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To assess how well MHAS meets the service specification
To ascertain areas of good practice
To examine whether the referral form is being used in an appropriate manner
To elucidate areas of good communication and whether any improvement can be made
Launched in 2012, MHAS is the single point of access service for mental health services for patients aged 16–65 years, with a general practitioner (GP) in Dudley, who are not currently open to secondary care. Assessments are completed by a medic, community psychiatric nurse or jointly. It aims to identify the most appropriate care pathway for patients. This audit was a comprehensive assessment of how effective MHAS is at ensuring patients are adequately triaged.
10 cases from each month between April 2018 and March 2019 were randomly selected from all 980 anonymised MHAS referrals. A proforma was developed based on current practice, previous audits and service specification. A team of four doctors assisted in the data collection and only electronic health records (EHR) were reviewed.
88.3% of referrals were recorded on the EHR. Only 61.7% of referrals used the proforma with the other referrals mostly being in the form of a letter, which often missed out information vital to the triaging process. Only 4.2% of referrals are from Primary Care Mental Health Nurses (PCMHN) with 85.8% arising from GPs. Urgent referrals were not discussed with MHAS via telephone contact in about 60% of cases. The majority of patients had telephone screening completed the same day and were then discussed the next working day at the daily referral meeting. Although a brief summary for the GP was being sent the same day in all cases, over half of the comprehensive assessments were not being sent within the five day timeframe.
All referrals must be uploaded to the EHR and completed using the service's proforma. PCMHNs may be currently under-utilised or effectively doing their jobs at managing mental health patients in primary care. GPs regularly referring via letter require further training and support to use the proforma. The proforma may require simplification to make it easier to complete. The service specification requires review as it makes unrealistic demands of the service. All referrals must be discussed at the daily referral meeting. Further investigation is required to understand why MHAS is struggling to meet timeframes for appointments and letters.
To assess intubation management in difficult airway patients by performing a multidisciplinary pre-operative examination of the airway using a flexible fibre-optic laryngoscope.
Patients with a known but stable difficult airway were evaluated prior to surgery in the pre-operative holding suite by both an ENT surgeon and an anaesthesiologist via a fibre-optic laryngeal examination.
Performing a pre-operative fibre-optic examination of the difficult airway led to a change in intubation strategy in 6 out of 12 cases. Intubation ‘first-pass’ success occurred in 9 out of 12 (75 per cent) of our patients.
By performing a multidisciplinary airway examination immediately prior to surgery, a safe plan to intubate on the initial attempt was developed. This resulted in improved first-pass success at intubation compared to historical data.
Depression is a highly prevalent disease and its costs can be burdensome to both patients and payers.
To compare the short-term costs, outcomes, and cost-effectiveness associated with major depressive disorder (MDD) treatment with venlafaxine XR and major market comparators (duloxetine and two selective serotonin reuptake inhibitors [SSRIs], namely escitalopram and sertraline HCL) in Italy from the Italian National Health Service perspective.
To inform treatment decisions based on cost effectiveness of MDD treatments.
A decision tree structure was used to model MDD treatment over 1 year. Patients were treated with one of the model comparators and based on published clinical literature; either remained depressed, achieved response but no remission, or achieved remission. Drug costs were set to the reimbursed price for the recommended dose of each treatment. Costs of hospitalization and utility weights were based on depression status.
Venlafaxine XR was estimated to be the most effective treatment (0.736 quality-adjusted life years [QALYs]) followed by the SSRIs (0.731) and duloxetine (0.714). Total annual MDD-related costs for venlafaxine (€691) were estimated to be lower than all comparators (duloxetine=€1,308, escitalopram=€874) except sertraline HCL (€638), owing largely to drug cost differences and hospitalization savings associated with better projected depression status. Venlafaxine was cost-saving (more effective, less costly) compared with duloxetine and escitalopram. The incremental cost per QALY gained vs. sertraline HCL was €9,844.
Based on the model, venlafaxine XR represents a cost-effective treatment option for MDD in Italy and may result in costsavings depending on the comparison.
To evaluate a small cohort of patients who presented with symptoms and signs consistent with acute infective sensorineural hearing loss who were treated with intratympanic steroids.
Seven patients received a 7-day course of oral antibiotics and oral prednisolone followed by 3 intratympanic injections of methylprednisolone and 1 week of topical dexamethasone drops.
Hearing improved in 57 per cent of patients (four out of seven). The mean improvement in this group was 24 dB (range, 10–52 dB). The magnitude of the sensorineural hearing loss at presentation was less in those who responded to intratympanic steroid therapy than in non-responders (mean pure tone average of 30 dB versus 65 dB pre-intratympanic steroids, and 14 dB versus 83 dB post-intratympanic steroids, respectively).
The results of our study suggest that intratympanic steroids provide a valuable contribution to the treatment of acute infective sensorineural hearing loss and may provide additional benefit by virtue of a concentrated local steroid effect in patients who do not respond to antibiotics.
Samter's triad is a well described condition manifesting as chronic rhinosinusitis with nasal polyposis, asthma and aspirin intolerance in a non-atopic individual. The underlying mechanism is still to be fully elucidated. However, aural disease has not been widely reported in these patients. In the few reported cases, most patients underwent major surgery with varying degrees of success.
We report two Samter's triad patients with aural involvement. Both were successfully managed by conservative treatment, thus avoiding the need for major surgery. It appears that more Samter's triad patients may have aural disease than previously thought.
We report good outcomes with conservative treatment, which is relevant because aural disease tends to reoccur in these patients.
We compared heart rate-corrected QT interval (QTc) and its within- and between-subject variability, in ECGs recorded several days apart for 207 patients with schizophrenia (age range 19–60 yr) with age- and gender-matched healthy controls. Patients had higher heart rates (mean±s.d.) than controls [75±15 beats per minute (bpm) vs. 63±10 bpm; p<0.0001]. QTc by Bazett's formula (QTcB) overestimated QTc interval at high heart rates; consequently QTcB was longer in patients (412±24 ms) than in controls (404±24 ms; p=0.0003). QTc by Fridericia's method (QTcF), which was not influenced by heart rate, was comparable (398±22 ms in patients vs. 401±19 ms in controls; p=0.17). Between-subject variability in QTcF was similar in patients (17 ms) and controls (16.2 ms) but within-subject variability was larger (13.1 ms vs. 10 ms, respectively). Thus, a larger sample size is required when thorough QTc studies with a cross-over design are performed in patients with schizophrenia than in healthy subjects; sample size is not increased for studies with a parallel design. Last, QTcF is preferred over QTcB in schizophrenia patients with higher heart rates.
The opening of the Indian Constitution proudly proclaims its resolve to constitute India into a “secular democratic republic” and to secure to all its citizens “liberty of thought, expression, belief, faith and worship” and “equality of status and of opportunity.” Though the country’s constitutional vision may be clear, the appropriateness of such a vision for a society as deeply religious and socially stratified as India is continuously subject to social and political challenge.
The task of securing religious liberty while upholding secular aspirations in a deeply religious society is a daunting one. Hinduism, the professed religion of over 80 percent of Indians, is often described as a “way of life,” highlighting the “profound tension that penetrates to the core of Indian constitutionalism, where ‘the State is secular . . . but the people are not’” (Jacobsohn 2003: 35–6). On one side of what is often a very polemical debate are those who advocate for equal treatment of religious groups in India, where the language of equal treatment may disguise a quest for assimilation through subordination. On the other side of the debate are those who argue that neutrality toward religion is a prescription for majoritarian rule, adding that minorities must be protected against the dominance of the majority Hindu culture.
In this work, TOPO(tri-octyl phosphine oxide)/TOP(tri-octyl phosphine)-capped cadmium selenide (CdSe) quantum dots (QD's) of varied sizes (5–9 nm) prepared at different input Cd:Se precursor ratio's (1:1–2:1) using chemical route were dispersed in conducting polymer matrices viz poly[2-methoxy,5-(2-ethyl-hexyloxy)-1,4-phenylene vinylene] (MEH-PPV) and poly(3-hexylthiophene) (P3HT) respectively. The properties of polymer:CdSe nanocomposites are evaluated by means of photoluminescence (PL), UV-VIS absorption, Raman, Fourier transform infrared (FTIR), transmission electron microscopy (TEM) and atomic force microscopy (AFM) techniques respectively. The emission and structural properties of polymer-CdSe nanocomposites are found to be dependent on their morphology. The better quality of smallest sized CdSe QD's (size ~5 nm) in conjunction with regioregular P3HT polymer, leads to higher photostability of P3HT:CdSe QD's nanocomposites as compared to that for corresponding MEH-PPV:CdSe nanocomposites, thus making it as an attractive candidate for hybrid solar cells application.
Ag on γ-alumina is a promising catalyst for hydrocarbon selective catalytic reduction in lean-burn gasoline and diesel engines for transportation applications. Although much is known about the mechanism of NOx reduction and the various intermediates, little agreement exists on the nature of the active silver species. In the present work, aberration-corrected STEM has provided new information about the nature of Ag on alumina both as impregnated and following treatments at various temperatures with exposure to simulated exhaust gas. Ex situ techniques have provided new insights into the evolution of Ag on alumina following exposure to temperature and simulated exhaust gas.