A tiered approach to inpatient psychosocial screening in an adult UK burns service.

National guidance in the UK advises that psychosocial screening is completed for all inpatients admitted to burns services for over 24 h. Acceptable methods of psychosocial screening have been nationally agreed. However, little is known about how different services conduct psychosocial screening. Moreover, data related to validity and reliability are lacking. This paper describes a tiered approach to inpatient psychosocial screening in a UK adult burns service and considers implications for services. Data collected over a seven-year period was analysed retrospectively. Of 891 patients, almost half (48%; n = 431) were screened face-to-face by a graduate level assistant psychologist. Almost one quarter (23%, n = 205) were screened face-to-face by a qualified clinical psychologist. Around a fifth (22%, n = 193) were screened indirectly through psychological discussions at multi-disciplinary team meetings with a member of the burns clinical psychology team present. A minority of patients were screened face-to-face by liaison psychiatry, or by both liaison psychiatry and a clinical psychologist. Screening and delivery of low-level psychological interventions by a graduate level assistant psychologist appeared to protect resources of qualified clinical psychologists for the most distressed patients. Results highlight the value and cost-effectiveness of a tiered approach to psychosocial screening and in guiding subsequent intervention. Future study is needed in relation to inpatient psychosocial screening and its validity and reliability. Investigating the predictive value of screening methods in identifying those with longer-term psychological difficulties would also be important clinically.

Using regulatory variants to detect gene-gene interactions identifies networks of genes linked to cell immortalisation.

The extent to which the impact of regulatory genetic variants may depend on other factors, such as the expression levels of upstream transcription factors, remains poorly understood. Here we report a framework in which regulatory variants are first aggregated into sets, and using these as estimates of the total cis-genetic effects on a gene we model their non-additive interactions with the expression of other genes in the genome. Using 1220 lymphoblastoid cell lines across platforms and independent datasets we identify 74 genes where the impact of their regulatory variant-set is linked to the expression levels of networks of distal genes. We show that these networks are predominantly associated with tumourigenesis pathways, through which immortalised cells are able to rapidly proliferate. We consequently present an approach to define gene interaction networks underlying important cellular pathways such as cell immortalisation.

Survival after non-resection of colorectal cancer: the argument for including non-operatives in consultant outcome reporting in the UK.

INTRODUCTION: Although the mainstay of colorectal cancer treatment remains operative, a significant proportion of patients end up without surgery. This is because they are either deemed to have no oncological benefit from the resection (too much disease) or to be unfit for major surgery (too frail). The aim of this study was to assess the proportion and survival of these two groups among the totality of practice in a tertiary unit and to discuss the implications on the conceptual understanding of outcome measures. METHODS: Data was collected over two study periods with the total duration of four years. Patient demographics, comorbidities, cancer staging and management pathways were all recorded. The primary endpoint was all-cause mortality. RESULTS: The total of 909 patients were examined. In the 29% who did not undergo resectional surgery, 6.5% had too little disease, 13.8% had too much disease, while 8.7% were deemed too frail. The highest two-year mortality was observed in the too much (83.2%) and too frail (75.9%) groups, whereas in patients with too little cancer the rate was 5.1%, and in those undergoing a resection it was 19.2% (P < 0.001). CONCLUSIONS: The study has expectedly shown poor survival in the too much and too frail groups. We believe that understanding the prognosis in these subgroups is vital, as it informs complex decisions on whether to operate. Moreover, an overall reporting taking into account the proportion of these groups in an multidisciplinary team practice (the non-surgical index) is proposed to render individual surgeon's mortality results meaningful as a comparative measure.

Sir Alexander Morison and The Physiognomy of Mental Diseases: Part 2.

Sir Alexander Morison's The Physiognomy of Mental Diseases and the original art work that formed the basis of the book have not had the scholarly attention they deserve. The published book and the commissioned portraits have not been studied in any detail. Historians have tended to offer cursory assessments that have reflected their own preconceived ideas rather than properly engaging with the material. This is a pity because Morison's work is a rich source that tells us much about the history of psychiatry. The pictures and text give us a glimpse into the world of the asylum and that of the patient. Although we see the patient through the eyes of the artist and Dr Morison, they do emerge as individuals. The accompanying texts reflect the psychiatric approach of the time and reveal contemporary notions of diagnosis, aetiology and treatment. Morison's work can also be located in the history of ideas about physiognomy. He himself was particularly influenced by Jean-Étienne-Dominique Esquirol, and Morison's work, in turn, influenced WAF Browne. These papers will outline Morison's career and consider in detail his book on The Physiognomy of Mental Diseases.

Sir Alexander Morison and The Physiognomy of Mental Diseases: Part 1.

Sir Alexander Morison's The Physiognomy of Mental Diseases and the original art work that formed the basis of the book have not had the scholarly attention they deserve. The published book and the commissioned portraits have not been studied in any detail. Historians have tended to offer cursory assessments that have reflected their own preconceived ideas rather than properly engaging with the material. This is a pity because Morison's work is a rich source that tells us much about the history of psychiatry. The pictures and text give us a glimpse into the world of the asylum and that of the patient. Although we see the patient through the eyes of the artist and Dr Morison, they do emerge as individuals. The accompanying texts reflect the psychiatric approach of the time and reveal contemporary notions of diagnosis, aetiology and treatment. Morison's work can also be located in the history of ideas about physiognomy. He himself was particularly influenced by Jean-Étienne-Dominique Esquirol, and Morison's work, in turn, influenced WAF Browne. These papers will outline Morison's career and consider in detail his book on The Physiognomy of Mental Diseases.

From The House with the Green Shutters to Our Lady of Perpetual Succour: the portrayal of alcohol in the modern Scottish novel.

In modern Scottish literature alcohol is a recurrent subject; this paper examines the different ways it is portrayed with particular emphasis on the novel. It has been seen as the resort of the weak-minded and the cause of personal degradation. It has been portrayed as a response to and a symptom of social disintegration. It has been depicted as leading to delirium and psychosis. On a positive note it has been hailed as a source of inspiration and as a means of celebration. It has helped some troubled characters find the road to redemption. Along the way we encounter various literary stereotypes of the drinker, while the pub forms the backdrop to much of the action.

The secular and the supernatural: madness and psychiatry in the short stories of Muriel Spark.

Edinburgh-born Muriel Spark is one of modern Scotland's greatest writers. Examination of her work reveals that the subjects of madness and psychiatry are recurrent themes in her writing. She herself had a mental breakdown when she was a young woman and she took an interest in the world of psychiatry and psychoanalysis. In her short stories, Spark approaches the subject of madness in a variety of ways: she relates it to the supernatural; to writing fiction; and to religion. She frequently juxtaposes secular and supernatural explanations of mental disturbance. Spark adopts a sceptical and, at times, mocking view of psychiatrists and psychiatric treatment. Both psychoanalysis and pills are seen as problematic.

The history of psychiatry: personal reflections.

Does an engagement with the history of psychiatry benefit the practising clinician? This paper adopts a personal perspective. It sketches the ideological conflicts which have raged in the study of the history of psychiatry in recent decades and looks at the often heated debates between historians and psychiatrists on the subject. It looks at the author's involvement with the subject and considers how this may have influenced both clinical practice and the approach to history. The paper then considers the author's work in the field and the interplay between historical theory and clinical practice. It concludes that studying the history of their subject can make doctors more reflective about their work.

To Drive or Not to Drive: Assessment Dilemmas for GPs.

Introduction. Most Australians are dependent on their cars for mobility, thus relinquishing driving licences for medical reasons poses challenges. Aims. To investigate how general practitioners (GPs) recognise and manage patients' fitness to drive, GPs' attitudes and beliefs about their role as assessors, and GPs' experiences in assessing and reporting to driving authorities and identify GPs' educational needs. Methods. Mixed methods: questionnaire mailed to GPs from three rural and two metropolitan Divisons of General Practice in Victoria, Australia. Results. 217/1028 completed questionnaires were returned: 85% recognised a patients' fitness to drive, 54% felt confident in their assessment ability, 21% felt the GP should have primary responsibility for declaring patients' fitness to drive, 79% felt that reporting a patient would negatively impact on the doctor-patient relationship, 74% expressed concern about legal liability, and 74% favoured further education. Discussion. This study provides considerable information including recommendations about GP education, the assessment forms, and legal clarification.

Nonagenarian surgical admissions for the acute abdomen: who benefits?

INTRODUCTION: Patients 90 years and older form an increasing proportion of the general population. Outcomes of their acute surgical admissions are not well documented. METHODS AND MATERIALS: Surgical management of 49 consecutive nonagenarian admissions (median age: 92 years) with an acute abdomen was compared with the management and outcome of 50 younger patients (median age: 53.5) admitted with a suspected acute abdomen over the same period. RESULTS: Nonagenarian group consisted of mainly women (71% vs. 50%; p = 0.003). The use of laboratory investigations and imaging was similar for the patients aged over 90 and the younger patients, although proportionately fewer nonagenarians were investigated by abdominal CT scan (8% vs. 24%). Of the 49 nonagenarian patients admitted, only 4% (n = 2) were operated on. In contrast, 38% (n = 19) of patients aged 50-59 (p = 0.0001) underwent a surgical intervention. A much greater proportion of nonagenarians died in hospital than patients in the 50-59 comparator group (16% nonagenarians vs. 4% comparator patients; p = 0.04). The very large majority of survivors in both age groups were discharged back to their preadmission domicile [39 (95%) nonagenarians vs. 46 (96%) comparator 50-59 year group]. CONCLUSIONS: In this study, when compared with younger patients, very few nonagenarian patients (2%) with a suspected acute abdomen benefited from surgical admission. Instead, the large majority of nonagenarians either died or were discharged back to their home address without surgery.

The blindness, deafness and madness of King George III: psychiatric interactions.

Recent research has thrown considerable doubt on the claim that King George III suffered from variegate porphyria, but indicates that he suffered recurrent attacks of mania as part of his bipolar disorder. George III's last episode of ill health occurred during the final decade of his life (1810-20). This has been diagnosed as chronic mania with an element of dementia. During this period the king was blind and possibly deaf, which may have contributed to his psychiatric condition. His blindness was due to bilateral cataracts; serious consideration was given at the time to surgery, but this was not carried out. The possible contribution of the king's blindness to his illness is discussed with respect to the roles of his medical attendants. It was also claimed that George III showed progressive deafness and this claim has been re-examined. However, the medical reports by the attending physicians and psychiatrists (mad doctors) do not support this claim.

Hotel NHS and the acute abdomen - admit first, investigate later.

AIM: To determine the financial consequences of a policy of admission first, followed by definitive investigation for patients with an admission diagnosis of suspected acute abdomen. RESULTS: Over a 1-month period, 122 patients were admitted with a suspected surgical diagnosis of acute abdomen (55 men, 67 women); age range 16-95 years (median: 56.5). Based on surgical operation required (n = 36), death after admission (n = 6, three postoperative deaths) and/or severe surgical illness (n = 17), 56 required surgical inpatient admission, while 66 did not. The patients who did not require admission spent significantly shorter time in hospital than those who required admission (median: 5 days vs. 8.5 days; p = 0.0000). Total hospital hotel and investigation cost (not including ITU or theatre costs) for all 122 patients was 330,468 pounds. Overall, 205,468 pounds was consumed by these 56 patients who required admission, while 125,000 pounds was spent on 66 patients whose clinical course did not justify admission; 92% of which was spent on hospital hotel costs and 8% on the cost of imaging and/or endoscopy. DISCUSSION AND CONCLUSION: On a national basis, emergency General Surgery admissions account for 1000 Finished Consultant Episodes per 100,000 population. The findings of this study suggest that this equates to a national NHS spend of 650 million pounds each year, for the hotel costs of patients that could arguably avoid surgical admission altogether. Continuing to admit patients with a suspected acute abdomen first and then requesting definitive investigation makes neither clinical nor economic sense.

What became of Arthur Conan Doyle's father? The last years of Charles Altamont Doyle.

This paper examines the fate of Arthur Conan Doyle's father, Charles Altamont Doyle, a Victorian illustrator, who spent his last years as an asylum inmate. Based on new archival research, it looks at the reasons for his institutionalisation and what befell him during his stay. It will consider Doyle's claim that he was wrongfully confined and also the suggestion that his family were responsible for having him committed. Finally, the paper will examine the nature of Doyle's condition and the creative work he produced whilst an asylum inmate.

Britain's Siberia: Mary Coutts's account of the asylum system.

This paper examines a pamphlet entitled Britain's Siberia. The High Statistics of Insanity Explained by a Certified Lunatic. Research has revealed that the writer was Mary Coutts and that she had been a detained patient in the Aberdeen Royal Asylum. The paper analyses what Coutts had to say about her experiences and compares this to the official asylum records and what they reveal about her inmate stay. The paper also relates Coutts' account to that of other patients who have written about their experiences. As one of the few women to have left a record of life in the asylum, Coutts' story is of particular interest.

The visibility of illicit drugs: implications for community-based drug control strategies.

OBJECTIVES: This study examined differences between the visibility of drugs and drug use in more than 2100 neighborhoods, challenging an assumption about drug use in poor, minority, and urban communities. METHODS: A telephone survey assessed substance use and attitudes across 41 communities in an evaluation of a national community-based demand reduction program. Three waves of data were collected from more than 42 000 respondents. RESULTS: Measures of neighborhood disadvantage, population density, and proportion of minority residents explained more than 57% of the variance between census tracts in visibility of drug sales but less than 10% of tract-to-tract variance in drug use. Visible drug sales were 6.3 times more likely to be reported in the most disadvantaged neighborhoods than in the least disadvantaged, while illicit drug use was only 1.3 times more likely. CONCLUSIONS: The most disadvantaged neighborhoods have the most visible drug problems, but drug use is nearly equally distributed across all communities. Thus, efforts to address drug-related problems in poorer areas need to take into account the broader drug market served by these neighborhoods.