Stakeholder perspectives on continuous observation in inpatient psychiatric wards.

WHAT IS KNOWN ON THE SUBJECT?: Continuous observation is often used in mental health wards to support the safety of service users, where they will be constantly watched by a member of staff. Evidence suggests that continuous observations may be unhelpful and restrictive, but not enough is known about the practice or the best ways to improve it. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This evaluation integrates the perspectives of service users, informal carers and staff to explore current continuous observation experiences and inform future improvements. While previous research highlights the importance of therapeutic engagement, this study additionally emphasizes how the observation procedure could be adapted to individual needs. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Continuous observations could be more beneficial if they are therapeutic, proportional to the level of risk and co-developed with the service user, informal carer and staff. Further training about communication could support staff engagement and the observation process could be formalized to ensure regular collaborative reviews. ABSTRACT: INTRODUCTION: Continuous observation is a frequently used tool to manage high levels of risk on psychiatric wards. However, there is little previous research on its use in practice. AIM: This qualitative service evaluation aims to explore the continuous observation experiences of service users, informal carers and staff in a local NHS Mental Health Trust, informing suggested future improvements to current practice. METHOD: Five service users, three informal carers and seven healthcare staff completed semi-structured interviews, which were thematically analysed to create four themes. RESULTS: Positive interaction and engagement in activities were critical for a therapeutic approach to observations, supporting service users and staff to minimize the unproductive behaviours that can arise. Difficulties balancing safety with privacy could suggest the importance of proportionate and tailored observation procedures for each service user. Ensuring the voices of service users and informal carers remain central to decisions regarding care could further improve the observation experience. IMPLICATIONS FOR PRACTICE: This study highlights therapeutic, proportionate and co-produced observations as key characteristics to improve practice. Further training and formalization of the observation process could foster cultural changes towards more long-term approaches to risk management.

Characteristics and outcomes of people in suicidal crisis at two emergency departments: a service evaluation.

Emergency departments (EDs) provide critical opportunities for nurses to support suicide prevention. This article details a service evaluation that was undertaken to explore the characteristics and outcomes of people in suicidal crisis at two EDs in the East of England during June 2023. Data routinely collected by the ED mental health liaison team were combined with a retrospective case note review of the local NHS mental health trust's electronic patient records. Attendees had a mean age of 35 years and seven months, and were often diagnosed with depression or emotionally unstable personality disorder. Most had a history of self-harm and were currently known to mental health services. Suicide-specific interventions were rarely recorded by nurses and relapse behaviours were prevalent after presentation. Local and national suicide prevention strategies should encourage nurses to address gaps in support, thereby improving patients' experiences in and beyond the ED.

Clinical letters to patients with intellectual disabilities after psychiatric review: A quality improvement project.

AIM: This Quality Improvement Project sought to improve communication between patients with intellectual disabilities and their psychiatrists by sharing medical information using an easy read letter format following psychiatric review. BACKGROUND: Writing directly to patients is in keeping with good medical practice. Previous studies have shown patients with intellectual disabilities prefer letters tailored to meet their needs. METHOD: An easy read letter was used by nine psychiatrists who handed them to 100 consecutive patients after review. Feedback of acceptability to patients was obtained using a three-item facial rating scale and the use of free text. Feedback of acceptability was obtained from participating psychiatrists. RESULTS: Patients found the easy read letter helpful and felt it should be used routinely. Psychiatrists felt this approach was beneficial as well as aiding patient understanding of review. CONCLUSIONS: The easy read letter was reported to improve communication following psychiatric review. Limitations are acknowledged but it is concluded that an easy read letter should be adopted as routine practice following psychiatric review, for people with intellectual disabilities.

Implementing proposed reforms of the Mental Health Act for people with intellectual disability and autism: the perspective of multidisciplinary professionals in intellectual disability teams.

BACKGROUND: A recent government white paper sets out proposals for reforms to the Mental Health Act 1983 (MHA). Some of these proposals affect people with intellectual disabilities and/or autism. AIMS: To explore both positive and unintended negative effects of the proposed reforms by gathering the perspectives of healthcare workers from multiple disciplines, working with intellectual disability and/or autism in community and in-patient settings. METHOD: A 14-question electronic questionnaire, comprising free-text, multiple choice and five-point Likert scale responses, was sent out via email between April and July 2021, to all multidisciplinary team professionals working in specialist intellectual disability community and in-patient teams in Hertfordshire Partnership University NHS Foundation Trust. RESULTS: There were 45 responders, of whom 53% worked in in-patient settings and 47% in out-patient teams. Respondents comprised healthcare professionals from multiple disciplines, 80% of which were non-medical. Most responders agreed with the general principles of the proposed reforms. However, 80% felt there would be potentially unintended consequences, and 76% thought that substantial investment in community services was required in advance of the proposed reforms. CONCLUSIONS: The proposed MHA reforms may have unintended consequences for people with intellectual disabilities and/or autism. The findings of this study raised key concerns that need to be explored further and addressed before the MHA reforms are implemented. These include community provision, safeguards and use of the Mental Capacity Act, the potential for under or overdiagnosis of mental illness, and effects associated with the criminal justice system.

Attention-deficit hyperactivity disorder in people with intellectual disability: statistical approach to developing a bespoke screening tool.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is common among people with intellectual disability. Diagnosing ADHD in this clinically and cognitively complex and diverse group is difficult, given the overlapping psychiatric and behavioural presentations. Underdiagnoses and misdiagnoses leading to irrational polypharmacy and worse health and social outcomes are common. Diagnostic interviews exist, but are cumbersome and not in regular clinical use. AIMS: We aimed to develop a screening tool to help identify people with intellectual disability and ADHD. METHOD: A prospective cross-sectional study, using STROBE guidance, invited all carers of people with intellectual disability aged 18-50 years open to the review of the psychiatric team in a single UK intellectual disability service (catchment population: 150 000). A ten-item questionnaire based on the DSM-V ADHD criteria was circulated. All respondents' baseline clinical characteristics were recorded, and the DIVA-5-ID was administered blinded to the individual questionnaire result. Fisher exact and multiple logistic regressions were conducted to identify relevant questionnaire items and the combinations that afforded best sensitivity and specificity for predicting ADHD. RESULTS: Of 78 people invited, 39 responded (26 men, 13 women), of whom 30 had moderate-to-profound intellectual disability and 38 had associated comorbidities and on were medication, including 22 on psychotropics. Thirty-six screened positive for ADHD, and 24 were diagnosed (16 men, eight women). Analysis showed two positive responses on three specific questions to have 88% sensitivity and 87% specificity, and be the best predictor of ADHD. CONCLUSIONS: The three-question screening is an important development for identifying ADHD in people with intellectual disability. It needs larger-scale replication to generate generalisable results.

A physician associate-led clinic for people with severe mental illness in the United Kingdom.

OBJECTIVE: To evaluate an enhanced physical health clinic led by physician associates (PAs) for patients with severe mental illness. METHODS: A guidance and data collection tool was developed to support and document the outcomes of the PA-led enhanced physical health clinic. RESULTS: The clinic led to diagnoses of diabetes, hyperlipidemia, and hematologic abnormalities. One patient was started on metformin, two patients started a prediabetes program with their general practitioner, one patient started simvastatin, one patient switched from cigarettes to e-cigarettes, and one patient switched from olanzapine to aripiprazole because of metabolic adverse reactions. Three patients intended to contact the National Health Service for cancer screening for which they were eligible but they had not taken up. CONCLUSIONS: PAs can be integrated into a community mental health multidisciplinary team and support the physical health of people with severe mental illness. Mental health trusts should consider roles for PAs in their workforce planning.

Guidance for the Treatment and Management of COVID-19 Among People with Intellectual Disabilities.

The current COVID-19 pandemic is a pressing world crisis and people with intellectual disabilities (IDs) are vulnerable due to disparity in healthcare provision and physical and mental health multimorbidity. While most people will develop mild symptoms upon contracting severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), some will develop serious complications. The aim of this study is to present guidelines for the care and treatment of people with IDs during the COVID-19 pandemic for both community teams providing care to people with IDs and inpatient psychiatric settings. The guidelines cover specific issues associated with hospital passports, individual COVID-19 care plans, the important role of families and carers, capacity to make decisions, issues associated with social distancing, ceiling of care/treatment escalation plans, mental health and challenging behavior, and caring for someone suspected of contracting or who has contracted SARS-CoV-2 within community or inpatient psychiatric settings. We have proposed that the included conditions recommended by Public Health England to categorize someone as high risk of severe illness due to COVID-19 should also include mental health and challenging behavior. There are specific issues associated with providing care to people with IDs and appropriate action must be taken by care providers to ensure that disparity of healthcare is addressed during the COVID-19 pandemic. We recognize that our guidance is focused upon healthcare delivery in England and invite others to augment our guidance for use in other jurisdictions.

"Sometimes, it just stops me from doing anything": A qualitative exploration of epilepsy management in people with intellectual disabilities and their carers.

PURPOSE: Epilepsy affects 1 in 5 people with an intellectual disability (ID), but little is known about their experiences of living with epilepsy. A qualitative study was conducted to investigate the impact and management of epilepsy in people with ID. MATERIALS AND METHODS: People with epilepsy and ID and their carers were invited to take part in semi-structured interviews. Eleven participants with ID and their carers were interviewed together, one participant with ID and their carer were interviewed separately, two interviews took place with the participant with ID only, and one interview took place with the carer only. The interviews were transcribed verbatim, coded, and analyzed thematically (dual independent coding for 30% of the transcripts). RESULTS: Three themes emerged (participant characteristics, living with epilepsy, epilepsy management and information needs) which indicated the following: 1) diversity regarding health profiles, communication abilities, severity of epilepsy, perceived control of epilepsy, and support needs; 2) a reduction in severity and frequency of seizures for a sizeable proportion of participants through antiepileptic drugs; 3) the lifelong impact of epilepsy and related seizures on participants' activities and quality of life; 4) the perceived burden of epilepsy and difficulty managing the condition for a large proportion of participants; 5) high levels of satisfaction with epilepsy-related services and care; and 6) an overall lack of written accessible information about epilepsy. CONCLUSIONS: This study has highlighted a significant impact of epilepsy and related seizures on the daily lives and quality of life of people with ID. Although a sizeable proportion of participants and their carers considered their epilepsy to be well controlled, the majority reported difficulties managing epilepsy and minimizing its impact on their wellbeing. Excluding care staff and the support provided by epilepsy clinics, the participants had not accessed any adapted self-management or information resources about epilepsy.

Smart Sensing System for the Prognostic Monitoring of Bone Health.

The objective of this paper is to report a novel non-invasive, real-time, and label-free smart assay technique for the prognostic detection of bone loss by electrochemical impedance spectroscopy (EIS). The proposed system incorporated an antibody-antigen-based sensor functionalization to induce selectivity for the C-terminal telopeptide type one collagen (CTx-I) molecules-a bone loss biomarker. Streptavidin agarose was immobilized on the sensing area of a silicon substrate-based planar sensor, patterned with gold interdigital electrodes, to capture the antibody-antigen complex. Calibration experiments were conducted with various known CTx-I concentrations in a buffer solution to obtain a reference curve that was used to quantify the concentration of an analyte in the unknown serum samples. Multivariate chemometric analyses were done to determine the performance viability of the developed system. The analyses suggested that a frequency of 710 Hz is the most discriminating regarding the system sensitivity. A detection limit of 0.147 ng/mL was achieved for the proposed sensor and the corresponding reference curve was linear in the range of 0.147 ng/mL to 2.669 ng/mL. Two sheep blood samples were tested by the developed technique and the results were validated using enzyme-linked immunosorbent assay (ELISA). The results from the proposed technique match those from the ELISA.

Wordless intervention for people with epilepsy and learning disabilities (WIELD): a randomised controlled feasibility trial.

OBJECTIVE: To investigate the feasibility of a full-scale randomised controlled trial of a picture booklet to improve quality of life for people with epilepsy and learning disabilities. TRIAL DESIGN: A randomised controlled feasibility trial. Randomisation was not blinded and was conducted using a centralised secure database and a blocked 1:1 allocation ratio. SETTING: Epilepsy clinics in 1 English National Health Service (NHS) Trust. PARTICIPANTS: Patients with learning disabilities and epilepsy who had: a seizure within the past 12 months, meaningful communication and a carer with sufficient proficiency in English. INTERVENTION: Participants in the intervention group used a picture booklet with a trained researcher, and a carer present. These participants kept the booklet, and were asked to use it at least twice more over 20 weeks. The control group received treatment as usual, and were provided with a booklet at the end of the study. OUTCOME MEASURES: 7 feasibility criteria were used relating to recruitment, data collection, attrition, potential effect on epilepsy-related quality of life (Epilepsy and Learning Disabilities Quality of Life Scale, ELDQOL) at 4-week, 12-week and 20-week follow-ups, feasibility of methodology, acceptability of the intervention and potential to calculate cost-effectiveness. OUTCOME: The recruitment rate of eligible patients was 34% and the target of 40 participants was reached. There was minimal missing data and attrition. An intention-to-treat analysis was performed; data from the outcome measures suggest a benefit from the intervention on the ELDQOL behaviour and mood subscales at 4 and 20 weeks follow-up. The booklet and study methods were positively received, and no adverse events were reported. There was a positive indication of the potential for a cost-effectiveness analysis. CONCLUSIONS: All feasibility criteria were fully or partially met, therefore confirming feasibility of a definitive trial. TRIAL REGISTRATION NUMBER: ISRCTN80067039.

Rapid and molecular selective electrochemical sensing of phthalates in aqueous solution.

Reported research work presents real time non-invasive detection of phthalates in spiked aqueous samples by employing electrochemical impedance spectroscopy (EIS) technique incorporating a novel interdigital capacitive sensor with multiple sensing thin film gold micro-electrodes fabricated on native silicon dioxide layer grown on semiconducting single crystal silicon wafer. The sensing surface was functionalized by a self-assembled monolayer of 3-aminopropyltrietoxysilane (APTES) with embedded molecular imprinted polymer (MIP) to introduce selectivity for the di(2-ethylhexyl) phthalate (DEHP) molecule. Various concentrations (1-100 ppm) of DEHP in deionized MilliQ water were tested using the functionalized sensing surface to capture the analyte. Frequency response analyzer (FRA) algorithm was used to obtain impedance spectra so as to determine sample conductance and capacitance for evaluation of phthalate concentration in the sample solution. Spectrum analysis algorithm interpreted the experimentally obtained impedance spectra by applying complex nonlinear least square (CNLS) curve fitting in order to obtain electrochemical equivalent circuit and corresponding circuit parameters describing the kinetics of the electrochemical cell. Principal component analysis was applied to deduce the effects of surface immobilized molecular imprinted polymer layer on the evaluated circuit parameters and its electrical response. The results obtained by the testing system were validated using commercially available high performance liquid chromatography diode array detector system.

Wordless intervention for epilepsy in learning disabilities (WIELD): study protocol for a randomized controlled feasibility trial.

BACKGROUND: Epilepsy is the most common neurological problem that affects people with learning disabilities. The high seizure frequency, resistance to treatments, associated skills deficit and co-morbidities make the management of epilepsy particularly challenging for people with learning disabilities. The Books Beyond Words booklet for epilepsy uses images to help people with learning disabilities manage their condition and improve quality of life. Our aim is to conduct a randomized controlled feasibility trial exploring key methodological, design and acceptability issues, in order to subsequently undertake a large-scale randomized controlled trial of the Books Beyond Words booklet for epilepsy. METHODS/DESIGN: We will use a two-arm, single-centre randomized controlled feasibility design, over a 20-month period, across five epilepsy clinics in Hertfordshire, United Kingdom. We will recruit 40 eligible adults with learning disabilities and a confirmed diagnosis of epilepsy and will randomize them to use either the Books Beyond Words booklet plus usual care (intervention group) or to receive routine information and services (control group). We will collect quantitative data about the number of eligible participants, number of recruited participants, demographic data, discontinuation rates, variability of the primary outcome measure (quality of life: Epilepsy and Learning Disabilities Quality of Life scale), seizure severity, seizure control, intervention's patterns of use, use of other epilepsy-related information, resource use and the EQ-5D-5L health questionnaire. We will also gather qualitative data about the feasibility and acceptability of the study procedures and the Books Beyond Words booklet. Ethical approval for this study was granted on 28 April 2014, by the Wales Research Ethics Committee 5. Recruitment began on 1 July 2014. DISCUSSION: The outcomes of this feasibility study will be used to inform the design and methodology of a definitive study, adequately powered to determine the impact of the Books Beyond Words intervention to improve the management of epilepsy in people with learning disabilities. TRIAL REGISTRATION: http://ISRCTN80067039 (Date of ISRCTN assignation: 23 April 2014).

Paget's disease in an Asian woman.

Extramammary Paget's disease is a rare disease, which mainly occurs in postmenopausal women. The case of Paget's disease of vulva, in a 40 year old Asian woman, who presented with a history of intense itching in vulva for 1 year is being reported. After being medically treated, she was diagnosed on Vulval biopsy. Local excision of the vulval lesion was performed, and histopathology revealed Paget's disease, extending close to the surgical margins. Therefore, a re-excision was performed and patient remained disease free at six months follow up.

Interactions between seizure frequency, psychopathology, and severity of intellectual disability in a population with epilepsy and a learning disability.

Despite observations associating lower IQ and psychopathology in epilepsy, the possible differential effects of varying severity of learning (intellectual) disability (LD) on the manifestation of psychopathology in people with LD and epilepsy have not been clarified. In this study of retrospectively collected data describing the epilepsy, learning disability, and psychopathology of 175 patients with epilepsy and LD over a 3-month period, we observed that 65 patients had no recent seizures, whereas 110 had experienced at least one seizure in the preceding 3 months. We found that depression and psychoses were more common in those with no seizures in the preceding 3 months, but that which of these psychiatric states was manifest was related to the severity of LD. Psychosis rates were higher in those with mild LD, whereas depression rates were higher in those with severe LD.