Teaching front-line health and voluntary workers to assess and manage suicidal patients.

BACKGROUND: To devise and evaluate the retention of a new brief training package for non-psychiatrically trained multidisciplinary staff to assess suicide risk and manage suicidal patients, including referral of patients at significant risk to psychiatric staff. METHOD: 8 h of interview skills training, using role play with modelling and video feedback, was taught to 33 health and voluntary workers. Evaluation used a controlled before and after training design. Performance of the interview skills was assessed blindly by raters using predetermined criteria from videotaped role played interviews with actors. Self-rated questionnaires (SIRI-2 and visual analogue scales) were used to assess the clinical skills and confidence respectively of the front-line workers. RESULTS: Suicide risk assessment and management skills such as problem solving, future coping and provision of immediate support were significantly improved at 1 month after training. Training did not significantly improve general interview skills, combating hopelessness nor the removal of lethal weapons. Performance on the SIRI-2 and confidence significantly improved after training. The assessment procedure itself did not improve clinical skills nor confidence. LIMITATIONS: Performance among individual health disciplines was not assessed. Design was not a randomised controlled trial with short follow up and no patient outcome data. CONCLUSIONS: A brief training package is available which is effective in teaching suicide risk assessment and clinical management skills.

The relation of sleep difficulties to fatigue, mood and disability in chronic fatigue syndrome.

The relationship of sleep complaints to mood, fatigue, disability, and lifestyle was examined in 69 chronic fatigue syndrome (CFS) patients without psychiatric disorder, 58 CFS patients with psychiatric disorder, 38 psychiatric out-patients with chronic depressive disorders, and 45 healthy controls. The groups were matched for age and gender. There were few differences between the prevalence or nature of sleep complaints of CFS patients with or without current DSM-IIIR depression, anxiety or somatization disorder. CFS patients reported significantly more naps and waking by pain, a similar prevalence of difficulties in maintaining sleep, and significantly less difficulty getting off to sleep compared to depressed patients. Sleep continuity complaints preceded fatigue in only 20% of CFS patients, but there was a strong association between relapse and sleep disturbance. Certain types of sleep disorder were associated with increased disability or fatigue in CFS patients. Disrupted sleep appears to complicate the course of CFS. For the most part, sleep complaints are either attributable to the lifestyle of CFS patients or seem inherent to the underlying condition of CFS. They are generally unrelated to depression or anxiety in CFS.

Tamoxifen: an overview of recent studies in the field of oncology.

The safety and efficacy of tamoxifen, administered as a single agent in the palliative treatment of advanced breast cancer, are well-established. The role of tamoxifen as part of combined modality treatment still needs to be fully investigated, as does its usefulness as an adjuvant to mastectomy. The use of tamoxifen for tumors other than those in the breast is as yet not clearly defined. Results currently available in these areas are reviewed here.

Use of tamoxifen in advanced male breast cancer.

Tamoxifen citrate has been administered continuously at various dosages to 31 males with evaluable advanced breast cancer in 16 different centers. There were 15 complete or partial responders (48%) and five patients who were assessed to have achieved disease stabilization. In this series, there were responses in visceral-dominant (five of ten), bone-dominant (two of five), and soft tissue-dominant (eight of 15) disease. Response to tamoxifen appeared to be related to estrogen receptor status and to response to prior or subsequent endocrine therapy, although no firm conclusions can be drawn from such small numbers.

An educational intervention for front-line health professionals in the assessment and management of suicidal patients (The STORM Project).

BACKGROUND: Suicide prevention is a health priority in many countries. Improved management of suicide risk may improve suicide prevention. This study aimed to assess the feasibility of health district-wide training in the assessment and management of people at risk of suicide; and to assess the impact of training on assessment and management skills. METHODS: Staff in three health care settings, namely primary care, accident and emergency departments and mental health services (N = 359), were offered suicide risk management training in a district-wide programme, using a flexible 'facilitator' approach. The main outcomes were the rate of attendance at training, and changes in suicide risk assessment and management skills following training. RESULTS: It was possible to deliver training to 167 health professionals (47 % of those eligible) during a 6 month training period. This included 95 primary care staff (39%), 21 accident and emergency staff(42%) and 51 mental health staff (78%). Of these, 103 (69%) attended all training. A volunteer sample of 28 staff who underwent training showed improvements in skills in the assessment and management of suicide risk. Satisfaction with training was high. The expected costs of district-wide training, if it were able to produce a 2.5% reduction in the suicide rate, would be 99,747 pound sterling per suicide prevented and 3,391 pound sterling per life year gained. CONCLUSIONS: Training in the assessment and management of suicide risk can be delivered to approximately half the targeted staff in primary care, accident and emergency departments and mental health services. The current training package can improve skills and is well accepted. If it were to produce a modest fall in the suicide rate, such training would be cost-effective. However, a future training programme should develop a broader training package to reach those who will not attend.

Antibiotic treatment of experimental pneumonic plague in mice.

A mouse model was developed to evaluate the efficacy of antibiotic treatment of pneumonic plague; streptomycin was compared to antibiotics with which there is little or no clinical experience. Infection was induced by inhalation of aerosolized Yersinia pestis organisms. Antibiotics were administered by intraperitoneal injection every 6 hours for 5 days, at doses that produced levels of drug in serum comparable to those observed in humans treated for other serious infections. These studies compared in vitro to in vivo activity and evaluated the efficacy of antibiotics started at different times after exposure. Early treatment (started 24 h after challenge, when 0 of 10 mice tested had positive blood cultures) with netilmicin, ciprofloxacin, ofloxacin, ceftriaxone, ceftazidime, aztreonam, ampicillin, and rifampin (but not cefazolin, cefotetan, or ceftizoxime) demonstrated efficacy comparable to streptomycin. Late treatment (started 42 h after exposure, when five of five mice tested had positive blood cultures) with netilmicin, ciprofloxacin, ofloxacin, and a high dose (20 mg/kg of body weight every 6 h) of gentamicin produced survival rates comparable to that with streptomycin, while all of the beta-lactam antibiotics (cefazolin, cefotetan, ceftriaxone, ceftazidime, aztreonam, and ampicillin) and rifampin were significantly inferior to streptomycin. In fact, all groups of mice treated late with beta-lactam antibiotics experienced accelerated mortality rates compared to normal-saline-treated control mice. These studies indicate that netilmicin, gentamicin, ciprofloxacin, and ofloxacin may be alternatives for the treatment of pneumonic plague in humans. However, the beta-lactam antibiotics are not recommended, based upon poor efficacy in this mouse model of pneumonic plague, particularly when pneumonic plague may be associated with bacteremia.

Investigating the impact of the local health care system in controlling blood glucose levels and preventing complications in patients with type 2 diabetes

OBJECTIVES: To determine if the local health-care system controls blood glucose levels and prevents complications in Trinidadian type 2 diabetic subjects. This study also focused on assessing the structures that are established to monitor blood glucose levels of type 2 diabetics in the public health facilities. DESIGN AND METHODS: This study was a cross-sectional retrospective study of 388 adult type 2 diabetic participants. Participants were taken from all four Regional Health Authorities (RHAs) in Trinidad. RESULTS: The mean and SD of fasting blood glucose of participants, over the 3 year monitoring period, was 197ñ61.67 and a standard error of ñ3.13. The blood glucose levels of the participants did not change significantly (p = 0.848). Results showed that the higher the fasting blood sugar values, the more complications a patient presented. Fasting blood sugar values were the standard for monitoring blood glucose levels, however HbA1c and other measures mandated under protocol were absent. CONCLUSIONS: Across all Regional Health Authorities in Trinidad, fasting blood sugar values were found to be out of control and remained high. It was noted that the higher a patient’s fasting blood sugar values, the more complications they presented.