Improved Attitudes to Psychiatry: A Global Mental Health Peer-to-Peer E-Learning Partnership.

OBJECTIVE: Health links aim to strengthen healthcare systems in low and middle-income countries through mutual exchange of skills, knowledge, and experience. However, student participation remains limited despite growing educational emphasis upon global health. Medical students continue to report negative attitudes to psychiatry in high-income countries, and in Somaliland, the lack of public sector psychiatrists limits medical students' awareness of mental healthcare. The authors describe the design, implementation, and mixed-methods analysis of a peer-to-peer psychiatry e-learning partnership between UK and Somaliland students arising from a global mental health link between the two countries. METHODS: Medical students at King's College London and Hargeisa and Amoud universities, Somaliland, were grouped into 24 pairs. Participants aimed to complete ten fortnightly meetings to discuss psychiatry topics via the website MedicineAfrica. Students completed initial and final evaluations including Attitudes toward Psychiatry (ATP-30) questions, a stigma questionnaire, and brief evaluations after each meeting. RESULTS: Quantitative findings demonstrated that enjoyment, interest, and academic helpfulness were rated highly by students in Somaliland and moderately by students in the UK. Somaliland students' attitudes to psychiatry were significantly more positive post-participation, whereas UK students' attitudes remained stable. Qualitative findings identified more gains in factual knowledge for Somaliland students, whereas UK students reported more cross-cultural learning. Reasons for non-completion and student-suggested improvements emphasized the need to ensure commitment to the program by participants. CONCLUSIONS: This partnership encouraged students to consider global mental health outside the standard medical education environment, through an e-learning format solely utilizing existing resources. This new approach demonstrates potential benefits to students in contrasting locations of brief, focused online peer-to-peer education partnerships, expanding the scope of health links to the medical professionals of the future.

Use of a bibliometric literature review to assess medical research capacity in post-conflict and developing countries: Somaliland 1991-2013.

OBJECTIVES: Effective healthcare systems require high-quality research to guide evidence-based interventions and strategic planning. In low- and middle-income countries, especially those emerging from violent conflict, research capacity often lags behind other aspects of health system development. Here, we sought to bibliometrically review health-related research output in Somaliland, a post-conflict self-declared, autonomous nation on the Horn of Africa, as a means of assessing research capacity. METHODS: We reviewed articles on health-related research conducted in Somaliland between 1991 and 2013 that included a description of the experimental design, and articles were published in either a peer-reviewed journal or as part of a scholarly programme receiving formal review. We did not include policy or social science research that did not enrol or interact with subjects from Somaliland. Using online databases, all studies meeting minimum eligibility criteria were reviewed in regard to Somaliland-based co-authorship, topic of research and specific measures of quality. RESULTS: A total of 37 studies were included in this review. Of these, only 19 (51%) included co-authorship by Somaliland-based researchers. Of the 21 studies reporting ethical approval, 16 (64%) received approval from the Somalia or Somaliland Ministry of Health, while five received approval from a university or national commission. More than two-thirds of published research was limited to a few areas of investigation with most (19, 51%) following basic cross-sectional study designs. The number of articles published per year increased from 0 to 1 in the years 1991-2007 to a maximum of 8 in 2013. CONCLUSIONS: Research activity in Somaliland is extremely limited. Investigators from high-income countries have largely directed the research agenda in Somaliland; only half of the included studies list co-authors from institutions in Somaliland. Leadership and governance of health research in Somaliland is required to define national priorities, promote scholarly activity and guide the responsible conduct of research. The methods used here to assess research capacity may be generalisable to other low- and middle-income countries and post-conflict settings to measure the impact of research capacity-building efforts.

Prescribing efficiency of proton pump inhibitors in China: influence and future directions.

BACKGROUND: Pharmaceutical expenditure is currently rising by 16% per annum in China, greater in recent years. Initiatives to moderate growth include drug pricing regulations, essential medicine lists and encouraging generic prescribing. These are principally concentrated in hospitals, which currently account for over 80% of total pharmaceutical expenditure. However, no monitoring of prescribing and perverse incentives encouraging physicians and hospitals to profit from drug procurement encourages irrational prescribing. This includes greater utilisation of originators versus generics as well as injectables when cheaper oral equivalents are available. The objective of the paper is to assess changes in proton pump inhibitor (PPI) utilisation and expenditure in China as more generics become available including injectables. METHODS: Observational retrospective study of PPI utilisation and procured expenditure between 2004 and 2013 in the largest teaching hospital in Chongqing District as representative of China. RESULTS: Appreciable increase in PPI utilisation during the study period rising 10.4 fold, with utilisation of generics rising faster than originators. Oral generics reached 84% of total oral preparations in 2013 (defined daily dose basis), with generic injectables 93% of total injectables by 2013. Injectables accounted for 42% of total PPI utilisations in 2008 and 2009 before falling to below 30%. Procured prices for oral preparations reduced over time (-34%). Generic oral omeprazole in 2010 was 87% below 2004 originator prices, mirroring reductions seen in Western Europe. Injectable prices also decreased over time (-19%). However, injectables typically 4.3 to 6.8 fold more expensive than equivalent orals - highest for injectable lansoprazole at 13.4 to 18.0 fold. High utilisation of more expensive oral PPIs as well as injectables meant that PPI expenditure increased 10.1 fold during the study period. Lower use of injectables, and only oral generic omeprazole, would result in accumulated savings of CNY249.65 million, reducing total accumulated expenditure by 84%. CONCLUSIONS: Encouraging to see high utilisation of generic PPIs and low prices for oral generics. However, considerable opportunities to enhance prescribing efficiency through greater use of oral generic omeprazole.

Can authorities appreciably enhance the prescribing of oral generic risperidone to conserve resources? Findings from across Europe and their implications.

BACKGROUND: Generic atypical antipsychotic drugs offer health authorities opportunities for considerable savings. However, schizophrenia and bipolar disorders are complex diseases that require tailored treatments. Consequently, generally there have been limited demand-side measures by health authorities to encourage the preferential prescribing of generics. This is unlike the situation with hypertension, hypercholaesterolaemia or acid-related stomach disorders.The objectives of this study were to compare the effect of the limited demand-side measures in Western European countries and regions on the subsequent prescribing of risperidone following generics; to utilise the findings to provide future guidance to health authorities; and where possible, to investigate the utilisation of generic versus originator risperidone and the prices for generic risperidone. METHODS: Principally, this was a segmented regression analysis of retrospective time-series data of the effect of the various initiatives in Belgium, Ireland, Scotland and Sweden following the introduction of generic risperidone. The study included patients prescribed at least one atypical antipsychotic drug up to 20 months before and up to 20 months after generic risperidone. In addition, retrospective observational studies were carried out in Austria and Spain (Catalonia) from 2005 to 2011 as well as one English primary care organisation (Bury Primary Care Trust (PCT)). RESULTS: There was a consistent steady reduction in risperidone as a percentage of total selected atypical antipsychotic utilisation following generics. A similar pattern was seen in Austria and Spain, with stable utilisation in one English PCT. However, there was considerable variation in the utilisation of generic risperidone, ranging from 98% of total risperidone in Scotland to only 14% in Ireland. Similarly, the price of generic risperidone varied considerably. In Scotland, generic risperidone was only 16% of pre-patent loss prices versus 72% in Ireland. CONCLUSION: Consistent findings of no increased prescribing of risperidone post generics with limited specific demand-side measures suggests no 'spillover' effect from one class to another encouraging the preferential prescribing of generic atypical antipsychotic drugs. This is exacerbated by the complexity of the disease area and differences in the side-effects between treatments. There appeared to be no clinical issues with generic risperidone, and prices inversely reflected measures to enhance their utilisation.

Incidence of breast and gynaecological cancers by ethnic group in England, 2001-2007: a descriptive study.

BACKGROUND: Although international comparisons reveal large geographical differences in the incidence of breast and gynaecological cancers, incidence data for ethnic groups in England remains scarce. METHODS: We compared the incidence of breast, ovarian, cervical and endometrial cancer in British Indians, Pakistanis, Bangladeshis, Black Africans, Black Caribbeans, Chinese and Whites between 2001 and 2007. We identified 357,476 cancer registrations from which incidence rates were calculated using mid-year population estimates from 2001 to 2007. Ethnicity was obtained through linkage to the Hospital Episodes Statistics database. Incidence rate ratios were calculated, comparing the 6 non-White ethnic groups to Whites, and were adjusted for age and income. RESULTS: We found evidence of differences in the incidence of all 4 cancers by ethnic group (p<0.001). Relative to Whites, South Asians had much lower rates of breast, ovarian and cervical cancer (IRRs of 0.68, 0.66 and 0.33 respectively), Blacks had lower rates of breast, ovarian and cervical cancer but higher rates of endometrial cancer (IRRs of 0.85, 0.62, 0.72 and 1.16 respectively), and Chinese had lower rates of breast and cervical cancer (IRRs of 0.72 and 0.68 respectively). There were also substantial intra-ethnic differences, particularly among South Asians, with Bangladeshis experiencing the lowest rates of all 4 cancers. CONCLUSIONS: Our study provides evidence that the risk of breast and gynaecological cancers varies by ethnic group and that those groups typically grouped together are not homogenous with regards to their cancer risk. Furthermore, several of our findings cannot be readily explained by known risk factors and therefore warrant further investigation.

Diffusion of e-health innovations in 'post-conflict' settings: a qualitative study on the personal experiences of health workers.

BACKGROUND: Technological innovations have the potential to strengthen human resources for health and improve access and quality of care in challenging 'post-conflict' contexts. However, analyses on the adoption of technology for health (that is, 'e-health') and whether and how e-health can strengthen a health workforce in these settings have been limited so far. This study explores the personal experiences of health workers using e-health innovations in selected post-conflict situations. METHODS: This study had a cross-sectional qualitative design. Telephone interviews were conducted with 12 health workers, from a variety of cadres and stages in their careers, from four post-conflict settings (Liberia, West Bank and Gaza, Sierra Leone and Somaliland) in 2012. Everett Roger's diffusion of innovation-decision model (that is, knowledge, persuasion, decision, implementation, contemplation) guided the thematic analysis. RESULTS: All health workers interviewed held positive perceptions of e-health, related to their beliefs that e-health can help them to access information and communicate with other health workers. However, understanding of the scope of e-health was generally limited, and often based on innovations that health workers have been introduced through by their international partners. Health workers reported a range of engagement with e-health innovations, mostly for communication (for example, email) and educational purposes (for example, online learning platforms). Poor, unreliable and unaffordable Internet was a commonly mentioned barrier to e-health use. Scaling-up existing e-health partnerships and innovations were suggested starting points to increase e-health innovation dissemination. CONCLUSIONS: Results from this study showed ICT based e-health innovations can relieve information and communication needs of health workers in post-conflict settings. However, more efforts and investments, preferably driven by healthcare workers within the post-conflict context, are needed to make e-health more widespread and sustainable. Increased awareness is necessary among health professionals, even among current e-health users, and physical and financial access barriers need to be addressed. Future e-health initiatives are likely to increase their impact if based on perceived health information needs of intended users.

Incidence of gastrointestinal cancers by ethnic group in England, 2001-2007.

OBJECTIVE: To compare the incidence of six gastrointestinal cancers (colorectal, oesophageal, gastric, liver, gallbladder and pancreatic) among the six main 'non-White' ethnic groups in England (Indian, Pakistani, Bangladeshi, Black African, Black Caribbean and Chinese) to each other and to Whites. METHODS: We analysed all 378 511 gastrointestinal cancer registrations from 2001-2007 in England. Ethnicity was obtained by linkage to the Hospital Episodes Statistics database and we used mid-year population estimates from 2001-2007. Incidence rate ratios adjusted for age, sex and income were calculated, comparing the six ethnic groups (and combined 'South Asian' and 'Black' groups) to Whites and to each other. RESULTS: There were significant differences in the incidence of all six cancers between the ethnic groups (all p<0.001). In general, the 'non-White' groups had a lower incidence of colorectal, oesophageal and pancreatic cancer compared to Whites and a higher incidence of liver and gallbladder cancer. Gastric cancer incidence was lower in South Asians but higher in Blacks and Chinese. There was strong evidence of differences in risk between Indians, Pakistanis and Bangladeshis for cancer of the oesophagus, stomach, liver and gallbladder (all p<0.001) and between Black Africans and Black Caribbeans for liver and gallbladder cancer (both p<0.001). CONCLUSIONS: The risk of gastrointestinal cancers varies greatly by individual ethnic group, including within those groups that have traditionally been grouped together (South Asians and Blacks). Many of these differences are not readily explained by known risk factors and suggest that important, potentially modifiable causes of these cancers are still to be discovered.

Incidence of haematological malignancies by ethnic group in England, 2001-7.

The aetiology of most haematological malignancies is largely unknown. Studies of migrant populations can provide insights into the relative importance of genetic and environmental risk factors for these diseases. This study compares incidence rates in British Indians, Pakistanis, Bangladeshis, Black Africans, Black Caribbeans, Chinese and Whites in England from 2001 to 2007. We analysed 134,302 haematological cancer registrations with ethnicity obtained by linkage to the Hospital Episodes Statistics database. Mid-year population estimates from 2001 to 2007 were used. Incidence rate ratios adjusted for age, sex and income were calculated, comparing the six ethnic groups to Whites and to each other. Whites had the highest rates for most subtypes. However, Blacks experienced more than double the incidence of plasma cell and mature T-cell neoplasms compared to other ethnic groups. There were also significant differences in incidence between Indians, Pakistanis and Bangladeshis for Hodgkin lymphoma and mature B-cell neoplasms and between Black African and Black Caribbeans for mature B-cell and other lymphoid neoplasms (all P < 0.001). Our results show that the risk of haematological cancers varies greatly by ethnic group, including within those groups that have traditionally been grouped together (South Asians and Blacks) with many of these differences not explicable by known risk factors.

Personalizing health care: feasibility and future implications.

Considerable variety in how patients respond to treatments, driven by differences in their geno- and/ or phenotypes, calls for a more tailored approach. This is already happening, and will accelerate with developments in personalized medicine. However, its promise has not always translated into improvements in patient care due to the complexities involved. There are also concerns that advice for tests has been reversed, current tests can be costly, there is fragmentation of funding of care, and companies may seek high prices for new targeted drugs. There is a need to integrate current knowledge from a payer's perspective to provide future guidance. Multiple findings including general considerations; influence of pharmacogenomics on response and toxicity of drug therapies; value of biomarker tests; limitations and costs of tests; and potentially high acquisition costs of new targeted therapies help to give guidance on potential ways forward for all stakeholder groups. Overall, personalized medicine has the potential to revolutionize care. However, current challenges and concerns need to be addressed to enhance its uptake and funding to benefit patients.

Telemedicine for peer-to-peer psychiatry learning between U.K. and Somaliland medical students.

OBJECTIVE: The proportion of U.K. medical students applying for psychiatry training continues to decline, whereas, in Somaliland, there are no public-sector psychiatrists. This pilot study assessed the usefulness and feasibility of online, instant messenger, peer-to-peer exchange for psychiatry education between cultures. METHOD: Twenty medical students from King's College, London, and Hargeisa University (Somaliland) met online in pairs every 2 weeks to discuss prearranged psychiatric topics, clinical cases, and treatment options, completing online evaluations throughout. RESULTS: Average ratings of the enjoyment, academic helpfulness, and interest of sessions were 4.31, 3.56, and 4.54 (of a maximum of 5), respectively; 83% would recommend the partnership to a friend. CONCLUSION: This partnership enabled students on both sides to exploit psychiatry-learning resources at the other's disposal, outside the standard medical education context, illustrating the benefits to medical students in dramatically different locations of partnership through telemedicine. This pilot study presents an innovative, cost-effective, under-used approach to international medical education.

Are prescribing initiatives readily transferable across classes: the case of generic losartan in Scotland?

BACKGROUND: There are on-going initiatives in Scotland to improve the quality and efficiency of prescribing in primary care. Activities to enhance prescribing of angiotensin-converting enzyme inhibitors (ACEIs) versus angiotensin receptor blockers (ARBs) include prescribing guidance, guidelines, benchmarking, prescribing targets and financial incentives. These measures stabilised reimbursed expenditure for renin-angiotensin inhibitor drugs between 2001 and 2007 despite a 159% increase in volumes. Generic losartan was included in the Drug Tariff from July 2010. As there is no appreciable difference between ARBs, and the prices of generic losartan are falling, health boards should be actively encouraging its prescribing. AIM: To primarily assess changes in utilisation patterns of losartan versus other ARBs after July 2010. Second, to assess the utilisation of generic versus originator losartan. METHOD: We used an interrupted time series analysis of ARB utilisation, measured in defined daily doses (DDDs) before and after July 2010. Utilisation data were obtained from the NHS National Services Scotland Corporate Warehouse. RESULTS: There was no significant change in the utilisation pattern of losartan or other ARBs combined before or after the introduction of generic losartan. Losartan accounted for 32% of total ARBs 12 months after listing. Between 98 and 99% of losartan was prescribed generically. In March 2012, the price of losartan was 88% below prepatent prices with potential savings of ?8m per year. CONCLUSION: Specific measures are needed to change prescribing habits especially with complex messages. The cost of deriving savings must be weighed against other quality initiatives and other ARBs losing or shortly losing their patents.

A quantitative assessment of the extent and distribution of textile fibre transfer to persons involved in physical assault.

Knowledge of the number of fibres transferred during a particular activity is essential for the interpretation of findings in similar criminal cases. In this regard, violent contacts and physical assaults still present a challenge, due to a lack of robust published data. Hereby, we present the outcome of an empirical study where different assault activities were simulated by a Jiu Jitsu team and participants were asked to play either the role of an aggressive 'assailant' or a defensive 'victim', wearing cotton garments (i.e., Gi's). Four different scenarios were simulated in replicates (n = 5), each of them involving different intensity levels (low and high) and duration times (30 and 60 s). Results showed that approximately 1,000 to 44,000 fibres were cross-transferred between the participants' garments, with noticeable differences between the different scenarios. These values were significantly larger than those published in previous studies and, therefore, suggested the possibility of a current underestimation of the number of fibres transferred in physical assaults. Furthermore, statistical analysis by ANOVA indicated that the all the variables tested (i.e., intensity level, duration time, and participants role) had a significant effect on the number of transferred fibres (p < 0.001) and, consequently, that some knowledge of the case circumstances may be important to make more educated estimations. This is the first time that such a methodology has been applied for the quantitative assessment of fibre transfer between participants in assault activities. Data are expected to help practitioners with the interpretation of findings in real casework and lead to a more robust evidential assessment.

Penile frenuloplasty: a simple and effective treatment for frenular pain or scarring.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Frenuloplasty, using common plastic surgical techniques for scar lengthening, is a commonly performed operation amongst urologists for isolated frenular pathology. However, there is very little data in the urological literature regarding either technique or assessment. The only other published study was a questionnaire follow-up with a 23% response rate and the technique used was not clarified. Other studies describe expensive, rarely used procedures and are hampered by small patient numbers or short-term follow-up only. Our study validates the common practice of using plastic surgical techniques for scar lengthening. We have 100% clinical short-term follow-up (3 months) and 91% long-term follow-up (up to 10 years) showing high patient satisfaction scores and low complication and re-operation rates. This provides an evidence base from which to counsel patients who are keen for foreskin sparing surgery for frenular pathology. The extra addition of our grading system allows patients to be risk-stratified as to the risk of re-operation depending on their status at presentation and underlying pathology. OBJECTIVE: To assess the long-term patient satisfaction and outcomes for penile frenuloplasty when offered as an alternative to circumcision for frenular pain and/or scarring. PATIENTS AND METHODS: Data was prospectively collected over 10 years, for a total of 106 men. The nature of the frenular problem was graded. Techniques of V-Y plasty, Z-plasty or a combination of the two were used. All patients were reviewed at 3 months and contacted via questionnaire ≥ 1 year after surgery. The questionnaire assessed satisfaction, cosmetic appearance, pain on intercourse, need for subsequent surgery and if they would recommend the procedure to a friend. RESULTS: Follow-up was 100% (106/106) at 3 months and 91% (96/106) ≥ 1 year. Patient satisfaction and cosmesis scores both averaged 8.9/10. Need for subsequent circumcision was 8% (9/96). There were minor complications (bruising/infection/partial dehiscence) in 8% (9/96) of patients. 97% (84/87) of patients would recommend the procedure to a friend. CONCLUSIONS: Penile frenuloplasty is a safe alternative to circumcision. There are high patient satisfaction rates after surgery. Low numbers of patients require a completion circumcision after penile frenuloplasty.

Letter: Real-time, intercontinental dermatology teaching of trainee physicians in Somaliland using a dedicated social networking portal.

We describe the use of MedicineAfrica.com, an innovative social networking portal, to deliver real-time, intercontinental, case-based dermatology teaching to geographically scattered trainee physicians in Somaliland by tutors based in the United Kingdom.