Driving and Psychotropic Medications: What Do Psychiatrists and Service Users Really Know?

Aims We ascertained the level of psychotropic medication use among drivers from a sample population and examined whether psychiatrists and mental health service users are sufficiently informed about the effects of medications on driving ability and about drug-driving legislation and guidelines in Ireland. Methods This cross-sectional survey included a convenience sample of 50 service users aged 18 and over who presented to the acute psychiatric unit in Portlaoise, Laois-Offaly Mental Health Services (LOMHS) for urgent psychiatric assessment, along with a survey of 37 doctors working with LOMHS. Results Almost half of surveyed service users (46%) reported that they currently drive, with the majority of these (78%) driving most days. Sixty-one percent (61%) of drivers reported taking psychotropic medication, with 64% of these taking more than one medication. Of 17 doctors who returned questionnaires, 8 (47%) reported that driving and medication use is a common concern in their practice, while only 1 (6%) had received training in relation to assessing medical fitness to drive. Overall, 94% (16) of clinicians and 54% of service users (rising to 71% for service users who drive and take medication) expressed a need for more information about this topic. Conclusion In this sample, the majority of mental health service users who drive do so while taking prescribed medications and they are unclear on the implications. Furthermore, there are significant deficits in training for psychiatrists in the area of assessing medical fitness to drive. Therefore, considering the potential serious risks involved, there is a clear need for more information and training about this topic for both clinicians and service users alike.

Loneliness and vascular biomarkers: the Dublin Healthy Ageing Study.

BACKGROUND: Loneliness has been associated with poor physical health and a link has been suggested between the presence of loneliness, cardiovascular health and inflammatory markers. OBJECTIVE: To investigate the association between vascular disease biomarkers and loneliness in a community-dwelling non-demented elderly population. DESIGN: cross-sectional community based assessment. PARTICIPANTS: 466 subjects with mean age 75.45 (SD, 6.06) years. 208 (44.6%) were male. RESULTS: Higher levels of HbA1c, but not other vascular biomarkers were independently associated with being lonely. CONCLUSION: Loneliness was associated with raised levels of HbA1c in a community dwelling elderly population. The mechanism for this association has yet to be elucidated but may reflect an abnormal stress response in people who are lonely.

Loneliness and cognition in older people: the Dublin Healthy Ageing study.

INTRODUCTION: While several studies have found a link between impaired cognition and social isolation, few have examined the relationship between cognition and loneliness. Loneliness has been thought to increase the risk of development of Alzheimer's dementia. AIM: The aims of this study were to explore the relationship between loneliness and cognition and to determine whether specific cognitive domains are associated with loneliness. DESIGN: Cross-sectional community-based study. PARTICIPANTS: This study included 466 community-dwelling subjects with mean age 75.45 (SD 6.06) years, of which 208(44%) were males. RESULTS: Loneliness was significantly associated with impaired global cognition independent of social networks and depression. The domains of psychomotor processing speed and delayed visual memory were specifically associated with self-reported loneliness. CONCLUSION: This cross-sectional study demonstrated an association between loneliness and specific aspects of cognition independent of depression, social networks and other demographics. The mechanism for this association is unclear and warrants further investigation.

Autistic spectrum disorder without intellectual impairment in adult mental health services - fostering new perspectives and enhancing existing services.

Autistic spectrum disorder (ASD) is a neuro-developmental disability with multi-systemic impacts. Individuals with ASD without intellectual impairment (DSM-V) or Aspergers (DSM-IV) are often particularly vulnerable to mental health problems such as anxiety disorders including social phobia and generalised anxiety disorder, depressive disorders and psychosis. Adults with ASD without intellectual impairment suffer higher rates of physical and psychiatric morbidity, display a poorer ability to engage with treatment and have a lower chance of recovery compared with the general population. It is widely acknowledged that adults with suspected ASD without intellectual impairment and co-morbid mental health problems are often not best supported through adult mental health services and often require more tailored supports. This review seeks to (a) increase awareness in the area of undiagnosed cases of ASD without intellectual impairment in adult mental health settings and (b) highlights the importance of identifying this population more efficiently by referring to best practice guidelines. The value of future research to examine the benefit of having a team of specialist staff within adult mental health teams who have received ASD training and who are supported to work with the 'core difficulties' of ASD is discussed and a model for the same is proposed. It is proposed that a specialist team could form a 'hub' for the development of expertise in ASD, which when adequately resourced and funded could reach across an entire region, offering consultancy and diagnostic assessments and interventions.

Associations between holotranscobalamin, vitamin B12, homocysteine and depressive symptoms in community-dwelling elders.

BACKGROUND: Vitamin B12 and homocysteine have been shown to be associated with depression or depressive symptoms, but the relationship has not been universal. Both vitamin B12 and homocysteine may exert an effect via vascular mechanisms; it is possible that other mechanisms apply. Holotranscobalamin is a novel, more accurate measure of tissue vitamin B12. OBJECTIVES: To examine associations between vitamin B12, serum folate, holotranscobalamin, homocysteine and depressive symptoms in a sample of healthy elderly. METHODS: Cross-sectional, observational community based study. RESULTS: Lower levels of holotranscobalamin and vitamin B12 were associated with higher levels of depressive symptoms when controlled for Mini-mental state examination scores and psychosocial and cardiovascular risk factors. Homocysteine was not associated with depressive symptoms when biological and psychosocial covariates were included. CONCLUSIONS: It is possible that low levels of vitamin B12 or holotranscobalamin are associated with depressive symptoms via mechanisms other than vascular pathology.

Chlorine dioxide inactivation of bacterial threat agents.

AIMS: To evaluate the efficacy of chlorine dioxide (ClO(2)) against seven species of bacterial threat (BT) agents in water. METHODS AND RESULTS: Two strains of Bacillus anthracis spores, Yersinia pestis, Francisella tularensis, Burkholderia pseudomallei, Burkholderia mallei and Brucella species were each inoculated into a ClO(2) solution with an initial concentration of 2.0 (spores only) and 0.25 mg l(-1) (all other bacteria) at pH 7 or 8, 5 or 25°C. At 0.25 mg l(-1) in potable water, six species were inactivated by at least three orders of magnitude within 10 min. Bacillus anthracis spores required up to 7 h at 5°C for the same inactivation with 2.0 mg l(-1) ClO(2). CONCLUSIONS: Typical ClO(2) doses used in water treatment facilities would be effective against all bacteria tested except B. anthracis spores that would require up to 7 h with the largest allowable dose of 2 mg l(-1) ClO(2). Other water treatment processes may be required in addition to ClO(2) disinfection for effective spore removal or inactivation. SIGNIFICANCE AND IMPACT OF STUDY: The data obtained from this study provide valuable information for water treatment facilities and public health officials in the event that a potable water supply is contaminated with these BT agents.

Chlorine disinfection of Francisella tularensis.

AIMS: To determine the range of free available chlorine (FAC) required for disinfection of the live vaccine strain (LVS) and wild-type strains of Francisella tularensis. METHODS AND RESULTS: Seven strains of planktonic F. tularensis were exposed to 0·5 mg·l(-1) FAC for two pH values, 7 and 8, at 5 and 25°C. LVS was inactivated 2 to 4 times more quickly than any of the wild-type F. tularensis strains at pH 8 and 5°C. CONCLUSIONS: Free available chlorine residual concentrations routinely maintained in drinking water distribution systems would require up to two hours to reduce all F. tularensis strains by 4 log10. LVS was inactivated most quickly of the tested strains. SIGNIFICANCE AND IMPACT OF THE STUDY: This work provides contact time (CT) values that are useful for drinking water risk assessment and also suggests that LVS may not be a good surrogate in disinfection studies.

The changing incidence of childhood-onset type 1 diabetes in Wales: Effect of gender and season at diagnosis and birth.

AIMS: Determinants of the changing incidence of childhood-onset type 1 diabetes remain uncertain. We determined the recent time-trend of type 1 diabetes incidence in Wales and explored the role of vitamin D by evaluating the influence of season both at diagnosis and at birth. METHODS: Data from all Welsh paediatric units 1990-2019, and from primary care to determine ascertainment. RESULTS: Log-linear modelling indicated a non-linear secular trend in incidence with peak and subsequent decline. The peak occurred around June 2010: 31∙3 cases/year/100,000 children aged < 15y. It occurred earlier in children younger at diagnosis and earlier in boys. There were more cases in males aged <2y and >12y but more in females aged 9-10 y. More were diagnosed in winter. Also, children born in winter had less risk of future diabetes. CONCLUSIONS: The risk of developing type 1 diabetes before age 15y in Wales is no longer increasing. The data on season are consistent with a preventative role for vitamin D both during pregnancy and later childhood. Metereological Office data shows increasing hours of sunlight since 1980 likely to increase vitamin D levels with less diabetes. Additional dietary supplementation with vitamin D might further reduce the incidence of type 1 diabetes.

UV light inactivation of bacterial biothreat agents.

Seven species of bacterial biothreat agents were tested for susceptibility to UV light (254 nm). All gram-negative organisms tested required <12 mJ/cm(2) for a 4-log(10) reduction in viability (inactivation). Tailing off of the B. anthracis spore inactivation curves began close to the 2-log(10) inactivation point, with a fluence of approximately 40 mJ/cm(2), and 3-log(10) inactivation still was not achieved with a fluence of 120 mJ/cm(2).

Occupational therapy for patients with Parkinson's disease.

BACKGROUND: Despite drug and surgical therapies for Parkinson's disease, patients develop progressive disability. It has both motor and non-motor symptomatology, and their interaction with their environment can be very complex. The role of the occupational therapist is to support the patient and help them maintain their usual level of self-care, work and leisure activities for as long as possible. When it is no longer possible to maintain their usual activities, occupational therapists support individuals in changing and adapting their relationship with their physical and social environment to develop new valued activities and roles. OBJECTIVES: To compare the efficacy and effectiveness of occupational therapy with placebo or no interventions (control group) in patients with Parkinson's disease. SEARCH STRATEGY: Relevant trials were identified by electronic searches of MEDLINE (1966-April 2007), EMBASE (1974-2000), CINAHL (1982-April 2007), Psycinfo (1806-April 2007), Ovid OLDMEDLINE (1950-1965), ISI Web of Knowledge (1981-April 2007), National Library for Health (NLH) (April 2007), Nursing, Midwifery and Allied Health (NMAP) (April 2007), Intute: Medicine (December 2005), Proquest Nursing Journals (PNJ, 1986 - April 2007); rehabilitation databases: AMED (1985-April 2007), MANTIS (1880-2000), REHABDATA (1956-2000), REHADAT (2000), GEROLIT (1979-2000); English language databases of foreign language research and third world publications: Pascal (1984-2000), LILACS (1982- April 2007), MedCarib (17th Century-April 2007), JICST-EPlus (1985-2000), AIM (1993-April 2007), IMEMR (1984-April 2007), grey literature databases: SIGLE (1980-2000), ISI-ISTP (1982-April 2007), DISSABS (1999-2000), Conference Papers Index (CPI, 1982-2000) and Aslib Index to Theses (AIT, 1716- April 2006), The Cochrane Controlled Trials Register (Issue 2, 2007), the CenterWatch Clinical Trials listing service (April 2007), the metaRegister of Controlled Trials (mRCT, April 2007), Current controlled trials (CCT) (April 2007), ClinicalTrials.gov (April 2007), CRISP (1972-April 2007), PEDro (April 2007), NIDRR (April 2007) and NRR (April 2007) and the reference lists of identified studies and other reviews were examined. SELECTION CRITERIA: Only randomised controlled trials (RCT) were included, however those trials that allowed quasi-random methods of allocation were allowed. DATA COLLECTION AND ANALYSIS: Data was abstracted independently by two authors and differences were settled by discussion. MAIN RESULTS: Two trials were identified with 84 patients in total. Although both trials reported a positive effect from occupational therapy, all of the improvements were small. The trials did not have adequate placebo treatments, used small numbers of patients and the method of randomisation and concealment of allocation was not specified in one trial. These methodological problems could potentially lead to bias from a number of sources reducing the strength of the studies further. AUTHORS' CONCLUSIONS: Considering the significant methodological flaws in the studies, the small number of patients examined, and the possibility of publication bias, there is insufficient evidence to support or refute the efficacy of occupational therapy in Parkinson's disease. There is now a consensus as to UK current and best practice in occupational therapy when treating people with Parkinson's disease. We now require large well designed placebo-controlled RCTs to demonstrate occupational therapy's effectiveness in Parkinson's disease. Outcome measures with particular relevance to patients, carers, occupational therapists and physicians should be chosen and the patients monitored for at least six months to determine the duration of benefit. The trials should be reported using CONSORT guidelines.

The burning of Bridget Cleary: psychiatric aspects of a tragic tale.

BACKGROUND: Bridget Cleary was brutally burned to death by her husband in the presence of her father and several close relatives in rural Ireland in 1895. The story has attracted public attention for more than a century now, for numerous reasons. AIMS: The issue of psychiatric illness in this tragedy, and the role of fairy mythology in belief systems in 19th Century rural Ireland are reviewed, particularly in relation to providing explanations for physical and psychiatric illness, along with learning disability. METHODS: Reference was made to a wide range of sources featuring the burning of Bridget Cleary. RESULTS: There is some evidence to suggest that the actions of Michael Cleary and other key protagonists were influenced by Capgras syndrome and folie a plusiers. CONCLUSIONS: Delusional belief in fairy mythology may have coloured the psychological make-up, motivations and behaviour of some of the people involved in the killing of Bridget Cleary.

Recent alcohol intake and suicidality--a neuropsychological perspective.

BACKGROUND: Alcohol use disorders and suicidal behaviours are among the most prevalent and damaging of all psychiatric phenomena in Ireland and worldwide. Furthermore, alcohol use both chronic and acute has long been identified as a potent riskfactor for suicidal behaviour. AIMS: In this paper, the authors review the observational and experimental evidence for the acute neuropsychological effects of alcohol intake on suicidal ideation and behaviour. METHODS: A selective review of the literature was conducted, using the PubMed database. Search terms employed included 'alcohol', 'suicide', 'binge' and 'acute alcohol intake'. RESULTS: Cognitive mechanisms implicated include alcohol-induced deficits in attention-allocation, prospective cognition, autobiographical memory and disinhibition. Emotional mechanisms include alcohol-induced dysphoria, depression and aggression. CONCLUSIONS: This paper serves to highlight the importance of identifying and tackling acute alcohol intake and binge drinking as a risk factor for suicidal behaviour.

Is incontinence associated with menopause?

OBJECTIVES: To estimate (1) the prevalence of urinary incontinence in a population-based sample of Australian women aged 45-55 and to identify the factors associated with urinary incontinence; (2) the incidence of urinary incontinence over a 7-year follow-up period and to identify whether the transition from pre- to postmenopause is associated with the development of urinary incontinence. METHODS: This was a cross-sectional study of 1897 women and a 7-year longitudinal follow-up of 373 of these women who were premenopausal at baseline. Annual interviews and physical measurements were taken in their homes. RESULTS: Cross-sectional: the prevalence of urinary incontinence was 15%; multivariate analysis found that urinary incontinence patients were significantly more likely than those without incontinence to have higher body mass index (odds ratio [OR] 1.50, 95% confidence interval [CI] 1.15, 1.95), have had gynecologic surgery (OR 2.17, 95% CI 1.42, 3.32), report urinary tract infections (OR 4.75, 95% CI 2.28, 9.90), diarrhea or constipation (OR 1.95, 95% CI 1.27, 3.00), and have had three or more children (OR 1.47, 95% CI 1.06, 2.05). Longitudinal: during the 7-year follow-up, the average prevalence of urinary incontinence was 18% and the overall incidence 35%. Women who experienced a hysterectomy during the follow-up period had a higher incidence. CONCLUSION: Urinary incontinence in middle-aged women is more closely associated with mechanical factors than with menopausal transition.

Surgical treatment of intrinsic urethral dysfunction. Slings.

Slings are a durable and effective treatment for intrinsic sphincter deficiency, regardless of its etiology. The history of slings throughout the 20th century, and the current surgical technique, is described in this article. A comparison of slings with alternative treatments of intrinsic sphincter deficiency, such as artificial sphincters and collagen is presented. Slings play a significant role in the treatment of stress incontinence.

Leak-point pressures.

The pressure based management of patients with neurogenic vesical dysfunction has led to greatly improved outcomes with respect to upper and lower urinary tract complications. At the heart of this management is detrusor leak-point pressure testing that verifies that a low intravesical pressure is achieved and subsequently maintained. The abdominal (or Valsalva) leak-point pressure that quantifies the degree and type of urethral sphincter dysfunction, is an essential test in selecting the appropriate treatment for stress urinary incontinence. The authors discuss the history, importance, and application of these two very different tests.

Videourodynamic studies.

Videourodynamic evaluation that incorporates radiographic imaging with simultaneous measurement of bladder and urethral pressure is the most precise method available for diagnosing complex incontinence and voiding disorders. In addition, videourodynamics has been instrumental to the development of our present knowledge about urethral and bladder function including the concepts of detrusor and abdominal leak point pressures. Although these studies are more expensive and time consuming, the authors have found videourodynamic evaluation indispensable when the diagnosis remains in question after simple urodynamics and when the studies and clinical scenario do not agree.

Transurethral Needle Ablation of the prostate (TUNA): clinical results and ultrasound, endoscopic, and histologic findings in pilot study of patients in urinary retention.

Transurethral Needle Ablation of the prostate (TUNA) is a new thermal ablation treatment for benign prostatic hyperplasia (BPH) utilizing radiofrequency electric current delivered by needles into the depth of the prostate to produce an area of coagulative necrosis. A pilot study of 10 patients in urinary retention was undertaken to assess the procedure. After treatment, nine patients voided at a median time of 3 days, although a further two required transurethral resection because of chronic infection in one and chronic urinary retention in the other. At 3 months' follow-up, the mean Qmax was 13.0 mL/sec, the mean AUA Symptom Score was 9.1, and the mean quality of life score was 1.6. The mean Pdet fell from 73.3 to 39.0 cm H2O. On transrectal ultrasound at 3 months, cystic lesions were seen in two patients, with a third having large cavities. A 10.2% reduction in mean prostatic volume, from 48.8 cc to 43.8 cc, was noted but considered to be not significant. On endoscopy at 3 months, mucosal retraction was seen in seven patients, with cavities in two patients. Histologic study in patients undergoing transurethral resection 4 to 6 months after TUNA showed necrosis and fibrosis. It is considered that an area of coagulative necrosis is produced by TUNA that resolves either by scar formation with retraction or by liquefaction with cyst formation. If the lesion communicates with the urethra, a cavity may form, which is undesirable. Our early experience is encouraging. The TUNA treatment is effective, can be given without anesthesia, and should be either a day case or an office procedure. It should prove to have a significant place in the treatment of BPH.

Common urological problems in women.

BACKGROUND: Significant advances in the management of some common urinary problems have occurred in recent years. Problems that are likely to present to the general practitioner include urinary incontinence, voiding dysfunction, recurrent bacterial cystitis and interstitial cystitis. OBJECTIVE: The aim of this article is to highlight the advances that have occurred in the management of these common problems and their management strategy in the primary care setting. DISCUSSION: The management of incontinence, particularly stress urinary incontinence includes an accurate diagnosis and treatment tailored to the condition identified. Urinary incontinence due to the overactive and/or underactive bladder is more difficult to cure but significant improvement can be achieved in the majority of people. While severe incontinence requires an accurate diagnosis, non-operative strategies without a urodynamic diagnosis can be used in the treatment of milder forms. It is important to obtain an accurate diagnosis when the patient is not improving with conservative strategies. The problem of recurrent bacterial infections is common in women of all ages but cure should be possible in the majority of affected women. While the enigmatic entity of interstitial cystitis is increasingly recognised in out patients the exact basis for this condition remains obscure. Symptomatic improvement is achievable to a variable degree in most patients.

Delirium: a key challenge for perioperative care.

Delirium is highly prevalent, occurring in 20% of acute hospital inpatients and up to 62% of surgical patients. It is a significant predictor of poor outcomes including mortality and institutionalisation, however it is often viewed as simply a marker of underlying illness and is frequently overlooked in older adults. Although delirium is commonly comorbid with dementia, it represents a more urgent diagnosis, requiring prompt intervention. Delirium presents most commonly with hypoactive features (e.g. withdrawal and reduced spontaneous movement and speech). The common stereotype of hyperactive delirium tremens (e.g. agitation, hallucinations), although more visible, is less common. All presentations share acute disimprovement of cognitive function. Delirium is a highly predictable and preventable occurrence, however a major barrier to improving delirium care and impacting upon outcomes is that it remains poorly detected, particularly in surgical populations and especially in patients with hypoactive presentations. Routine ward-based screening for delirium, particularly in high-risk populations, and improved staff awareness of the significance of the problem can improve detection rates. Preventative strategies, particularly multicomponent approaches, have been most efficacious in improving patient outcomes. Optimising perioperative risk factors can lead to reduced incidence. Appropriate treatment of delirium requires thorough investigation, management of the underlying illness, avoidance of complications and simplification of the care environment. Studies suggest a role for pharmacological prophylaxis, particularly in relation to anaesthetic and sedative agents used intra- and post-operatively. Furthermore, gathering evidence suggests that judicious use of antipsychotic medications may be helpful in delirium prevention and treatment.