Gatekeeping access to community mental health teams: a qualitative study

BACKGROUND

Gatekeeping access to services at the interface with primary care has been identified as one of the key issues that community mental health teams (CMHTs) have to confront.

OBJECTIVES

The aim of this study was to develop a better understanding of the contextual influences that impact upon the outcome of gatekeeping decisions.

DESIGN

An interview-based qualitative study, informed by the philosophy of critical realism.

SETTING

An urban catchment area in Northern England.

PARTICIPANTS

Twenty-nine interviews were conducted with gatekeeping clinicians and service managers.

METHOD

A convenience sample of clinicians was initially approached to take part in a series of semi-structured interviews. This was followed up by a purposive sample of clinicians and service managers, as specific contextual influences were identified and explored in detail. The emerging analysis was then subjected to critical scrutiny by a further sample of gatekeeping clinicians.

FINDINGS

A clear hierarchy of appropriateness was identified with four dimensions: severity, risk, beneficence and a moral dimension. It was suggested that the salient contextual influences that shaped the hierarchy were: (a) the need to fit in with strategic planning directives, (b) the burden of responsibility that clinicians carried, (c) the high number of referrals and the relatively slow turnover of patients on clinical caseloads, (d) the position of CMHTs in the economy of care and (e) the character of the relationship between clinicians and service managers.

CONCLUSION

The findings from the study support a multi-level view of the gatekeeping process within CMHTs, which takes account of the role that key contextual influences play in shaping the range of options that are available to gatekeeping clinicians.

Panitumumab antitumor activity in patients (pts) with metastatic colorectal cancer (mCRC) expressing low (1–9%) or negative (<1%) levels of epidermal growth factor receptor (EGFr)

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Background: Panitumumab is a fully human monoclonal antibody directed against EGFr. We investigated the antitumor activity of panitumumab in pts with mCRC who failed prior therapy and had low or negative EGFr tumor expression. Methods: In this multicenter, phase 2 study of 150 planned pts, pts had documentation of disease progression (PD) during or after adequate doses of fluoropyrimidine, irinotecan, and oxaliplatin (centrally confirmed refractory disease [CCRD]), 2–3 prior regimens, ECOG score 0–2, and low or negative EGFr staining (by IHC) in evaluable tumor cells. Pts received panitumumab at 6 mg/kg Q2W until PD or drug intolerability. Tumor assessments (modified WHO, blinded central review) were taken periodically from wk 8 until PD. Endpoints were objective response (OR) through wk 16 (+ ≥ 4 wk confirmation; primary) and OR throughout study, response duration, progression-free survival (PFS) time, survival time, and safety (secondary). Results: In this interim analysis (6/05), 88 pts were enrolled and had ≥ 1 dose of panitumumab (safety set); 23 pts had ≥ 20 wks before the cutoff and CCRD (efficacy set). The efficacy set consisted of 16M/7W, median age of 65 (range: 46, 85) yrs, 83% white, 100% with ECOG ≤ 1, 74% colon cancer and 26% rectal cancer; all received ≥ 2 prior regimens (equivalent characteristics for safety set). 2/11 (18%) pts with EGFr-negative tumors and 1/12 (8%) with low EGFr staining had a partial response. Duration was up to 16 wks. 7/23 (30%) of all pts had SD. Median (95% CI) PFS was 7.9 (7.0, 23.0) wks. In the safety set, all pts had a treatment-related adverse event; 19% grade (gr) 3; 2% gr 4. Integument and eye toxicities were: 92% skin, 17% eye, 28% nail, 8% hair, and 2% chelitis. 20 (23%) had diarrhea (1 gr 3); 7 (8%) had hypomagnesemia (2 gr 3/4). Three pts had an infusion reaction-1 gr 3 (led to panitumumab discontinuation) and 2 gr 1/2. In 65 pts with both a baseline and post-baseline sample, no human anti-human antibodies to panitumumab were detected. Updated data will be presented. Conclusions: Responses to panitumumab were seen in pts with mCRC with both low and negative EGFr levels. Efficacy appears similar to that in other studies with panitumumab in pts with higher EGFr tumor levels.

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A randomized trial of first-line irinotecan/fluoropymidine combinations with or without celecoxib in metastatic colorectal cancer (BICC-C)

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Background: This multicenter, randomized study assessed efficacy & safety for 3 irinotecan/fluoropyrimidines combinations in previously untreated mCRC. In a 3 × 2 factorial design, we also assessed whether celecoxib added to chemotherapy (CT) improved CT efficacy and/or reduced toxicity. Methods: Pts were randomized to: FOLFIRI - irinotecan (I) 180 mg/m2, leucovorin (LV) 400 mg/m2, 5-FU bolus 400 mg/m2, & infusional 5-FU 2400 mg/m2 over 46 hours q 2 wks; modified IFL (m-IFL) - I 125 mg/m2, LV 20 mg/m2, & bolus 5-FU 500 mg/m2 wkly × 2, q 3 wks; or CapeIri - I 250 mg/m2 day 1 & capecitabine 1000 mg/m2 po BID × 14 days, q 3 wks. Pts were also randomized to concurrent celecoxib (400 mg po BID) or placebo in a double-blind fashion. Time to progression (TTP) was the primary endpoint. Results: 430 pts were enrolled from 2/03 to 4/04, prior to an amendment that added bevacizumab to CT arms. Baseline characteristics were balanced. TTP for FOLFIRI (median = 8.2 mos) was significantly better than for either m-IFL (6.0 mos; p = 0.01) or CapeIri (5.7 mos; p = 0.01). Overall survival (OS) also favored FOLFIRI (median = 23.1 mos) compared to either m-IFL (17.6 mos; p=0.10) or CapeIri (18.8 mos; p = 0.19). Common grade ≥ 3 toxicities are listed below. CapeIri had the highest rates of nausea, vomiting, diarrhea, dehydration & hand-foot syndrome, whereas FOLFIRI had lower rates. Among all 430 pts, median TTP did not differ for pts randomized to celecoxib compared to placebo (6.9 vs 6.9 mos; p=0.71). Median OS was also similar for celecoxib vs placebo (19.5 vs 18.8 mos; p=0.63). CT toxicities did not differ for celecoxib vs placebo. Rates for MI/stroke were 1.5% for celecoxib and 1.9% for placebo. Conclusions: First-line FOLFIRI offers a superior TTP when compared to m-IFL or CapeIri; OS & toxicity analyses also favored FOLFIRI. Celecoxib neither improved CT efficacy nor reduced CT toxicity. Updated survival data & data on pts enrolled after the addition of bevacuzimab will be presented.

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Information integration from heterogeneous data sources: a Semantic Web approach

Although the decentralized and autonomous implementation of health information systems has made it possible to extend the reach of surveillance systems to a variety of contextually disparate domains, public health use of data from these systems is not primarily anticipated. The Semantic Web has been proposed to address both representational and semantic heterogeneity in distributed and collaborative environments. We introduce a semantic approach for the integration of health data using the Resource Definition Framework (RDF) and the Simple Knowledge Organization System (SKOS) developed by the Semantic Web community.

Specialist educational intervention for acute inpatient mental health nursing staff: service user views and effects on nursing quality

AIM

This paper reports a study to evaluate the impact of an innovative 18-day educational intervention for acute ward-based mental healthcare nursing staff on documented quality of nursing care and on service user views of that care.

BACKGROUND

There are grave concerns internationally about the quality of inpatient mental health care for people with acute psychiatric problems. It is claimed that specialist educational courses are needed to improve these services. However, whilst such courses may lead to positive learning outcomes for participants, the impact on the actual care of service users is unknown.

METHOD

An uncontrolled before-and-after evaluation of three acute mental health wards from different United Kingdom National Health Service trusts was carried out. Quality of nursing care was evaluated by extracting documentary evidence from service user records, assessed by two independent researchers according to predefined quality criteria. The views of a purposive sample of mental health service users, currently receiving services from the three designated wards, were ascertained by semi-structured interview.

RESULTS

Both documentary evidence and service user views revealed some important baseline deficiencies in the quality of care offered at the study sites. Following the educational intervention, statistically significant improvements were observed in the quality of care planning, initial assessments and the provision of therapeutic care. No statistically significant changes were observed in the quality of risk assessments, medication management or external agency involvement.

CONCLUSIONS

Education can have an impact on nursing care but may not be sufficient alone to change mental healthcare practices on acute inpatient wards in the radical manner demanded by policymakers and service user lobby groups. Educational interventions need to be implemented in conjunction with organizational changes that are specifically designed to maximize the opportunities presented by a newly skilled and positive workforce.

The clinical effectiveness of guided self-help versus waiting-list control in the management of anxiety and depression: a randomized controlled trial

BACKGROUND

There are significant barriers to accessing effective psychological therapy in primary care resulting from a lack of suitably trained therapists to meet current demand. More efficient service delivery using minimal interventions (such as bibliotherapy) provided by paraprofessional therapists may be one method of overcoming these problems, and is the subject of attention in the UK and elsewhere. A randomized trial was conducted to test the clinical effectiveness of this model. Assistant psychologists delivered a guided self-help intervention to patients with anxiety and depression who were currently waiting for psychological therapy.

METHOD

A total of 114 patients were randomized either to guided self-help or a waiting-list control group. All patients were followed up 3 months later, prior to starting conventional psychological therapy. Measures included self-reported adherence to the intervention, anxiety and depressive symptoms, social functioning and patient satisfaction.

RESULTS

Adherence to the guided self-help intervention was acceptable and patients reported satisfaction with the intervention. However, there were no statistically significant differences between groups in anxiety and depression symptoms at 3 months.

CONCLUSIONS

The results demonstrate that this model of guided self-help did not provide additional benefit to patients on a waiting list for psychological therapy. The results are considered in the context of possible internal and external validity threats, and compared with previous trials of minimal interventions. The implications of the results for the design of future minimal interventions are considered.

Functional plasticity of human respiratory tract dendritic cells: GM-CSF enhances T(H)2 development

BACKGROUND

Dendritic cells within the human respiratory mucosa (RTDCs) are proposed to initiate immune responses to foreign antigens. Their capacity to polarize T-cell responses, however, has not been investigated.

OBJECTIVE

To compare RTDCs with peripheral blood dendritic cells (PBDCs) with regard to phenotype, cytokine production, capacity to polarize T-cell responses, and effects of exposure to the pleiotropic cytokine, GM-CSF.

METHODS

CD1a(+) RTDCs and CD1c(+) PBDCs were purified from nasal turbinates of patients with nonatopic rhinitis and peripheral blood of healthy individuals, respectively. In some experiments, matched CD1c(+) RTDCs and PBDCs from patients with rhinitis were compared. The phenotype of DC was examined by flow cytometry and cytokine production by cytometric bead array. DCs were cocultured with allogeneic naive CD4(+) T cells, and cytokine production was determined by immunophenotyping, cytometric bead array, and ELISA.

RESULTS

Both RTDCs and PBDCs exhibited an immature phenotype, but RTDCs expressed lower levels of MHC class II antigen. Cross-linking of CD40 on PBDCs, but not RTDCs, induced production of IL-12p70. In mixed lymphocyte cultures, RTDCs induced a T(H)1/T(H)2 profile, whereas PBDCs induced a T(H)1 profile. Exposure of RTDCs to GM-CSF induced a T(H)2 pattern of response in the mixed lymphocyte cultures. In contrast, exposure of PBDCs to GM-CSF promoted a T(H)1 response.

CONCLUSION

This report emphasizes the importance of studying tissue-derived primary DCs, demonstrates functional plasticity of RTDCs, and implicates GM-CSF in amplifying the potential of RTDCs to initiate T(H)2 responses in the airways.

Specialist educational intervention for mental health nursing staff: delivery, content and personal impact

AIM

This paper reports a study to ascertain the views of acute ward-based mental health nursing staff on the delivery, content and personal impact of an innovative 18-day, whole team educational intervention in acute mental health care.

BACKGROUND

There are grave concerns internationally about the quality of inpatient mental health care for people with acute psychiatric problems. Educational courses are needed to improve these services. However, existing schemes are often selective, hard to access and limited to developing highly specialist skills for senior nurses. They have also been criticized for making no difference to clinical practice. There is little evidence to guide the development of these or alternative team-based courses.

METHOD

Qualitative data were collected over a 6-week period using 12 focus group interviews and individual questionnaires.

RESULTS

Four themes were identified. The joint education of nursing staff from different organizations was welcomed and reduced feelings of ward isolation. Mixing qualified and unqualified staff was not regarded positively. In terms of course content and learning themes, unqualified staff were more likely to report positive learning outcomes for knowledge, skills, attitude, morale and personal development; qualified nurses were more likely to indicate positive outcomes in anonymized data from questionnaires than from focus groups. Both groups reported little chance of knowledge implementation without changes in the organization of care.

CONCLUSION

Whilst it may be desirable to educate whole nursing teams, more benefit might be gained from shared education between several organizations and separating the education of qualified and unqualified staff before combining these groups in team education. Participants remained pessimistic about their chances of implementing new knowledge and skills in current acute inpatient mental health environments.

Randomized Phase III Study of Docetaxel Compared With Paclitaxel in Metastatic Breast Cancer

Purpose

This randomized, controlled, multicenter, open-label, phase III study compared docetaxel versus paclitaxel in patients with advanced breast cancer that had progressed after an anthracycline-containing chemotherapy regimen.

Patients and Methods

Patients (n = 449) were randomly assigned to receive either docetaxel 100 mg/m2(n = 225) or paclitaxel 175 mg/m2(n = 224) on day 1, every 21 days until tumor progression, unacceptable toxicity, or withdrawal of consent.

Results

In the intent-to-treat population, both the median overall survival (OS, 15.4 v 12.7 months; hazard ratio [HR], 1.41; 95% CI, 1.15 to 1.73; P = .03) and the median time to progression (TTP, 5.7 months v 3.6 months; HR, 1.64; 95% CI, 1.33 to 2.02; P < .0001) for docetaxel were significantly longer than for paclitaxel, and the overall response rate (ORR, 32% v 25%; P = .10) was higher for docetaxel. These results were confirmed by multivariate analyses. The incidence of treatment-related hematologic and nonhematologic toxicities was greater for docetaxel than for paclitaxel; however, quality-of-life scores were not statistically different between treatment groups over time.

Conclusion

Docetaxel was superior to paclitaxel in terms of OS and TTP. ORR was higher for docetaxel. Hematologic and nonhematologic toxicities occurred more frequently in the docetaxel group. The global quality-of-life scores were similar for both agents over time.

A phase III trial of pemetrexed plus gemcitabine versus gemcitabine in patients with unresectable or metastatic pancreatic cancer

BACKGROUND

This randomized phase III study compared the overall survival (OS) of pemetrexed plus gemcitabine (PG) versus standard gemcitabine (G) in patients with advanced pancreatic cancer.

PATIENTS AND METHODS

Patients with unresectable locally advanced or metastatic pancreatic cancer and no prior systemic therapy (including 5-fluorouracil as a radiosensitizer) were randomized to receive either 1,250 mg/m(2) gemcitabine on days 1 and 8 plus pemetrexed 500 mg/m(2) after gemcitabine on day 8 (PG arm) of each 21-day cycle, or gemcitabine 1,000 mg/m(2) on days 1, 8 and 15 of each 28-day cycle (G arm).

RESULTS

Five hundred and sixty-five patients with well-balanced baseline characteristics were randomly assigned (283 PG, 282 G). OS was not improved on the PG arm (6.2 months) compared with the G arm (6.3 months) (P=0.8477). Progression-free survival (3.9 versus 3.3 months; P=0.1109) and time to treatment failure (3 versus 2.2 months; P=0.2680) results were similar. Tumor response rate (14.8% versus 7.1%; P=0.004) was significantly better on the PG arm. Grade 3 or 4 neutropenia (45.1% versus 12.8%), thrombocytopenia (17.9% versus 6.2%), anemia (13.9% versus 2.9%), febrile neutropenia (9.9% versus 0.4%; all P <0.001) and fatigue (15% versus 6.6%; P=0.002) were significantly more common on the PG arm. Four treatment-related deaths occurred on the PG arm and none in the G arm.

CONCLUSIONS

Pemetrexed plus gemcitabine therapy did not improve OS. Single-agent gemcitabine remains the standard of care for advanced pancreatic cancer.

Epidemiology of exercise-related transient abdominal pain at the Sydney city to Surf community run

A questionnaire was administered to 848 participants (76% runners, 24% walkers) at the conclusion of the 14 km City to Surf community run in order to investigate their experience of exercise-related transient abdominal pain (ETAP). Twenty-seven percent of respondents reported experiencing ETAP during the event, with the condition reported more frequently (p< 0.01) by runners (30%) than walkers (16%). ETAP was mostly described as well-localised (88%) and of an aching (25%), sharp (22%) or cramping (22%) sensation. The most commonly-reported sites of the pain were the right (46%) and left lumbar (23%) regions of the abdomen. Forty-two percent of the respondents who experienced ETAP reported that the pain was detrimental to their performance. Reports of ETAP decreased with age (r= -0.23, p< 0.01) but were unrelated to gender, body mass index or the time taken to complete the event. Among respondents who ran, those who consumed a large mass of food relative to body weight in the time interval 1-2 hr before the event were more likely to develop symptoms of ETAP (p < 0.05). The nutritional content of the pre-event meal did not influence the experience of ETAP. Sufferers of ETAP were more likely to experience nausea (r = 0.12, p< 0.01) and report shoulder tip pain (r= 0.14, p< 0.01). The results indicate that ETAP is a commonly experienced problem and provide insights into the cause of the complaint.

Plasmon resonances on metal tips: Understanding tip-enhanced Raman scattering

Calculations of the electric-field enhancements in the vicinity of an illuminated silver tip, modeled using a Drude dielectric response, have been performed using the finite difference time domain method. Tip-induced field enhancements, of application in "apertureless" Raman scanning near-field optical microscopy (SNOM), result from the resonant excitation of plasmons on the metal tip. The sharpness of the plasmon resonance spectrum and the highly localized nature of these modes impose conditions to better exploit tip plasmons in tip-enhanced apertureless SNOM. The effect of tip-to-substrate separation and polarization on the resolution and enhancement are analyzed, with emphasis on the different field components parallel and perpendicular to the substrate.