weaknesses. Variety needs to be balanced by economy. However, it must be remembered that technology is not the overriding issue. The design of the learning environment and the learning experience itself are far more important. Technologies are generally flexible and can be used in a variety of ways. Knowledge of these technologies will help guide appropriate selection. The following tools are described: 1. Telecommunications services; 2. Communications tools (social software) including email, newsgroups, weblogs and wikis; 3. Richmedia in interactive training and learning; 4. Compact discs (CDs) and digital video discs (DVDs); 5. Virtual learning environments (VLE); 6. Sophisticated communications - videoconferencing, webcasting and podcasts; 7. Interactive television; and 8. Virtual reality.

Moving to a purpose built acute psychiatric unit on a general hospital site--does the new environment produce change for the better?

The environment of a hospital can have a significant impact on the experiences of patients. In March 2003 a new purpose built acute psychiatric admission unit opened on the site of Kilkenny General hospital, while the admission wards of the 2 local stand-alone psychiatric hospitals closed. We sought to compare admissions before and after the move, hypothesising that there would be lower levels of aggression, sedative prescribing and intoxicant abuse in the new unit. Details of 98 acute admissions that occurred during the first 3 months of 2002 were compared to 97 acute admissions that occurred during the first 3 months of 2004. Average daily diazepam and chlorpromazine equivalents were calculated for each patient. The Modified Overt Aggression Scale (MOAS) was used to compare levels of aggression. Compared to 2002 fewer patients left the hospital against medical advice in 2004 (OR 0.35, p = 0.027). Overall levels of aggression fell significantly (p = 0.001). Levels of benzodiazapine prescribing also fell (Mean diazepam daily dose 5.75 mg in 2002 versus 4.14 mg in 2004; p = 0.003). There were trends towards reductions in involuntary admissions, admissions of intoxicated people, patients abusing intoxicants in hospital and in antipsychotic prescribing. It is likely that the more pleasant, better designed and less stigmatising environment of the new unit together with the renewed energy and optimism of clinical staff contributed to the changes observed.

Pol eta is required for DNA replication during nucleotide deprivation by hydroxyurea.

Hydroxyurea reduces DNA replication by nucleotide deprivation, whereas UV damage generates DNA photoproducts that directly block replication fork progression. We show that the low fidelity class Y polymerase Pol eta is recruited to proliferating cell nuclear antigen at replication forks both by hydroxyurea and UV light. Under nucleotide deprivation, Pol eta allows cells to accumulate at the G1/S boundary by facilitating slow S-phase progression and promotes apoptosis. Normal cells consequently enter apoptosis at a faster rate than Pol eta-deficient cells. Coincident with hydroxyurea-induced S-phase delay, Pol eta-deficient cells undergo more replication fork breakage and accumulate more foci of the Mre11/Rad50/Nbs1 complex and phosphorylated histone H2AX. We conclude that under conditions of nucleotide deprivation, Pol eta is required for S-phase progression but is proapoptotic. However, as Pol eta is reported to require higher nucleotide concentrations than class B replicative polymerases, its recruitment by hydroxyurea requires it to function under suboptimal conditions. Our results suggest that hydroxyurea-induced apoptosis occurs at the G1/S boundary and that initiation of the S-phase requires greater nucleotide concentrations than does S-phase progression.

Parasuicide assessment in the emergency department.

Parasuicide is an important predictor of future suicide. We collected information on all parasuicides presenting to the emergency department of a general hospital over a 3-month period. We examined detection rates, referral patterns and compared emergency department risk assessments of parasuicide with those of the psychiatric liaison team. We detected 123 parasuicides. One hundred and five (85.4%) were detected in the emergency department. Ninety-five (77.2%) were referred to the liaison psychiatry service. Liaison psychiatric risk assessment agreed with emergency department risk assessment in all cases that emergency doctors judged to be at low risk of suicide. However in cases that emergency doctors judged to be high risk the liaison assessment agreed in only 38.5% of cases. Emergency doctors appear to be appropriately cautious in their assessment of risk. However, parasuicides regularly go undetected in hospital and are not always referred for psychiatric evaluation when detected. More training in the detection, assessment and management of parasuicide is required for emergency doctors.

Prospective evaluation of neurological soft signs in first-episode schizophrenia in relation to psychopathology: state versus trait phenomena.

BACKGROUND: Although patients with schizophrenia have increased rates of neurological soft signs, few studies have examined prospectively their trait or state characteristics in relation to psychopathology. METHOD: In a prospective study of 97 patients with first-episode schizophrenia (DSM-IV criteria) we assessed neurological soft signs and psychopathology at presentation and at 6 month follow-up for 73 cases. To establish whether soft signs were associated with variations in clinical state, neurological soft signs were measured using two validated examinations (Neurological Evaluation Scale and Condensed Neurological Examination); psychopathology was assessed using the Positive and Negative Syndrome Scale. RESULTS: There was significant improvement in overall neurological function, primarily in motor-related and cortical signs, which were associated with improvement in psychopathology. Conversely, 'harder' signs were unrelated to improvement in psychopathology. CONCLUSIONS: Neurological soft signs in schizophrenia are heterogenous. Motor and cortical signs evidence state-like characteristics and vary with clinical course, while 'harder' signs evidence more static, trait-like characteristics in accordance with a neurodevelopmental basis.

Human platelet glycoprotein VI function is antagonized by monoclonal antibody-derived Fab fragments.

Platelet interactions with adhesive ligands exposed at sites of vascular injury initiate the normal hemostatic response but may also lead to arterial thrombosis. Platelet membrane glycoprotein (GP)VI is a key receptor for collagen. Impairment of GPVI function in mice results in a long-term antithrombotic protection and prevents neointimal hyperplasia following arterial injury. On the other hand, GPVI deficiency in humans or mice does not result in serious bleeding tendencies. Blocking GPVI function may thus represent a new and safe antithrombotic approach, but no specific, potent anti-GPVI directed at the human receptor is yet available. Our aim was to produce accessible antagonists of human GPVI to evaluate the consequences of GPVI blockade. Amongst several monoclonal antibodies to the extracellular domain of human GPVI, one, 9O12.2, was selected for its capacity to disrupt the interaction of GPVI with collagen in a purified system and to prevent the adhesion of cells expressing recombinant GPVI to collagen and collagen-related peptides (CRP). While 9O12.2 IgGs induced platelet activation by a mechanism involving GPVI and Fc gamma RIIA, 9O12.2 Fab fragments completely blocked collagen-induced platelet aggregation and secretion from 5 microg mL-1 and fully prevented CRP-induced activation from 1.5 microg mL-1. 9O12.2 Fabs also inhibited the procoagulant activity of collagen-stimulated platelets and platelet adhesion to collagen in static conditions. Furthermore, 9O12.2 Fabs impaired platelet adhesion, and prevented thrombi formation under arterial flow conditions. We thus describe here for the first time a functional monoclonal antibody to human GPVI and demonstrate its effect on collagen-induced platelet aggregation and procoagulant activity, and on thrombus growth.

Polymerase eta and p53 jointly regulate cell survival, apoptosis and Mre11 recombination during S phase checkpoint arrest after UV irradiation.

Xeroderma pigmentosum variant (XPV) cells lack the damage-specific polymerase eta and undergo a protracted arrest at the S phase checkpoint(s) following UV damage. The S phase checkpoints encompass several qualitatively different processes, and stimulate downstream events that are dependent on the functional state of p53. Primary fibroblasts with wild-type p53 arrest in S, and require a functional polymerase eta (pol eta) to carry out bypass replication, but do not recruit recombination factors for recovery. XPV cells with non-functional p53, as a result of transformation by SV40 or HPV16 (E6/E7), recruit the hMre11/hRad50/Nbs1 complex to arrested replication forks, coincident with PCNA, whereas normal transformed cells preferentially use the pol eta bypass replication pathway. The formation of hMre11 foci implies that arrested replication forks rapidly undergo a collapse involving double strand breakage and rejoining. Apoptosis occurs after UV only in cells transformed by SV40, and not in normal or XPV fibroblasts or HPV16 (E6/E7) transformed cells. Conversely, ultimate cell survival in XPV cells was much less in HPV16 (E6/E7) transformed cells than in SV40 transformed cells, indicating that apoptosis was not a reliable predictor of cell survival. Inhibition of p53 transactivation by pifithrin-alpha or inhibition of protein synthesis by cycloheximide did not induce hMre11 foci or apoptosis in UV damaged fibroblasts. Inhibition of kinase activity with wortmannin did not increase killing by UV, unlike the large increase seen with caffeine. Since HPV16 (E6/E7) transformed XPV cells were highly UV sensitive and not further sensitized by caffeine, it appears likely that caffeine sensitization proceeds through a p53 pathway. The S phase checkpoints are therefore, a complex set of different checkpoints that are coordinated by p53 with the capacity to differentially modulate cell survival, apoptosis, bypass replication and hMre11 recombination.