Addressing the gap for racially diverse research involvement: The King's Model for minority ethnic research participant recruitment.

Objectives: Ethnic minorities (EM) are still underrepresented in research recruitment. Despite wide literature outlining the barriers, enablers and recommendations for driving inclusion and diversity in research, there is still little evidence for successful diversity in research participation, which has a direct impact on the quality of care provided to ethnically diverse individuals. A new, comprehensive approach to recruitment strategies is therefore necessary. Study design: service improvement initiative. Methods: In the light of the Covid-19 pandemic and the key public health need to address the disparity in care provided to non-white populations, we used a novel, comprehensive approach (The King's Model) comprising of local and community actions to promote inclusive research recruitment. We then compared rates of diverse recruitment in studies where the novel approach, was applied to studies which had been closed to recruitment at the time of analysis and where ethnicity data was available. Results: Our results demonstrate that following the introduction of the King's Model for diverse recruitment, commercial interventional study diverse recruitment increased from 6.4% to 16.1%, and for non-commercial studies, from 30.2% to 41.0% and 59.2% in the selected studies. Conclusions: King's Model is potentially a useful tool in enhancing non-Caucasian recruitment to clinical research. Enriched by additional recommendations based on our experiences during the Covid-19 research recruitment drive, we propose the King's Model is used to support ethnically diverse research recruitment. Further evidence is needed to replicate our findings, although this preliminary evidence provides granular details necessary to address the key unmet need of validating clinical research outcomes in non-white populations.

Attaining the age threshold for adolescent mental health services: factors associated with transition of care in the independent sector in Ireland.

OBJECTIVES: The transition from adolescent to adult mental health services (AMHS) is associated with disengagement, poor continuity of care and patient dissatisfaction. The aim of this retrospective and descriptive study was to describe the 'care pathways' in an independent mental health service when adolescents reach age 18 and to investigate the level of engagement of those who transitioned to independent AMHS. METHODS: This is a retrospective, naturalistic and descriptive study in design. All patients discharged from the St Patrick's Adolescent Mental Health Service aged 17 years and 6 months and older, during a 3-year period between January 2014 and December 2016, were included. Electronic records were used to collect socio-demographic and clinical details and to determine engagement rates in adolescents who transferred to independent adult services. RESULTS: A total of 180 patients aged over 17 years and 6 months were discharged from the adolescent service. Of these, 45.6% were discharged to their GP, 28.9% to public mental health services and 25.6% to independent mental health services. The majority who transitioned to independent AMHS went to a Young Adult Service, which had high engagement rates at 3 and 12 months post-transition. CONCLUSIONS: In this independent mental health service, less than half of adolescents who reach the transition age are referred onto AMHS. Engagement rates were found to be high among those referred on to a specialised young adult service.

Psychotic experiences in a mental health clinic sample: implications for suicidality, multimorbidity and functioning.

BACKGROUND: Recent community-based research has suggested that psychotic experiences act as markers of severity of psychopathology. There has, however, been a lack of clinic-based research. We wished to investigate, in a clinical sample of adolescents referred to a state-funded mental health service, the prevalence of (attenuated or frank) psychotic experiences and the relationship with (i) affective, anxiety and behavioural disorders, (ii) multimorbid psychopathology, (iii) global functioning, and (iv) suicidal behaviour. METHOD: The investigation was a clinical case-clinical control study using semi-structured research diagnostic psychiatric assessments in 108 patients newly referred to state adolescent mental health services. RESULTS: Psychotic experiences were prevalent in a wide range of (non-psychotic) disorders but were strong markers of risk in particular for multimorbid psychopathology (Z = 3.44, p = 0.001). Young people with psychopathology who reported psychotic experiences demonstrated significantly poorer socio-occupational functioning than young people with psychopathology who did not report psychotic experiences, which was not explained by multimorbidity. Psychotic experiences were strong markers of risk for suicidal behaviour. Stratified analyses showed that there was a greatly increased odds of suicide attempts in patients with a major depressive disorder [odds ratio (OR) 8.89, 95% confidence interval (CI) 1.59-49.83], anxiety disorder (OR 15.4, 95% CI 1.85-127.94) or behavioural disorder (OR 3.13, 95% CI 1.11-8.79) who also had psychotic experiences compared with patients who did not report psychotic experiences. CONCLUSIONS: Psychotic experiences (attenuated or frank) are an important but under-recognized marker of risk for severe psychopathology, including multimorbidity, poor functioning and suicidal behaviour in young people who present to mental health services.

Telepsychiatry and carer education for schizophrenia.

OBJECTIVE: Despite the scientific evidence, most families of people with schizophrenia in Europe never receive a carer education programme. We evaluated whether a carer education course delivered by telepsychiatry was as effective as a carer education course delivered in situ. METHOD: We delivered the carer education course for schizophrenia simultaneously to a carers group in rural north west Ireland (remote) via three ISDN lines and live to a carers group in a city (host). We compared knowledge gains using the Knowledge Questionnaire before and after each course. RESULTS: Fifty-six carers of people with schizophrenia participated in the trial. At baseline, participants at the remote and host centers did not differ in terms of knowledge about schizophrenia. After the course, carers at both centers improved significantly and the knowledge gains between groups were equivalent at 6 weeks. CONCLUSION: Telepsychiatry can deliver effective carer education programmes about schizophrenia and may provide one solution to bridging the chasm between scientific evidence and clinical reality.

The Letter-Number Sequencing Test and its association with potential to work among people with psychotic illness.

Post hoc analysis of occupational attainment and performance on a standard neurocognitive battery suggests that performance on letter-number sequencing is strongly associated with work attainment. Letter-number sequencing may warrant further investigation as a clinically useful tool to inform decisions around vocational rehabilitation.

Effectiveness of surveillance of infrainguinal grafts.

OBJECTIVE: To audit the surveillance programme of infrainguinal vein graft in a tertiary vascular unit, and find out how effective it was in preventing occlusion of grafts. DESIGN: Retrospective study. SETTING: Teaching hospital, Scotland. SUBJECTS: 59 consecutive patients who had 61 vein grafts between 1996 and 1998 for critical limb ischaemia. INTERVENTIONS: Grafts scanned at 3-monthly intervals for at least a year, and clinical review. MAIN OUTCOME MEASURES: Survival with an intact limb and patency of the graft. RESULTS: 52 of the 59 patients (90%) were alive at the time of follow up, and 55 of the 61 involved limbs (90%) were intact. Median follow up was 660 days (range 180-1995). 23 stenoses were detected by the surveillance programme. 17 grafts were revised, all of which were patent at follow up, and 8 other grafts occluded requiring 6 major amputations. One-year cumulative primary, primary-assisted, and secondary patency, and limb salvage rates were 63%, 88%, 88%, and 90% respectively. CONCLUSIONS: Surveillance of infrainguinal grafts by duplex scanning is effective and has resulted in high rates of limb salvage and secondary patency in patients who presented with critical ischaemia.

Optimum lead positioning for recording bipolar atrial electrocardiograms during sinus rhythm and atrial fibrillation.

BACKGROUND: To date, Holter monitoring has been predominantly utilized in the investigation and monitoring of ventricular arrhythmias and myocardial ischemia. Whether currently employed lead configurations are optimal for recording atrial electrocardiograms (ECGs) is unknown. HYPOTHESIS: This study was undertaken to determine which conventional and novel lead configurations are optimal for recording atrial electrical activity during sinus rhythm and atrial fibrillation. METHODS: Recordings were performed on eight healthy volunteers in sinus rhythm and four patients in atrial fibrillation. Each subject had 10 ECGs of three bipolar and three augmented unipolar leads recorded during supine rest, while rising to upright, and during standing rest, yielding a total of 60 leads (30 bipolar leads). Each tracing was inspected by two observers, and parameters such as P-wave amplitude and duration, whether the P-wave onset was clearly seen, atrial fibrillatory-wave amplitude, and amplitude of noise during standing were scored. RESULTS: Leads recording inferiorly and leftward orientated bipoles provided the best registration of sinus P waves. The P-wave amplitude in the standard bipolar C5 lead (0.12 +/- 0.02 mV) was, however, inferior to others such as recordings between C1 and C6 positions (P-wave amplitude 0.16 +/- 0.02 mV) or from below the right clavicle to the left upper quadrant of the abdomen (0.16 +/- 0.01 mV). Optimal recording of fibrillatory waves was from different leads, such as a bipole from below the left clavicle to a low C1 position (fibrillatory wave amplitude 0.27 +/- 0.03 mV). CONCLUSION: When Holter recordings are performed for the investigation of atrial arrhythmias, nonstandard lead configurations provide superior recording of atrial electrical activity. We advocate the use of electrodes positioned from C1 to C6, from below the left clavicle to a low C1 position, and a vertically orientated lead from the manubium to the twelfth vertebra or the xiphisternum.

Acute exercise and markers of endothelial injury in peripheral arterial disease.

OBJECTIVES: To determine the acute effects of exercise on plasma levels of markers of endothelial damage in patients with symptomatic peripheral arterial occlusive disease (PAOD). DESIGN: Prospective observational study of patients with angiographically proven PAOD undergoing treadmill exercise testing prior to surgical or radiological intervention. MATERIALS AND METHODS: Ante-cubital venous blood sampling was performed in 20 patients with symptomatic PAOD prior to, and 2 min after, treadmill exercise testing. Samples were then assayed for von Willebrand factor (vWf), tissue-type plasminogen activator (tPa), and plasminogen activator inhibitor (PAI) levels. RESULTS: Despite a significant fall in median ankle-brachial pressure indices from 0.96 pre-exercise to 0.59 post-exercise on the right, and from 0.92 to 0.40 on the left (both p < 0.005), there were no significant changes in plasma levels of vWf, tPa, or PAI following claudication-inducing exercise. CONCLUSIONS: Claudication-inducing exercise does not produce acute alterations in plasma markers of endothelial damage, and the results of this study do not support the belief that claudication-inducing exercise in PAOD is damaging to vascular endothelium.

Insonation and impedance analysis in graft surveillance.

Seventy consecutive patients with infrainguinal bypass grafts entered a 1-year graft surveillance programme involving colour duplex scanning, direct graft insonation and computer-assisted impedance analysis. Graft patients with a positive duplex scan, high frequencies on graft insonation or an impedance value above 0.50 subsequently underwent arteriography. Sixteen patients were excluded before the initial surveillance visit. The 54 remaining patients with grafts (30 vein, 24 synthetic) underwent a total of 137 surveillance visits, with 21 grafts confirmed to be 'at risk'. The sensitivity of an impedance value above 0.55 in identifying these grafts was 86 per cent, rising to 95 per cent when combined with graft insonation. Duplex scanning did not identify any abnormalities in 11 grafts that were either shown by arteriography to be 'at risk' or occluded before arteriography. Impedance measurement and graft insonation are simple screening techniques with a high sensitivity (when combined), which identify 'at risk' infrainguinal grafts. Positive graft insonation or an impedance value over 0.55 will identify all 'at risk' vein grafts while minimizing the number of unnecessary arteriograms.