A rapid realist review of clinical neuropsychology rehabilitation programmes to improve psychological wellbeing and quality of life for people with acquired brain injuries.

Approximately 20% of acquired brain injury (ABI) survivors experience reduced psychological wellbeing (PWB). Neuropsychological rehabilitation (NPR) is one approach supporting people with ABI to participate meaningfully in activities despite challenges. Although literature supports NPR effectiveness, little is known about change mechanisms. This systematic realist review identifies what NPR programmes have been designed, delivered, and evaluated for people with ABI to improve PWB and/or quality of life (QOL), as well as providing a context-relevant understanding of what NPR includes and how NPR might lead to positive outcomes. A rapid realist review was conducted in three phases: (1) structured retrieval and evidence extraction; (2) stakeholder consultation; (3) analysis and synthesis. Searches were completed, and findings from 35 publications and one stakeholder consultation were synthesized into a refined logic model. Six context-mechanism-outcome chains (CMOCs) were identified. Participants' relationships to internal experiences, and feelings of self-worth, mastery, and connection appeared to be mechanisms that led to improved PWB and QOL. Adaptation and individualized programmes were also key mechanisms to explain successful NPR. Embedding CMOCs into NPR could improve PWB and/or QOL for people with ABI. The logic model will inform ongoing development of a new online, group-based, NPR programme.

Optimizing Botox regimens in patients with adductor spasmodic dysphonia and essential tremor of voice: A 31-year experience.

Objective: The purpose of this study was to quantitatively compare the effectiveness of unilateral and bilateral botulinum toxin A (BTX-A) injections for mitigating undesirable weak/breathy voice quality and dysphagia for patients with adductor spasmodic dysphonia and/or essential tremor of voice (ETV). Methods: Data were collected from the medical records of 319 patients, yielding three treatment cohorts: patients who received an equal dose bilateral injection regimen (BL=) throughout their course of treatment at VUMC, patients who switched to a unilateral injection regimen (UL), and patients who switched to an unequal dose bilateral injection regimen (BL≠). Changes in length of improvement, duration of weak/breathy voice, and dysphagia severity were compared. Results: The BL = treatment group reported the longest duration of improved voice. Shorter periods of improved voice were reported at baseline by patients who later switched to UL or BL ≠ injection regimens. Patients receiving UL injections reported significantly reduced weak/breathy voice and dysphagia. Patients receiving BL ≠ injections reported increased length of improved voice; however, dysphagia symptoms increased. Ninety-two percent of patients with ETV switched to a UL regimen, with 61% of patients transitioning within the first three injections. Conclusions: Patients with pronounced dysphagia and extended periods of weak/breathy voice may benefit from a UL injection approach to mitigate side effects from BTX-A without sacrificing improved voice outcomes. For patients seeking to extend their length of improved voice, a BL ≠ injection regimen may be effective provided the adverse side effects from BTX-A are minimal. Patients with ETV may benefit from a UL injection approach at the outset of their course of treatment with BTX-A. Level of evidence: III.

Mental and physical health in service member and veteran students who identify as American Indians and Alaskan natives.

OBJECTIVE: The purpose of this study was to explore (a) current utilization rates of university mental health services among American Indian/Alaskan Native/Native Hawaiian (AI/AN/NH) student veterans and (b) predictors of mental health service utilization among AI/AN student veterans. Participants: Data for this cross-sectional study were obtained from the American College Health Association (ACHA)'s 2011-2014 National College Health Assessment II (n = 103). Methods: University mental health service utilization rates were calculated as a percentage for AI/AN/NH student veterans. Multivariable logistic regression was used to determine predictors of mental health service utilization. Results: Results showed that 14% of AI/AN/NH student veterans have used university mental health services. Predictors of mental health service utilization in this population included financial stress, lack of deployment during service, suicidal ideation, and a diagnosis of depression, model χ2 (13) = 162. 128, p < 0.001, Nagelkerke R2 = 0.130. Conclusion: This research identified gaps in service provision for AI/AN service member and veteran students on college campuses and provided possible models for intervention development.

The effects of acaricide treatment of sheep on red grouse Lagopus lagopus scotica tick burdens and productivity in a multi-host system.

Ixodes ricinus (Ixodida: Ixodidae) ticks are of economic and pathogenic importance across Europe. Within the uplands of the U.K., management to reduce ticks is undertaken to benefit red grouse Lagopus lagopus scotica (Galliformes: Phasianidae). Management strategies focus on the acaricide treatment of domestic sheep Ovis aries (Artiodactyla: Bovidae), but the effectiveness of this is less certain in the presence of wild hosts, particularly red deer Cervus elaphus (Artiodactyla: Cervidae) and mountain hare Lepus timidus (Lagomorpha: Leporidae). This study examines the effects of sheep management on grouse tick burdens and productivity using sites with a range of wild host densities. Sites at which applications of acaricide were more frequent had lower tick burdens; this relationship was similar on sites with a range of deer densities. However, no direct link was detected between acaricide treatment interval and grouse productivity. Sites with higher deer densities had higher grouse tick burdens and lower productivity [mean ± standard error (SE) young : adult ratio: 1.2 ± 0.2] compared with sites with lower deer densities (mean ± SE young : adult ratio: 1.8 ± 0.1). Sites with higher grouse brood sizes and higher proportions of hens with broods were also those with higher mountain hare abundance indices. This study highlights the importance of the frequent treatment of sheep with acaricide to reduce tick burdens on grouse, even in the presence of wild hosts.

Abrogation of red blood cell G6PD enzyme activity through Heat treatment: development of survey material for the UK NEQAS G6PD scheme.

INTRODUCTION: Participation in external quality assessment (EQA) is central to the maintenance of high-quality laboratory results in patient diagnosis and clinical trials. Laboratories in the TAF112582 DETECTIVE study (ClinicalTrials.gov identifier: NCT01376167) are enrolled in the United Kingdom National Quality Assessment Scheme (UK NEQAS) for glucose-6-phosphate dehydrogenase (G6PD) quantitative assay, which utilizes ovine (sheep) blood as a readily available source of apparently G6PD-deficient survey material. A substitute for sheep blood was sought because some non-UK sites in the study encountered participation difficulties due to the strict regulations on the import of sheep blood into their countries. METHODS: G6PD activity in normal human donor blood was abrogated by the action of heat under controlled conditions. Residual G6PD activity in the heated samples was measured by UK NEQAS using the Trinity Biotech 345 kit (Trinity Biotech) and a Jenway 6715 UV/Vis spectrophotometer with external temperature control to monitor enzyme kinetics and linearity over a set time. Heat-treated material was also assayed for G6PD activity and assessed for its acceptability as EQA survey material by selected UK laboratories. RESULTS: Blood heated at 45 °C for 15 h showed a reduction in G6PD activity of 76.3 ± 4.6% (n = 6) and was considered acceptable as EQA material in terms of appearance and behaviour by the majority of UK sites in the trial. CONCLUSIONS: We have developed a simple heat-treatment procedure to produce EQA survey material with low/intermediate G6PD activity, similar to that found in females heterozygous for G6PD deficiency.

Differentiating the bipolar disorders from borderline personality disorder.

OBJECTIVE: To identify features differentiating bipolar disorder (BP) from borderline personality disorder (BPD) and with each condition variably defined. METHOD: Participants were assigned a BP or BPD diagnosis on the basis of DSM criteria and, separately, by clinical judgment, and undertook a diagnostic interview and completed self-report measures. RESULTS: Predictors of BPD status varied according to diagnostic decisions, but with the most consistent items being childhood sexual abuse, childhood depersonalization, personality variables relating to relationship difficulties and sensitivity to criticism, and the absence of any BP family history. Across diagnostic groups, personality measure items alone predicted diagnostic allocation with an accuracy of 81-84%, the refined study variables other than hypo/manic features improved the classification rates to 88%, and when the presence or absence of hypo/manic features was added, classification rates increased to 92-95%. CONCLUSION: Study findings indicate that BPD can be differentiated from BP with a high degree of accuracy.

Indications for Red Cell Transfusion in the Intensive Care Unit at the University Hospital of the West Indies.

OBJECTIVE: To determine current red cell transfusion practices, transfusion indications and their relationship to patient outcome in intensive care unit (ICU) patients at the University Hospital of the West Indies (UHWI). METHOD: An observational study was conducted over seven months in the two ICUs at the UHWI, on all patients over 16 years who had been admitted for more than 24 hours. Patient demographics, indication(s) for transfusion, haemoglobin level at the time of transfusion, details of ICU admission and patient outcome were recorded. Data analysis was done using Stata v12. RESULTS: Of the 203 patients included in the study, 79 were transfused (39%). A low haemoglobin level was the most common indication for transfusion, with a mean of 7.3 ± 1.5 g/dL. Patients who were transfused had higher phlebotomy volumes [61.9 versus 126.1 mL, p < 0.001], were more likely to require mechanical ventilation (p = 0.002) and inotropic support (p = 0.007). Most were surgical patients (p = 0.01) and were post-open heart/thoracic surgery (66% transfusion rate). Patient outcome was correlated with transfusion, as transfused patients had longer ICU stays (13.0 versus 6.7 days, p < 0.001) and increased mortality rates (32.9% compared to 20.2%, p = 0.04). Most transfusions occurred within the first week of admission (83.5%). CONCLUSION: The mean haemoglobin for transfusion at the ICU, UHWI, is 7.3 g/dL, just above the recommended trigger of 7.0 g/dL in a restrictive transfusion practice. Transfusion policies are needed to better allocate a scarce commodity and minimize complications associated with blood transfusion.

The magnetic recoil spectrometer for measurements of the absolute neutron spectrum at OMEGA and the NIF.

The neutron spectrum produced by deuterium-tritium (DT) inertial confinement fusion implosions contains a wealth of information about implosion performance including the DT yield, ion-temperature, and areal-density. The Magnetic Recoil Spectrometer (MRS) has been used at both the OMEGA laser facility and the National Ignition Facility (NIF) to measure the absolute neutron spectrum from 3 to 30 MeV at OMEGA and 3 to 36 MeV at the NIF. These measurements have been used to diagnose the performance of cryogenic target implosions to unprecedented accuracy. Interpretation of MRS data requires a detailed understanding of the MRS response and background. This paper describes ab initio characterization of the system involving Monte Carlo simulations of the MRS response in addition to the commission experiments for in situ calibration of the systems on OMEGA and the NIF.

The 'real world' utility of a web-based bipolar disorder screening measure.

OBJECTIVE: To determine whether those completing a self-report bipolar self-test measure and identified as having a likely bipolar disorder judged the self-test as useful and had a subsequent superior illness course. METHOD: We invited those completing the web-based Mood Swings Questionnaire (or MSQ) to provide contact details and contribute to a 3-month study evaluating their responses to being identified as having a likely bipolar disorder, any subsequent action taken and the impact of such actions on their illness trajectory. RESULTS: We analysed data received from 665 participants screening 'positive' on the MSQ and completing baseline and 3-month follow-up data. High rates of satisfaction with the MSQ were quantified, with respondents viewing the measure as informative, validating and/or motivating. Of those receiving a confirmed bipolar diagnosis, such clarification occurred on average 12 years after their first depressive episode. Most implemented self-management strategies irrespective of whether seeking formal diagnostic clarification or not. Participants improved on depressive, quality of life and overall functioning measures over the study period, but with results indicating (via analysis of three sample subsets differing by the degree of 'actions taken') that those who took assertive action and had the diagnosis confirmed had the most superior outcome. CONCLUSION: This is the first study to formally evaluate the clinical impact of a self-report bipolar disorder screening measure. High acceptance and superior outcomes quantified for those acting assertively in response to such a new diagnosis argue for its 'real world' utility.

Measuring the absolute deuterium-tritium neutron yield using the magnetic recoil spectrometer at OMEGA and the NIF.

A magnetic recoil spectrometer (MRS) has been installed and extensively used on OMEGA and the National Ignition Facility (NIF) for measurements of the absolute neutron spectrum from inertial confinement fusion implosions. From the neutron spectrum measured with the MRS, many critical implosion parameters are determined including the primary DT neutron yield, the ion temperature, and the down-scattered neutron yield. As the MRS detection efficiency is determined from first principles, the absolute DT neutron yield is obtained without cross-calibration to other techniques. The MRS primary DT neutron measurements at OMEGA and the NIF are shown to be in excellent agreement with previously established yield diagnostics on OMEGA, and with the newly commissioned nuclear activation diagnostics on the NIF.

Impact of age and sex on primary preventive treatment for cardiovascular disease in the West Midlands, UK: cross sectional study.

OBJECTIVES: To establish the impact of age and sex on primary preventive treatment for cardiovascular disease in a typical primary care population. DESIGN: Cross sectional study of anonymised patient records. PARTICIPANTS: All 41,250 records of patients aged ≥ 40 registered at 19 general practices in the West Midlands, United Kingdom, were extracted and analysed. MAIN OUTCOME MEASURES: Patients' demographics, risk factors for cardiovascular disease (blood pressure, total cholesterol concentration), and prescriptions for primary preventive drugs were extracted from patients' records. Patients were subdivided into five year age bands up to 85 (patients aged ≥ 85 were analysed as one group) and prescribing trends across the population were assessed by estimating the proportion of patients prescribed with antihypertensive drug or statin drug, or both, in each group. RESULTS: Of the 41,250 records screened in this study, 36,679 (89%) patients did not have a history of cardiovascular disease and therefore could be considered for primary preventive treatment. The proportion receiving antihypertensive drugs increased with age (from 5% (378/6978) aged 40-44 to 57% (621/1092) aged ≥ 85) as did the proportion taking statins up to the age of 74 (from 3% (201/6978) aged 40-44 to 29% (675/2367) aged 70-74). In those aged 75 and above, the odds of a receiving prescription for a statin (relative to the 40-44 age group) decreased with every five year increment in age (odds ratio 12.9 (95% confidence interval 10.8 to 15.3) at age 75-79 to 5.7 (4.6 to 7.2) at age ≥ 85; P<0.001). There were no consistent differences in prescribing trends by sex. CONCLUSIONS: Previously described undertreatment of women in secondary prevention of cardiovascular disease was not observed for primary prevention. Low use of statins in older people highlights the need for a stronger evidence base and clearer guidelines for people aged over 75.

Is context everything to the definition of clinical depression? A test of the Horwitz and Wakefield postulate.

BACKGROUND: In arguing for the need to distinguish clinical depression from sadness, Horwitz and Wakefield argued for weighting consideration to nuances of life event stressors. Their definition of clinical depression corresponds to the concept of endogenous depression or melancholia, while their model would position reactive (or context specific) non-melancholic depressive disorders more as manifestations of 'sadness' rather than as clinical depression. METHOD: We test their postulate by examining the extent to which 141 clinically diagnosed melancholic and non-melancholic depressed patients reported episodes as being preceded by a life event stressor or not--and the salience of any life stressor to episode onset and severity. RESULTS: While melancholic patients were more likely than non-melancholic patients to report episodes coming 'out of the blue' and to be more severe than might be expected from the severity of antecedent stressors, differences were more ones of degree and not absolute. Such context variables appeared, however, to differentiate melancholic and non-melancholic patients more consistently than depression symptom variables. As depression severity and impairment levels did not differ across the melancholic and non-melancholic patients, findings were unlikely to be artefacts of such factors. CONCLUSIONS: The study finds some support for the Horwitz and Wakefield hypothesis of clinical (or, at least melancholic) depression requiring independence of context or an antecedent stressor, but with precision likely to be compromised by nuances intrinsic to assessment of life event stressors and their contribution to depression onset, difficulties in defining valid 'melancholic' and 'non-melancholic' depressive sub-groups and the parsimony of the hypothesis.

Successful treatment of severe abulia with co-beneldopa.

Abulia is a disorder of the executive and frontal lobe function. It is characterised by severe psychomotor slowing that is not due to depressive illness or catatonic schizophrenia. Abulia is thought to be due to disruption of the meso-cortico-limbic dopaminergic system. Preliminary evidence suggests that patients with abulia may respond to treatment with dopaminergic drugs. We extend this evidence by reporting a significant and sustained functional improvement in a severely abulic patient after treatment with co-beneldopa (Madopar).

Performance of stroke risk scores in older people with atrial fibrillation not taking warfarin: comparative cohort study from BAFTA trial.

OBJECTIVE: To compare the predictive power of the main existing and recently proposed schemes for stratification of risk of stroke in older patients with atrial fibrillation. DESIGN: Comparative cohort study of eight risk stratification scores. SETTING: Trial of thromboprophylaxis in stroke, the Birmingham Atrial Fibrillation in the Aged (BAFTA) trial. PARTICIPANTS: 665 patients aged 75 or over with atrial fibrillation based in the community who were randomised to the BAFTA trial and were not taking warfarin throughout or for part of the study period. MAIN OUTCOME MEASURES: Events rates of stroke and thromboembolism. RESULTS: 54 (8%) patients had an ischaemic stroke, four (0.6%) had a systemic embolism, and 13 (2%) had a transient ischaemic attack. The distribution of patients classified into the three risk categories (low, moderate, high) was similar across three of the risk stratification scores (revised CHADS(2), NICE, ACC/AHA/ESC), with most patients categorised as high risk (65-69%, n = 460-457) and the remaining classified as moderate risk. The original CHADS(2) (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes, previous Stroke) score identified the lowest number as high risk (27%, n = 180). The incremental risk scores of CHADS(2), Rietbrock modified CHADS(2), and CHA(2)DS(2)-VASc (CHA(2)DS(2)-Vascular disease, Age 65-74 years, Sex) failed to show an increase in risk at the upper range of scores. The predictive accuracy was similar across the tested schemes with C statistic ranging from 0.55 (original CHADS(2)) to 0.62 (Rietbrock modified CHADS(2)), with all except the original CHADS(2) predicting better than chance. Bootstrapped paired comparisons provided no evidence of significant differences between the discriminatory ability of the schemes. CONCLUSIONS: Based on this single trial population, current risk stratification schemes in older people with atrial fibrillation have only limited ability to predict the risk of stroke. Given the systematic undertreatment of older people with anticoagulation, and the relative safety of warfarin versus aspirin in those aged over 70, there could be a pragmatic rationale for classifying all patients over 75 as "high risk" until better tools are available.

Evaluating the first 1000 patients referred to a specialist depression clinic: a case for tertiary referral facilities.

BACKGROUND: We report on the assessment and outcome of the first 1000 patients referred to a tertiary referral depression clinic established to assess the utility of diagnostic sub-typing on clinical course of illness. METHODS: Diagnostic, treatment recommendations, prognostic judgments and 12-week outcome data were examined. RESULTS: Nearly 40% of those with a primary mood disorder were diagnosed with bipolar disorder, of whom three-quarters received such a diagnosis for the first time. Alternative diagnoses or formulations were provided for 68% of the total sample, with the therapeutic paradigm altered for the majority (86%) of patients. Improvement rates were indicative of a higher level of improvement in those diagnosed with bipolar disorder (some 70%) compared to those with unipolar disorders (some 60%). Overall, however, rates of 'full remission' were low, being 2% and up to 12% for bipolar and unipolar patients respectively and perhaps reflecting the tertiary nature of the assessing clinical facility. Baseline clinician predictions were in the order of 60% accuracy in predicting outcome, irrespective of diagnostic grouping. LIMITATIONS: Anticipation factors (e.g. attending a specialist tertiary referral service) may have contributed non-specifically to outcome. Use of clinician-derived diagnoses rather than strict DSM-IV criteria limits comparisons to other studies. CONCLUSIONS: The high rates of a first-time bipolar diagnosis suggest that detection and diagnosis of this condition continues to be problematic. Low remission rates underline the chronic nature of many mood disorders, and the need for ongoing management given the high risk of relapse. Our findings offer support for the importance of identifying bipolar disorder and distinguishing depressive sub-types in order to shape more targeted treatments, a task that might be advanced by the establishment of more tertiary referral services.

Impact of study design on recruitment of patients to a primary care trial: an observational time series analysis of the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) study.

BACKGROUND: recruitment targets to randomized controlled trials (RCTs) are often not met. Many interventions are used to improve recruitment but there is little empirical evidence on whether these approaches work. OBJECTIVE: to examine whether changes to the design and conduct of a primary care-based RCT were associated with changes in patient recruitment. METHODS: an observational time series analysis of recruitment to a primary care-based multi-centre RCT of aspirin versus warfarin for stroke prevention, which involved 330 practices. Several changes to the trial protocol and procedures were made over the 4 years of patient recruitment. For each quarter throughout the recruitment period, the recruitment rate per 1000 total population in active practices was calculated. RESULTS: the recruitment target of 930 patients was exceeded. Fluctuations in recruitment rate occurred during the recruitment period. Following protocol changes aimed to reduce clinical workload, there was a significant increase in recruitment during the final 6 months of the study, during a period when there was not a similarly large increase in the total population available. CONCLUSIONS: these findings suggest that the conduct of a trial is an important consideration if studies are to recruit successfully. Expanding the number of centres may not be the most effective way to improve recruitment.

Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care.

OBJECTIVES: To assess the accuracy in diagnosing heart failure of clinical features and potential primary care investigations, and to perform a decision analysis to test the impact of plausible diagnostic strategies on costs and diagnostic yield in the UK health-care setting. DATA SOURCES: MEDLINE and CINAHL were searched from inception to 7 July 2006. 'Grey literature' databases and conference proceedings were searched and authors of relevant studies contacted for data that could not be extracted from the published papers. REVIEW METHODS: A systematic review of the clinical evidence was carried out according to standard methods. Individual patient data (IPD) analysis was performed on nine studies, and a logistic regression model to predict heart failure was developed on one of the data sets and validated on the other data sets. Cost-effectiveness modelling was based on a decision tree that compared different plausible investigation strategies. RESULTS: Dyspnoea was the only symptom or sign with high sensitivity (89%), but it had poor specificity (51%). Clinical features with relatively high specificity included history of myocardial infarction (89%), orthopnoea (89%), oedema (72%), elevated jugular venous pressure (70%), cardiomegaly (85%), added heart sounds (99%), lung crepitations (81%) and hepatomegaly (97%). However, the sensitivity of these features was low, ranging from 11% (added heart sounds) to 53% (oedema). Electrocardiography (ECG), B-type natriuretic peptides (BNP) and N-terminal pro-B-type natriuretic peptides (NT-proBNP) all had high sensitivities (89%, 93% and 93% respectively). Chest X-ray was moderately specific (76-83%) but insensitive (67-68%). BNP was more accurate than ECG, with a relative diagnostic odds ratio of ECG/BNP of 0.32 (95% CI 0.12-0.87). There was no difference between the diagnostic accuracy of BNP and NT-proBNP. A model based upon simple clinical features and BNP derived from one data set was found to have good validity when applied to other data sets. A model substituting ECG for BNP was less predictive. From this a simple clinical rule was developed: in a patient presenting with symptoms such as breathlessness in whom heart failure is suspected, refer directly to echocardiography if the patient has a history of myocardial infarction or basal crepitations or is a male with ankle oedema; otherwise, carry out a BNP test and refer for echocardiography depending on the results of the test. On the basis of the cost-effectiveness analysis carried out, such a decision rule is likely to be considered cost-effective to the NHS in terms of cost per additional case detected. The cost-effectiveness analysis further suggested that, if likely benefit to the patient in terms of improved life expectancy is taken into account, the optimum strategy would be to refer all patients with symptoms suggestive of heart failure directly for echocardiography. CONCLUSIONS: The analysis suggests the need for important changes to the NICE recommendations. First, BNP (or NT-proBNP) should be recommended over ECG and, second, some patients should be referred straight for echocardiography without undergoing any preliminary investigation. Future work should include evaluation of the clinical rule described above in clinical practice.

A before and after study of the impact of Specialist Workers for Older People.

BACKGROUND: Case management of vulnerable older people by Community Matrons has been introduced into the UK. A locally designed case management approach, The Specialist Workers for Older People (SWOP) Service, was implemented by a Central England Primary Care Trust. Here we report an evaluation of this service. METHODS: Before and after study of 418 people (207 before; 211 after) aged > or =75 at high risk of emergency hospital admission. SWOPs carry out assessments of social and medical needs, produce individual care plans, coordinate care and refer to appropriate agencies. Univariable analysis was used to determine the association of SWOPs on changes in hospital admission rates and primary care workload. RESULTS: There was a non-significant reduction in hospital admissions from 0.91 to 0.67 per patient. There was a significant increase in routine GP surgery visits, from an average 1.3 to 2.6 per patient. The number of emergency home visits decreased from an average 2.8 to 1.1 per patient (P < 0.001). CONCLUSIONS: Case management might reduce hospital admissions and is potentially a cost-effective service. However, not all case management schemes are successful. With the introduction of Community Matrons, it is important to understand what elements of the SWOP service contributed to its success.

Is bipolar II depression phenotypically distinctive?

OBJECTIVE: We examine the depressive symptom profile of bipolar II disorder patients compared with a comparator (composite) group of those with unipolar depression, with stratification by melancholic and non-melancholic subtypes. METHOD: Out-patients (n = 394) attending a specialist depression clinic comprised the sample. Data on severity and prototypic status of depressive symptoms were analysed. RESULTS: Age-matched analyses revealed minimal differentiation between bipolar II and composite unipolar groups. Stratified analyses suggested that 'bipolar II depression' more closely approximated melancholic depression in terms of psychomotor and cognitive slowing. Severity-based analyses and prototypic symptom patterns yielded differing results, suggesting that definition of bipolar II depression is influenced by rating strategies, and age. CONCLUSION: We found limited differentiation of bipolar II depression from unipolar, melancholic and non-melancholic depression. Differences suggested previously may reflect age, gender and severity differences, highlighting the need for appropriately matched groups in defining bipolar II depression.

A before and after study of the impact of Specialist Workers for Older People.

BACKGROUND: Case management of vulnerable older people by Community Matrons has been introduced into the UK. A locally designed case management approach, the Specialist Workers for Older People (SWOP) Service, was implemented by a Central England Primary Care Trust. Here, we report an evaluation of this service. METHODS: Before and after study of 418 people (207 before; 211 after) aged >or=75 at high risk of emergency hospital admission. SWOPs carry out assessments of social and medical needs, produce individual care plans, co-ordinate care and refer to appropriate agencies. Univariable analysis was used to determine the association of SWOPs on changes in hospital admission rates and primary care workload. RESULTS: There was a non-significant reduction in hospital admissions from 0.91 to 0.67 per patient. There was a significant increase in routine general practitioner surgery visits, from an average 1.3 to 2.6 per patient. The number of emergency home visits decreased from an average 2.8 to 1.1 per patient (P < 0.001). CONCLUSIONS: Case management might reduce hospital admissions and is potentially a cost-effective service. However, not all case management schemes are successful. With the introduction of Community Matrons, it is important to understand what elements of the SWOP service contributed to its success.