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Violence and aggression among patients suffering from mental health problems undoubtedly pose a challenge to healthcare professionals, families and carers. Aggressive behaviours affect all aspects of clinical care. The goal of professionals is to ensure safety while effectively managing behavioural emergencies. ‘Rapid tranquillisation’ implies prescribing pharmacological agents to manage these behaviours. This article highlights changing prescription trends. Appraisal of global guidelines suggests that factors other than scientific evidence dictate their evolution. High-quality randomised controlled trials are needed to develop a global guideline.
The number of beds in care homes (with and without nurses) in the United Kingdom is three times greater than the number of beds in National Health Service (NHS) hospitals. Care homes are predominantly owned by a range of commercial, not-for-profit or charitable providers and their residents have high levels of disability, frailty and co-morbidity. NHS support for care home residents is very variable, and it is unclear what models of clinical support work and are cost-effective.
To critically evaluate how the NHS works with care homes.
A review of surveys of NHS services provided to care homes that had been completed since 2008. It included published national surveys, local surveys commissioned by Primary Care organisations, studies from charities and academic centres, grey literature identified across the nine government regions, and information from care home, primary care and other research networks. Data extraction captured forms of NHS service provision for care homes in England in terms of frequency, location, focus and purpose.
Five surveys focused primarily on general practitioner services, and 10 on specialist services to care home. Working relationships between the NHS and care homes lack structure and purpose and have generally evolved locally. There are wide variations in provision of both generalist and specialist healthcare services to care homes. Larger care home chains may take a systematic approach to both organising access to NHS generalist and specialist services, and to supplementing gaps with in-house provision. Access to dental care for care home residents appears to be particularly deficient.
Historical differences in innovation and provision of NHS services, the complexities of collaborating across different sectors (private and public, health and social care, general and mental health), and variable levels of organisation of care homes, all lead to persistent and embedded inequity in the distribution of NHS resources to this population. Clinical commissioners seeking to improve the quality of care of care home residents need to consider how best to provide fair access to health care for older people living in a care home, and to establish a specification for service delivery to this vulnerable population.
The evidence base for rapid tranquillisation is small in higher-income countries but is even smaller in sub-Saharan Africa. We initiated the first ever survey on the use of rapid tranquillisation in Zambia in 2009; a further survey was then done in 2010, after a programme of teaching and training. It demonstrated an overall improvement in clinical practice, safety, awareness and use of medications within therapeutic doses. It also led to a reduction in inappropriate use of medications. These improvements in practice occurred within a short time span and with minimal effort. Further international collaborative partnerships are required to build stronger mental health infrastructure in Zambia.
Radiological terrorism has been recognized as a probable scenario with high impact. Radiological preparedness planning at the federal and state levels has been encouraging, but translating complex doctrines into operational readiness at the local level has proved challenging. Based on the authors' experience with radiological response planning for the City of Baltimore, this article describes an integrated approach to municipal-level radiological emergency preparedness planning, provides information on resources that are useful for radiological preparedness planning, and recommends a step-by-step process toward developing the plan with relevant examples from the experience in Baltimore. Local governmental agencies constitute the first line of response and are critical to the success of the operation. This article is intended as a starting framework for local governmental efforts toward developing a response plan for radiological incidents in their communities.
(Disaster Med Public Health Preparedness. 2011;5:S151-S158)
Clinical studies of antipsychotic medication are a primary source of data on the nature of, and relative liability for, adverse effects, relevant to prescribing decisions in clinical practice.
To identify how safety and tolerability data were collected and reported in recent clinical studies of antipsychotics.
A survey was conducted of all 167 eligible studies published between 2002 and 2007 on the Cochrane Schizophrenia Group register.
Extrapyramidal side-effects (EPS) and weight gain were most frequently assessed. A minority of reports addressed metabolic abnormalities, aversive subjective experiences and sexual dysfunction. Published rating scales were frequently used to evaluate EPS, but systematic methods were rarely applied to other treatment-emergent problems. The definition of individual adverse effects and the manner of reporting were inconsistent.
The way in which safety and tolerability data are collected and reported in clinical studies does not allow for fair and meaningful comparison of the relative risk profiles of individual antipsychotic drugs.
Environmental perturbations during early mammalian development can affect aspects of offspring growth and cardiovascular health. We have demonstrated previously that maternal gestational dietary protein restriction in mice significantly elevated adult offspring systolic blood pressure. Therefore, the present study investigates the key mechanisms of blood pressure regulation in these mice. Following mating, female MF-1 mice were assigned to either a normal-protein diet (NPD; 18 % casein) or an isocaloric low-protein diet throughout gestation (LPD; 9 % casein), or fed the LPD exclusively during the pre-implantation period (3·5 d) before returning to the NPD for the remainder of gestation (Emb-LPD). All offspring received standard chow. At 22 weeks, isolated mesenteric arteries from LPD and Emb-LPD males displayed significantly attenuated vasodilatation to isoprenaline (P = 0·04 and P = 0·025, respectively), when compared with NPD arteries. At 28 weeks, stereological analysis of glomerular number in female left kidneys revealed no significant difference between the groups. Real-time RT-PCR analysis of type 1a angiotensin II receptor, Na+/K+ ATPase transporter subunits and glucocorticoid receptor expression in male and female left kidneys revealed no significant differences between the groups. LPD females displayed elevated serum angiotensin-converting enzyme (ACE) activity (P = 0·044), whilst Emb-LPD males had elevated lung ACE activity (P = 0·001), when compared with NPD offspring. These data demonstrate that elevated offspring systolic blood pressure following maternal gestational protein undernutrition is associated with impaired arterial vasodilatation in male offspring, elevated serum and lung ACE activity in female and male offspring, respectively, but kidney glomerular number in females and kidney gene expression in male and female offspring appear unaffected.
To estimate the proportion of attrition at which results of drug trials for people with schizophrenia lose enough credibility to become mistrusted by relevant groups of stakeholders. A piloted questionnaire was sent to 128 local clinicians, 100 relevant researchers and 104 service users and carers.
We received the biggest number of responses from the service user and carer group (n=81, 76%); 43% of clinicians and 32% of researchers responded. All three groups suggested that the follow-up rate for a 12-week schizophrenia drug trial should be around 70–75% for the trial to be credible.
This survey suggests that relevant stakeholders, including researchers, fundamentally mistrust results of the majority of drug trials in schizophrenia. Adopting a more pragmatic trial design can help address this.
No treatment has caused a greater revolution in the treatment of people with schizophrenia than chlorpromazine. The new generation of drugs has been embraced by psychiatry with an enthusiasm fostered by the unmet needs of both patients and industry. Recent, independently funded trials have highlighted already existing data illustrating how the new antipsychotics drugs are an additional advance but not a revolution. In this story there are lessons for psychiatry to opt for science rather than seduction.
Chinese herbal medicine has been used to treat millions of people with schizophrenia for thousands of years.
To evaluate Chinese herbal medicine as a treatment for schizophrenia.
A systematic review of randomised controlled trials (RCTs).
Seven trials were included. Most studies evaluated Chinese herbal medicine in combination with Western antipsychotic drugs; in these trials results tended to favour combination treatment compared with antipsychotic alone (Clinical Global Impression ‘not improved/worse’ n= 123, RR=0.19, 95% CI 0.1-0.6, NNT=6,95% CI 5–11; n=109, Brief Psychiatric Rating Scale ‘not improved/worse’ RR=0.78,95% CI 0.5-1.2; n=109, Scale for the Assessment of Negative Symptoms ‘not improved/worse’ RR=0.87,95% CI 0.7-1.2; n= 109, Scale for the Assessment of Positive Symptoms ‘not improved/worse’ RR=0.69,95% CI 0.5-1.0, NNT=6 95% CI 4-162). Medium-term study attrition was significantly less for people allocated the herbal/antipsychotic mix (n=897, four RCTs, RR=0.34,95% CI 0.2–0.7, NNT=23,95% CI 18-43).
Results suggest that combining Chinese herbal medicine with antipsychotics is beneficial.
Most people with schizophrenia live in low- and middle-income countries in
which clinicians/policy makers are not the first targets of marketing.
Because it is years after a drug is first launched that the full effects
become known with confidence, the evidence upon which to base practice in
low- and middle-income countries may be less biased than that in richer
Historically, few randomized controlled trials (RCTs) have been conducted in primary care and problems have been experienced applying this methodology in these settings. In 2001, The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) was developed. This RCT aimed to compare two detoxification drugs to inform best practice for the treatment of opiate users presenting to primary care requesting detoxification. This paper presents descriptive data from a postal survey of 12 general practitioners (GPs) from 10 primary care practices who were involved in the LEEDS trial. The questionnaire was sent out in November 2004, used open and closed questions and was self-administered. It uncovered factors that affected patient recruitment, GPs' views on the trial and their experience of randomizing opiate using patients. Flexible solutions to overcoming recruitment difficulties are presented alongside idealistic solutions to the problems experienced. The implications of our experiences of conducting this RCT in primary care practices are discussed in the light of conducting RCTs in primary care settings. This will benefit other research teams and clinicians who may be planning to use a similar research methodology.
Randomised trials remain the gold standard for evaluating health interventions. This applies to the criminal justice system as well as to health.
To identify and survey randomised trials relevant to forensic mental health services.
We searched 29 electronic bibliographic databases and acquired randomised trials involving sex offenders, arsonists or people clearly and actively aggressive, or abusive of children or spouse. Two researchers reliably extracted data.
Of 409 studies found, we were able to acquire 300 for further inspection. They all involved particularly violent people (total n=28 669), mostly adult men; the mean study size was 197 (median 52, mode 60, range 1–1200). In these 300 randomised trials over 700 interventions were evaluated and short-term outcomes were recorded on 345 different scales.
Wider collaboration, rationalising treatments and simplifying outcomes could further strengthen the tradition of trialling in forensic psychiatry. Systematic reviews of these studies are overdue.
The pharmacological management of violence in people with psychiatric disorders is under-researched.
To compare interventions commonly used for controlling agitation or violence in people with serious psychiatric disorders.
We randomised 200 people to receive intramuscular lorazepam (4 mg) or intramuscular haloperidol (10 mg) plus promethazine (25–50 mg mix).
At blinded assessments 4 h later (99.5% follow-up), equal numbers in both groups (96%) were tranquil or asleep. However, 76% given the haloperidol-promethazine mix were asleep compared with 45% of those allocated lorazepam (RR=2.29, 95% CI 1.59–3.39; NNT=3.2, 95% CI 2.3–5.4). The haloperidol-promethazine mix produced a faster onset of tranquillisation/sedation and more clinical improvement over the first 2 h. Neither intervention differed significantly in the need for additional intervention or physical restraints, numbers absconding, or adverse effects.
Both interventions are effective for controlling violent/agitated behaviour. If speed of sedation is required, the haloperidol-promethazine combination has advantages over lorazepam.