Discharge planning in mental health care: a systematic review of the recent literature

OBJECTIVE

To determine and estimate the efficacy of discharge planning interventions in mental health care from in-patient to out-patient treatment on improving patient outcome, ensuring community tenure, and saving costs.

METHOD

A systematic review and meta-analysis identified studies through an electronic search on the basis of defined inclusion and exclusion criteria and extracted data.

RESULTS

Of eleven studies included, six were randomised controlled trials, three were controlled clinical trials, and two were cohort studies. The discharge planning strategies used varied widely, most were limited to preparation of discharge during in-patient treatment. Pooled risk ratios were 0.66 (95% CI = 0.51 to 0.84; P < 0.001) for hospital readmission rate, and 1.25 (1.07 to 1.47; P < 0.001) for adherence to out-patient treatment. Effect sizes (Hedge's g) were -0.25 (-0.45 to -0.05; P = 0.02) for mental health outcome, and 0.11(-0.05 to 0.28; NS) for quality of life.

CONCLUSION

Discharge planning interventions are effective in reducing rehospitalisation and in improving adherence to aftercare among people with mental disorders.

Characterisation of psoriasis susceptibility locus 6 (PSORS6) in patients with early onset psoriasis and evidence for interaction with PSORS1

BACKGROUND

Psoriasis is a genetically complex, chronic inflammatory skin disease. The authors have previously identified a susceptibility locus on chromosome 19p13 (PSORS6).

METHODS AND RESULTS

In a follow-up linkage disequilibrium (LD) study in an independent family based cohort, the authors found evidence for association to a newly discovered microsatellite at this locus (D19SPS21, p<5.3x10(-5)). An LD based association scan in 300 trios revealed association to several single, single nucleotide polymorphisms (SNPs) in one LD block. When the authors stratified this cohort for carrying the PSORS1 risk allele at the HLA-C locus, evidence for association became much stronger at single SNP and haplotype levels (p values between 1.0x10(-4) and 8.0x10(-4)). In a replication study of 1114 patients and 937 control individuals, evidence for association was also observed after stratification to the PSORS1 risk allele. In both study groups, logistic regression showed evidence for interaction between the risk alleles at PSORS1 and PSORS6. Best p values for rs12459358 in both study groups remained significant after correction for multiple testing. The associated LD block did not comprise any known genes. Interestingly, an adjacent gene, MUC16, coding for a large glycosylated protein expressed in epithelia and of unknown function, could be shown to be also expressed in tissues relevant for pathogenesis of psoriasis such as skin and thymus. Immunohistochemical analyses of skin revealed focal staining for MUC16 in suprabasal epidermal cells. Further functional studies are required to clarify its potential role in psoriasis and identify the causal variant(s) at this locus.

CONCLUSION

The data establish PSORS6 as a confirmed psoriasis susceptibility locus showing interaction with PSORS1.

Outbreak of Streptococcus equi subsp. zooepidemicus infection in a group of rhesus monkeys (Macaca mulatta)

Background  A severe upper respiratory tract infection occurred in a breeding group of rhesus monkeys housed together in one of six indoor/outdoor corals of the German Primate Center. The clinical signs of the disease included severe purulent conjunctivitis, rhinitis, pharyngitis, respiratory distress and lethargy. Six of 45 animals died within a few days after developing signs of infection.

Methods and results  Histopathologic and microbiologic examinations of the dead animals were consistent with a severe fibrinopurulent bronchopneumonia. Microbiology revealed a Lancefield group C streptococcus identified as Streptococcus equi subsp. zooepidemicus as the causative agent of infection.

Conclusions  The infection was passed on from animal to animal but did not spread to the other five breeding groups nearby. Extensive diagnostic testing failed to reveal the consisting presence of copathogens in individual cases. A visitor with upper respiratory disease was suspected as source of infection.

Optical spectroscopy of rubidium Rydberg atoms with a 297 nm frequency-doubled dye laser

We demonstrate Doppler-free, purely optical detection of laser-excited rubidium Rydberg atoms in a room-temperature gas cell. The Rydberg atoms are excited with a frequency-doubled dye laser at 297 nm in a single-excitation step from the ground state; the detection is performed with a 780 nm diode laser in a scheme similar to electron shelving. Laser spectroscopy of Rydberg transitions is demonstrated, and a frequency-doubled dye is stabilized to one Rydberg transition in the UV. The performance of this stabilization is measured with an atomic-beam apparatus and a time of flight experiment.

Anatomic relationship between the pubic symphysis and ischial spines and its clinical significance in the assessment of fetal head engagement and station during labor

OBJECTIVE

To develop a geometric model from computed tomographic (CT) images in non-pregnant women that would objectively reflect clinical head station in laboring patients, against which to test the accuracy of digital examinations.

METHOD

CT scans were performed in 70 non-pregnant women to determine, using a geometric model, which angle in a mid-sagittal transperineal ultrasound (TPU) image best coincided with the mid-point of a line drawn between the ischial spines (zero station). Using a geometric algorithm, TPU angles were then assigned for other clinical stations (-5 to + 5). Finally, clinical station was assessed by digital examination and simultaneous TPU assessments in 88 laboring patients to see how closely the clinical examination correlated with the station calculated from the above geometric model.

RESULTS

The mean angle between the long axis of the symphysis pubis and the mid-point of the line connecting the two ischial spines for the 70 non-pregnant subjects was 99 degrees . The geometric model developed allowed us to build an algorithm to assign a specific set of theoretical angles to each computed station. Relationships between digitally assessed fetal head station, TPU angle for each station, and the geometrical model created with CT data, are reported. Clinical digital assessment of station correlated poorly with computed station, especially at stations below zero, where it could have greater clinical impact.

CONCLUSION

The TPU angle of 99 degrees correlated with zero station, and each station above or below this station could be assigned a specific corresponding angle for reference.

Three microsatellites from the T1DGC MHC data set show highly significant association with type 1 diabetes, independent of the HLA-DRB1, -DQA1 and -DQB1 genes

AIM

The aim of this study was to test the microsatellites in the Type 1 Diabetes Genetics Consortium major histocompatibility complex (MHC) data set for association with type 1 diabetes (T1D) independent of the HLA-DRB1, -DQA1 and -DQB1 genes.

METHODS

The data set was edited to contain only one affected child per family, and broad ethnic subgroups were defined. Genotypes for HLA-DRB1, -DQA1 and -DQB1 were replaced by a haplotype code spanning all three loci, with phase inferred based on common haplotypes. The final data set contained 8190 samples in 2301 families, 59 microsatellites and the DRB1-DQA1-DQB1 haplotype code. Statistical analyses consisted of conditional logistic regression and haplotype estimations and linkage disequilibrium calculations.

RESULTS

The data set was screened using a main effects test approach adjusted for DRB1-DQA1-DQB1, and significant results tested for validity. After these procedures, four markers remained significant at the Bonferroni-corrected threshold: D6S2773 (p = 0.00014), DG6S185 (p = 0.00015), DG6S398 (p = 0.00043) and D6S2998 (p = 0.00015). These results were supported by allelic tests conditioned on DRB1-DQA1-DQB1 haplotypes, except for DG6S185, which may contain artefacts.

CONCLUSIONS

We have identified three microsatellites that mark additional risk factors for T1D at highly significant levels in the MHC. Further analyses are needed to establish the relationship with other possible genetic determinants in this region.

Family Needs, Children and Parenthood in People with Mental Illness

Objective:

Given that parental mental diseases affect the whole family system, a family centered support and help system seems appropriate for families with a mentally ill mother/father. However, the majority of mental health services do not integrate interventions for the family system into psychiatric treatment programs.

Aims:

To introduce a counselling and support service for families with a mentally ill parent (FIPS) that has been established at a psychiatric hospital serving a large catchments area. Preliminary results of a qualitative study that focused on the clients’ family background as well as on their reasons for utilising the service and service satisfaction will be presented.

Methods:

Factors that impact the family system are considered and brought to a concept for counselling and support service for families with a mentally ill parent. Problem-focused interviews with 14 clients (mentally ill parents and relatives) of the counselling service for families were subjected to content analysis.

Results:

Most clients came to the counselling centre because of worries that the parent's mental illness might negatively affect children's well-being. Mentally ill mothers described their daily lives as utterly burdensome and also reported strong feelings of guilt towards their children. The concept of FIPS includes psychoeducation, social therapy, case management and family therapy. Clients assessed the counselling service as helpful and reported some significant changes.

Effects of symptom reduction and psychotropic medication on cognitive impairment in depression

BACKGROUND

Depression is related to cognitive performance. This follow-up study examines the influence of depression symptoms and psychopharmacological treatment on change in the cognitive performance of patients with depressive episodes over a 2-year period.

SAMPLING AND METHODS

Sixty-two in- and outpatients with depression of varying severity (ICD-10: F31-F33) were examined in an open prospective naturalistic observational study with 3 points of measurement and tested by use of 3 computerized cognitive performance tests [Visual Attentiveness Test (VAT), Continuous Attention Test (CAT), Word Recognition Test (WRT)], while the psychotropic medication was classified by subclass and dosage. Statistical analysis was performed by random-effects regression models.

RESULTS

The raw values of VAT speed, CAT speed and WRT quality improved over time. However, the positive time trend disappeared after the patients' clinical and personal characteristics were controlled for. The processing speed of the VAT was found to be negatively influenced by depressive symptoms. That of the CAT developed favorably with increasing level of education. The performance qualities of the VAT, WRT and CAT were positively related to the participants' educational level. The patients who received antipsychotic treatment performed worse on WRT quality than those who were not treated with antipsychotics.

CONCLUSIONS

The cognitive performance was relatively stable during the treatment process and not affected by clinical characteristics or type of medication. Cognitive deficits in patients with depression could be a trait rather than a state marker.

Development and characterization of nine polymorphic microsatellite markers for Mexican spadefoot toads (Spea multiplicata) with cross-amplification in Plains spadefoot toads (S. bombifrons)

We developed nine polymorphic microsatellite markers for the Mexican spadefoot toad, Spea multiplicata. Allele numbers range from five to 12, with observed heterozygosities from 0.48 to 0.87. Because two loci are in linkage disequilibrium, these nine loci provide eight independent markers. Three loci exhibit departure from Hardy-Weinberg equilibrium, possibly resulting from null alleles or population admixture. These markers will be useful for assessing population structure and relatedness in S. multiplicata. Based on our success at cross-amplification in the Plains spadefoot toad (Spea bombifrons), these loci also may be useful in this species with additional optimization.

Conditional analyses on the T1DGC MHC dataset: novel associations with type 1 diabetes around HLA-G and confirmation of HLA-B

The major histocompatibility complex (MHC) is known to harbour genetic risk factors for type 1 diabetes (T1D) additional to the class II determinants HLA-DRB1, -DQA1 and -DQB1, but strong linkage disequilibrium (LD) has made efforts to establish their location difficult. This study utilizes a dataset generated by the T1D genetics consortium (T1DGC), with genotypes for 2965 markers across the MHC in 2321 T1D families of multiple (mostly Caucasian) ethnicities. Using a comprehensive approach consisting of complementary conditional methods and LD analyses, we identified three regions with T1D association, independent both of the known class II determinants and of each other. A subset of polymorphisms that could explain most of the association in each region included single nucleotide polymorphisms (SNPs) in the vicinity of HLA-G, particular HLA-B and HLA-DPB1 alleles, and SNPs close to the COL11A2 and RING1 genes. Apart from HLA-B and HLA-DPB1, all of these represent novel associations, and subpopulation analyses did not indicate large population-specific differences among Caucasians for our findings. On account of the unusual genetic complexity of the MHC, further fine mapping is demanded, with the possible exception of HLA-B. However, our results mean that these efforts can be focused on narrow, defined regions of the MHC.

[Congenital absence of the portal vein (CAPV). Two cases of Abernethy malformation type 1 and review of the literature]

The Abernethy malformation is a rare congenital portosystemic shunt in which the blood directly drains into the systemic vein bypassing the liver either through a complete (type 1) or a partial shunt (type 2). The diagnosis is most frequently established primarily with ultrasound. CT and MRI are used for further classification of the shunt and assessment of accompanying liver tumors and malformations. There is a wide spectrum of therapeutic options ranging from noninvasive conservative treatment to liver transplantation. The main prognostic factors are the occurrence of concomitant hepatic neoplasms and hepatic encephalopathy. We report two cases diagnosed with a type 1 shunt, hepatic encephalopathy, and associated liver tumors who underwent successful liver transplantation after having considered all therapeutic options.

Expression levels of FAS are regulated through an evolutionary conserved element in intron 2, which modulates cystic fibrosis disease severity

We have analyzed frequent naturally occurring variants in the autogene FAS in two independent cystic fibrosis (CF) patient populations. Analysis of FAS expression levels from intestinal epithelial biopsies from 16 unrelated F508del-CFTR homozygotes showed a correlation between FAS intron 2 SNP rs7901656 and signals for Affymetrix GeneChip U133 Plus 2.0 probeset 204781_s_at consistent with a dominant model (P=0.0009). Genotype and haplotype analysis at six informative SNPs spanning the FAS gene locus was carried out on 37 nuclear families representing extreme clinical phenotypes that were selected from the European CF Twin and Sibling Study population of more than 300 affected sibling pairs. Case-control comparison of the haplotype composed of rs2296603-rs7901656-rs1571019 encompassing intron 2 of FAS reached significance (P=0.0246). Comparative phylogenetic analysis and functional annotation of the FAS intron 2 sequence revealed a conserved non-coding sequence surrounding rs7901656 and predicted binding sites for four transcription factors whereby the binding site of c-Rel is altered by rs7901656. Taken together, these findings from two independent CF patient cohorts indicate that allelic variants within FAS intron 2 alter FAS gene expression and that these functional variants modulate the manifestation of CF disease.

[Late stage stenoses of bile ducts after iatrogenic bile duct injuries following cholecystectomy]

INTRODUCTION

Iatrogenic bile duct injuries represent a severe complication after cholecystectomy. For the attending physician therapy and management of these injuries are a challenge. Inadequate and delayed treatment can lead to stenoses at a late stage, which can necessitate further surgical intervention.

METHODS

In a study data of 74 patients, who were treated in our clinic for bile duct injuries following cholecystectomy, were analysed retrospectively.

RESULTS

A total of 8 patients with late stage bile duct strictures following iatrogenic bile duct injury including the subsequent therapy could be identified. The data of these patients were analysed in respect of cause and strategies to prevent late stage stenoses. In 62 patients the bile duct injury occurred following laparoscopic and in 12 patients following open cholecystectomy. In 16 patients the injury was combined with a vascular lesion. The interval between primary intervention and definitive therapy was 11 days in 53 patients and 1-15 years in 21 patients. In 8 patients the reason for the re-operation after a long interval (1-15 years) was a late stage stenosis. A hepatico-jejunostomy was performed subsequently and during follow-up 5 / 8 patients were symptom-free; 7 patients were re-operated due to a stenosed primary biliodigestive anastomosis and 3 patients each due to atrophy of the right liver lobe and recurrent cholangitis. One patient complained of recurrent cholangitis and a further patient of symptoms due to adhesions.

DISCUSSION

If treated inadequately bile duct injuries occurring during cholecystectomy can in the long-term lead to considerable problems such as recurrent cholangitis, late stage stenoses and even to secondary biliary cirrhosis. Therefore, a complex inter-disciplinary therapeutic concept aiming at timely treatment is necessary.