Violent behaviour in U.K. military personnel returning home after deployment

BACKGROUND

There is growing concern about an alleged rise in violent behaviour amongst military personnel returning from deployment to Iraq and Afghanistan. The aims of this study were to determine the prevalence of violence in a sample of U.K. military personnel following homecoming from deployment in Iraq and to examine the impact of deployment-related experiences, such as combat trauma, on violence, and the role of sociodemographics and pre-enlistment antisocial behaviour.

METHOD

This study used baseline data from a cohort study of a large randomly selected sample of U.K. Armed Forces personnel in service at the time of the Iraq war (2003). Regular personnel (n=4928) who had been deployed to Iraq were included. Data, collected by questionnaire, included information on deployment experiences, sociodemographic and military characteristics, pre-enlistment antisocial behaviour, post-deployment health outcomes and a self-report measure of physical violence in the weeks following return from deployment.

RESULTS

Prevalence of violence was 12.6%. This was strongly associated with pre-enlistment antisocial behaviour [adjusted odds ratio (aOR) 3.6, 95% confidence interval (CI) 2.9-4.4]. After controlling for pre-enlistment antisocial behaviour, sociodemographics and military factors, violence was still strongly associated with holding a combat role (aOR 2.0, 95% CI 1.6-2.5) and having experienced multiple traumatic events on deployment (aOR for four or more traumatic events 3.7, 95% CI 2.5-5.5). Violence on homecoming was also associated with mental health problems such as post-traumatic stress disorder (aOR 4.8, 95% CI 3.2-7.2) and alcohol misuse (aOR 3.1, 95% CI 2.5-3.9).

CONCLUSIONS

Experiences of combat and trauma during deployment were significantly associated with violent behaviour following homecoming in U.K. military personnel. Post-deployment mental health problems and alcohol misuse are also associated with increased violence.

Criminal conviction among offspring with parental history of mental disorder

BACKGROUND

Offspring of parents with mental disorder are at risk of a range of adverse outcomes. We sought to establish whether such risks extend to offending by examining rates of criminal conviction, including conviction for violent and sexual offences, among offspring of parents with mental disorder compared to offspring without parental disorder.

METHOD

From a random sample of the Danish population, a cohort aged ≤15 years (n=412,117) was followed for the occurrence of conviction between January 1981 and December 2006. Incidence rate ratios (IRRs) and cumulative incidences for offspring conviction by parental mental disorder status were calculated using a Cox regression model. Analyses were repeated for conviction for a serious first offence.

RESULTS

Offspring with history of parental mental disorder had higher rates of conviction than those without parental disorder; rates were highest for those with two affected parents [IRR 3.39, 95% confidence interval (CI) 3.08-3.73]. The association persisted when parental gender, offspring gender and the nature of parental disorder were considered. Absolute rates were lower but relative rates higher for female offspring (IRR 3.26 for males with two affected parents, 4.52 for females). Similar patterns were seen for conviction for serious offences. Associations were attenuated after adjustment was made for family socio-economic position (SEP) and parental criminality.

CONCLUSIONS

Offspring of parents with mental disorder represent a group at elevated risk of criminality. This raises the possibility of shared familial vulnerability for mental disorder and criminal behaviour, and highlights the need to consider early identification and intervention in this group.

A multi-site randomized controlled trial of a cognitive skills programme for male mentally disordered offenders: social-cognitive outcomes

BACKGROUND

Cognitive skills programmes have been associated with improvements on psychometric measures and reductions in antisocial behaviour in mentally disordered offenders (MDOs). However, to date there have been no randomized controlled trials (RCTs) of such programmes with this population. In the first RCT of a cognitive skills programme with MDOs we aimed to determine if participation in the Reasoning and Rehabilitation (R&R) programme was associated with improvements in social-cognitive skills and thinking styles.

METHOD

A total of 84 men with a primary diagnosis of psychotic disorder and a history of violence were recruited from medium-secure forensic units and allocated to receive R&R (n=44) or treatment as usual (TAU; n=40). At baseline and post-treatment interviews, participants completed questionnaires to assess social problem-solving, criminal attitudes, anger experience, blame externalizing and perspective-taking. Researchers were not blind to group status.

RESULTS

The R&R group demonstrated significant improvements on measures of social problem-solving relative to the TAU group, some of which were maintained at 12 months post-treatment. Only half of those allocated to receive R&R completed the full programme. In post-hoc analyses programme completers showed improvements in social problem-solving at the end of treatment and changes in criminal attitudes at 12 months post-treatment.

CONCLUSIONS

Among male MDOs, R&R participation was associated with improvements in social-cognitive skills, some of which were maintained for up to 12 months post-treatment. Our finding that programme completers do better may reflect pre-treatment patient characteristics. This study establishes that multi-site RCTs can be conducted in medium-secure forensic units.

Mental health and health service use among post-national service veterans: results from the 2007 Adult Psychiatric Morbidity Survey of England

BACKGROUND

There is concern surrounding the psychological health and uptake of treatment services among veterans of the UK Armed Forces.

METHOD

Data from a cross-sectional, nationally representative sample were used to compare health outcomes and treatment seeking among 257 post-national service veterans aged 16-64 years and 504 age and sex frequency-matched non-veterans living in the community in England. Early leavers (<4 years service) were compared with longer serving veterans.

RESULTS

Male veterans reported more childhood adversity and were more likely to have experienced a major trauma in adulthood than non-veterans. There was no association between any measure of mental health and veteran status in males, except reporting more violent behaviours [adjusted odds ratio (aOR) 1.44, 95% confidence interval (CI) 1.01-2.06]. In females, a significant association was found between veteran status and ever having suicidal thoughts (aOR 2.82, 95% CI 1.13-7.03). No differences in treatment-seeking behaviour were identified between veterans and non-veterans with any mental disorder. Early service leavers were more likely to be heavy drinkers (aOR 4.16, 95% CI 1.08-16.00), to have had suicidal thoughts (aOR 2.37, 95% CI 1.21-4.66) and to have self-harmed (aOR 12.36, 95% CI 1.61-94.68) than longer serving veterans.

CONCLUSIONS

The findings of this study do not suggest that being a veteran is associated with adversity in terms of mental health, social disadvantage or reluctance to seek treatment compared with the general population. Some evidence implies that early service leavers may experience more mental health problems than longer-serving veterans.

Combining dimensional and categorical representation of psychosis: the way forward for DSM-V and ICD-11?

BACKGROUND

There is good evidence that psychotic symptoms segregate into symptom dimensions. However, it is still unclear how these dimensions are associated with risk indicators and other clinical variables, and whether they have advantages over categorical diagnosis in clinical practice. We investigated symptom dimensions in a first-onset psychosis sample and examined their associations with risk indicators and clinical variables. We then examined the relationship of categorical diagnoses to the same variables.

METHOD

We recruited 536 patients as part of a population-based, incidence study of psychosis. Psychopathology was assessed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). A principal axis factor analysis was performed on symptom scores. The relationship of dimension scores with risk indicators and with clinical variables was then examined employing regression analyses. Finally, regression models were compared to assess the contribution of dimensions versus diagnosis in explaining these variables.

RESULTS

Factor analysis gave rise to a five-factor solution of manic, reality distortion, negative, depressive and disorganization symptom dimensions. The scores of identified dimensions were differentially associated with specific variables. The manic dimension had the highest number of significant associations; strong correlations were observed with shorter duration of untreated psychosis, acute mode of onset and compulsory admission. Adding dimensional scores to diagnostic categories significantly increased the amount of variability explained in predicting these variables; the reverse was also true but to a lesser extent.

CONCLUSIONS

Categorical and dimensional representations of psychosis are complementary. Using both appears to be a promising strategy in conceptualising psychotic illnesses.

Effect of clinical audits of radiation use in one hospital district in Finland

BACKGROUND

A clinical audit is a systematic, independent, and documented process to improve the quality of radiological processes and radiation safety for patients.

PURPOSE

To evaluate the effect of an audit process by comparing the results of two consecutive audits at the same units.

MATERIAL AND METHODS

Audits were carried out twice at each imaging unit in the southwest hospital district of Finland: first, at the end of 2003, and again in November 2007. Both evaluations were carried out in a similar way: by interviewing personnel and examining documents, independent experts from other hospital districts ensured that diagnostic medical imaging processes at each unit were carried out according to generally accepted standards for good medical radiological procedures. The results of the consecutive audits were compared in order to analyze the effects of the clinical audits.

RESULTS

The use of radiation was in accordance with the requirements and standards of good medical procedures at every audited unit during both evaluations. The list of audit criteria was fulfilled satisfactorily on both occasions at all of the audited units, and clearly better during the second run. In the first audit, the auditors made 80 recommendations for improving diagnostic procedures and, in the second audit, 53 recommendations. During the first audit, most of the recommendations (22/80) concerned instructions in the fundamental practice of examining a patient. During the second audit, most recommendations were in the category of radiation doses.

CONCLUSION

The clinical audit had a positive impact on the practice of work procedures in radiological departments. Most of the recommendations made after the first audit had been taken into consideration by the time of the second audit.

Analysis of urobilinogen and urine bilirubin for intra-abdominal injury in blunt trauma patients

OBJECTIVE

To determine the point prevalence of urine bilirubin, urine hemoglobin and urobilinogen in blunt trauma patients, and to evaluate its utility as a screening tool for intra-abdominal injury.

METHODS

Data analysis of 986 consecutive trauma patients of which 698 were adult blunt trauma patients. Five-hundred sixteen subjects had a urinalysis and a CT scan of the abdomen/pelvis or exploratory laparotomy. We reviewed initial urinalysis results from trauma patients in the emergency department (ED) for the presence of urine hemoglobin, uroblinogen and urine bilirubin. Computed tomography (CT) scan results and operative reports were reviewed from the trauma registry for evidence of liver laceration, spleen laceration, bowel or mesenteric injuries.

RESULTS

There were 73 injuries and 57/516 patients (11%) with intra-abdominal injury. Urinalysis was positive for urobilinogen in 28/516 (5.4%) patients, urine bilirubin in 15/516 (2.9%) patients and urine hemoglobin in 313/516 (61%) patients. Nineteen/forty-seven (4%) subjects had liver lacerations, 28/56 (5%) splenic lacerations, and 15/5 (3%) bowel or mesenteric injury. Comparing the proportion of patients that had urobilinogen detected in the group with and without intra-abdominal injury, 8/28 (29%) subjects with urobilinogen, 5/15 (33%) subjects with bilirubin and 47/313 (15%) subjects with urine hemoglobin were found to have liver lacerations, spleen lacerations, or bowel/mesenteric injuries. Preexisting liver or biliary conditions were not statistically associated with elevation of urine bilirubin, urine hemoglobin or urobilinogen on initial urinalysis after blunt abdominal trauma. Point prevalence for urobilinogen, urine bilirubin and urine hemoglobin are 5.43% (28/516), 2.91% (15/516) and 60.7% (313/516) respectively.

CONCLUSIONS

The utility of the initial routine urinalysis in the ED for adult blunt abdominal trauma patients should not be used as a screening tool for the evaluation of intra-abdominal injury.

Minor physical anomalies in patients with first-episode psychosis: their frequency and diagnostic specificity

BACKGROUND

An increased prevalence of minor physical anomalies (MPAs) has been extensively documented in schizophrenia but their specificity for the disorder remains unclear. We investigated the prevalence and the predictive power of MPAs in a large sample of first-episode psychotic patients across a range of diagnoses.

METHOD

MPAs were examined in 242 subjects with first-episode psychosis (50% schizophrenia, 45% affective psychosis and 5% substance-induced psychosis) and 158 healthy controls. Categorical principal components analysis and analysis of variance were undertaken, and individual items with the highest loading were tested using the chi2 test.

RESULTS

Overall facial asymmetry, assymetry of the orbital landmarks, and frankfurt horizontal significantly differentiated patients with schizophrenia and affective psychosis from controls, as did a 'V-shaped' palate, reduced palatal ridges, abnormality of the left ear surface and the shape of the left and right ears. Patients with affective psychosis had significantly lowered eye fissures compared with control subjects.

CONCLUSIONS

MPAs are not specific to schizophrenia, suggesting a common developmental pathway for non-affective and affective psychoses. The topographical distribution of MPAs in this study is suggestive of an insult occurring during organogenesis in the first trimester of pregnancy.

Predictors of violent victimization amongst those with psychosis

OBJECTIVE

The aim of this study was to establish the prevalence and predictors of violent victimization amongst a community-dwelling sample of individuals with psychosis.

METHOD

The 2-year prevalence of self-reported violent victimization was estimated for a sample of 708 individuals with chronic psychosis living in the community in four urban UK centres. Baseline socio-demographic and clinical factors were examined as possible risk factors for victimization over the 2-year follow-up period.

RESULTS

The 2-year prevalence of violent victimization in the sample was 23%. Four factors were found to be independently predictive of victimization - history of victimization, less than daily family contact, young age at illness onset and the presence of co-morbid Cluster B personality disorder.

CONCLUSION

Those with psychotic illnesses are at elevated risk of being assaulted. Given the likely adverse health implications, clinicians should routinely enquire about victimization in their assessments of those with psychotic disorders particularly amongst those who are socially isolated, with a younger age of illness onset and in those with co-morbid personality disorder.

A comparison of symptoms and family history in schizophrenia with and without prior cannabis use: implications for the concept of cannabis psychosis

BACKGROUND

There is considerable interest in cannabis use in psychosis. It has been suggested that the chronic psychosis associated with cannabis use, is symptomatically distinct from idiopathic schizophrenia. Several studies have reported differences in psychopathology and family history in people with schizophrenia according to whether or not they were cannabis users. We set out to test the hypotheses arising from these studies that cannabis use is associated with more bizarre behaviour, more thought disorder, fewer negative symptoms including blunted affect, more delusions of reference, more paranoid delusions and a stronger family history of schizophrenia.

METHOD

We used a case register that contained 757 cases of first onset schizophrenia, 182 (24%) of whom had used cannabis in the year prior to first presentation, 552 (73%) had not and 3% had missing data. We completed the OPCRIT checklist on all patients and investigated differences in the proportion of people with distractibility, bizarre behaviour, positive formal thought disorder, delusions of reference, well organised delusions, any first rank symptom, persecutory delusions, abusive/accusatory hallucinations, blunted affect, negative thought disorder, any negative symptoms (catatonia, blunted affect, negative thought disorder, or deterioration), lack of insight, suicidal ideation and a positive family history of schizophrenia, using chi square tests. Logistic regression modelling was then used to determine whether prior cannabis use affected the presence of the characteristics after controlling for age, sex and ethnicity.

RESULTS

There was no statistically significant effect of cannabis use on the presence of any of the above. There remained however a non-significant trend towards more insight (OR 0.65 p=0.055 for "loss of insight") and a finding of fewer abusive or accusatory hallucinations (OR 0.65 p=0.049) of borderline significance amongst the cannabis users. These were in the hypothesised direction. There was no evidence of fewer negative symptoms or greater family history amongst cannabis users.

CONCLUSION

We found few appreciable differences in symptomatology between schizophrenic patients who were or were not cannabis users. There were no differences in the proportion of people with a positive family history of schizophrenia between cannabis users and non-users. This argues against a distinct schizophrenia-like psychosis caused by cannabis.

Aggressive behaviour at first contact with services: findings from the AESOP First Episode Psychosis Study

BACKGROUND

Aggressive behaviour is increased among those with schizophrenia but less is known about those with affective psychoses. Similarly, little is known about aggressive behaviour occurring at the onset of illness.

METHOD

The main reasons for presentation to services were examined among those recruited to a UK-based first episode psychosis study. The proportion of individuals presenting with aggressive behaviour was determined and these individuals were compared to those who were not aggressive on a range of variables including sociodemographic, clinical, criminal history, service contact, and symptom characteristics. Among the aggressive group, those who were physically violent were distinguished from those who were not violent but who were still perceived to present a risk of violence to others.

RESULTS

Almost 40% (n=194) of the sample were aggressive at first contact with services; approximately half of these were physically violent (n=103). Younger age, African-Caribbean ethnicity and a history of previous violent offending were independently associated with aggression. Aggressive behaviour was associated with a diagnosis of mania and individual manic symptoms were also associated with aggression both for the whole sample and for those with schizophrenia. Factors differentiating violent from non-violent aggressive patients included male gender, lower social class and past violent offending.

CONCLUSIONS

Aggressive behaviour is not an uncommon feature in those presenting with first episode psychosis. Sociodemographic and past offending factors are associated with aggression and further differentiate those presenting with more serious violence. A diagnosis of mania and the presence of manic symptoms are associated with aggression.

Minor physical anomalies across ethnic groups in a first episode psychosis sample

Minor physical anomalies (MPAs) are more prevalent amongst individuals with psychosis, supporting a neurodevelopmental model for psychotic disorders. The aim of this study was to investigate the possibility that neurodevelopmental adversity contributes to the excess of psychosis found in some ethnic groups in the UK. Subjects with first onset psychosis and healthy neighbourhood controls were enrolled in the AESOP study in South East London and Nottingham between 1997 and 1999. MPA rates were estimated in four broad ethnic groupings (White, African Caribbean, Black African and Other). Patients (n=245) had a higher mean total MPA score than healthy controls (n=158). This held true across each of the four ethnic groupings. The results of this study suggest that neurodevelopmental factors play a role in the aetiology of psychosis across all ethnic groups.

Mutual cross-talk between reactive oxygen species and nuclear factor-kappa B: molecular basis and biological significance

Reactive oxygen species (ROS) are emerging as key effectors in signal transduction. This role of ROS is especially evident in the pathways leading to programmed cell death (PCD) elicited in response to certain stress stimuli and cytokines. In these pathways, cytotoxic ROS signaling appears to be mediated in part by activation of the c-Jun-N-terminal kinase (JNK) mitogen-activated protein kinase (MAPK) cascade. Another pathway that is under ROS-mediated control in some systems is that leading to activation of transcription factor nuclear factor-kappa B (NF-kappaB), which is a central regulator of immunity, inflammation and cell survival. Remarkably, new evidence has unveiled the existence of a reciprocal, negative control that NF-kappaB exerts on ROS and JNK activities. This NF-kappaB-imposed restraint on ROS and JNK signaling is crucial for antagonism of PCD elicited by the proinflammatory cytokine tumor necrosis factor (TNF)alpha and likely other triggers. Effectors of this antagonistic cross-talk between NF-kappaB and ROS/JNK pathways have recently been identified. Because of the key roles that the prosurvival function of NF-kappaB plays in organismal physiology and disease, gaining a further mechanistic understanding of this cross-talk and NF-kappaB-dependent survival may be key to developing new therapies for the treatment of widespread human illnesses, such as cancer and chronic inflammatory conditions.

Grey matter correlates of minor physical anomalies in the AeSOP first-episode psychosis study

BACKGROUND

Minor physical anomalies are more prevalent among people with psychosis. This supports a neurodevelopmental aetiology for psychotic disorders, since these anomalies and the brain are both ectodermally derived. However, little is understood about the brain regions implicated in this association.

AIMS

To examine the relationship between minor physical anomalies and grey matter structure in a sample of patients with first-episode psychosis.

METHOD

Sixty patients underwent assessment of minor physical anomalies with the Lane scale. High-resolution magnetic resonance images and voxel-based methods of image analysis were used to investigate brain structure in these patients.

RESULTS

The total anomalies score was associated with a grey matter reduction in the prefrontal cortex and precuneus and with a grey matter excess in the basal ganglia, thalamus and lingual gyrus.

CONCLUSIONS

Minor physical anomalies in a sample of patients with first-episode psychosis are associated with regional grey matter changes. These regional changes may be important in the pathogenesis of psychotic disorder.

Double-heater-wire circuits and heat-and-moisture exchangers and the risk of ventilator-associated pneumonia

OBJECTIVE

To compare the incidence of ventilator-associated pneumonia (VAP) in patients ventilated in intensive care by means of circuits humidified with a hygroscopic heat-and-moisture exchanger with a bacterial viral filter (HME) or hot-water humidification with a heater wire in both inspiratory and expiratory circuit limbs (DHW) or the inspiratory limb only (SHW).

DESIGN

A prospective, randomized trial.

SETTING

A metropolitan teaching hospital's general intensive care unit.

PATIENTS

Three hundred eighty-one patients requiring a minimum period of mechanical ventilation of 48 hrs.

INTERVENTIONS

Patients were randomized to humidification with use of an HME (n=190), SHW (n=94), or DHW (n=97).

MEASUREMENTS AND MAIN RESULTS

Study end points were VAP diagnosed on the basis of Clinical Pulmonary Infection Score (CPIS) (), HME resistance after 24 hrs of use, endotracheal tube resistance, and HME use per patient. VAP occurred with similar frequency in all groups (13%, HME; 14%, DHW; 10%, SHW; p=0.61) and was predicted only by current smoking (adjusted odds ratio [AOR], 2.1; 95% confidence interval [CI], 1.1-3.9; p=.03) and ventilation days (AOR, 1.05; 95% CI, 1.0-1.2; p=.001); VAP was less likely for patients with an admission diagnosis of pneumonia (AOR, 0.40; 95% CI, 0.4-0.2; p=.04). HME resistance after 24 hrs of use measured at a gas flow of 50 L/min was 0.9 cm H2O (0.4-2.9). Endotracheal tube resistance was similar for all three groups (16-19 cm H2O min/L; p=.2), as were suction frequency, secretion thickness, and blood on suctioning (p=.32, p=.06, and p=.34, respectively). The HME use per patient per day was 1.13.

CONCLUSIONS

Humidification technique does not influence either VAP incidence or secretion characteristics, but HMEs may have air-flow resistance higher than manufacturer specifications after 24 hrs of use.

The NF-κB-mediated control of the JNK cascade in the antagonism of programmed cell death in health and disease

NF-kappaB/Rel transcription factors have recently emerged as crucial regulators of cell survival. Activation of NF-kappaB antagonizes programmed cell death (PCD) induced by tumor necrosis factor-receptors (TNF-Rs) and several other triggers. This prosurvival activity of NF-kappaB participates in a wide range of biological processes, including immunity, lymphopoiesis and development. It is also crucial for pathogenesis of various cancers, chronic inflammation and certain hereditary disorders. This participation of NF-kappaB in survival signaling often involves an antagonism of PCD triggered by TNF-R-family receptors, and is mediated through a suppression of the formation of reactive oxygen species (ROS) and a control of sustained activation of the Jun-N-terminal kinase (JNK) cascade. Effectors of this antagonistic activity of NF-kappaB on this ROS/JNK pathway have been recently identified. Indeed, further delineating the mechanisms by which NF-kappaB promotes cell survival might hold the key to developing new highly effective therapies for treatment of widespread human diseases.

The Healthgrid White Paper

Over the last four years, a community of researchers working on Grid and High Performance Computing technologies started discussing the barriers and opportunities that grid technologies must face and exploit for the development of health-related applications. This interest lead to the first Healthgrid conference, held in Lyon, France, on January 16th-17th, 2003, with the focus of creating increased awareness about the possibilities and advantages linked to the deployment of grid technologies in health, ultimately targeting the creation of a European/international grid infrastructure for health. The topics of this conference converged with the position of the eHealth division of the European Commission, whose mandate from the Lisbon Meeting was "To develop an intelligent environment that enables ubiquitous management of citizens' health status, and to assist health professionals in coping with some major challenges, risk management and the integration into clinical practice of advances in health knowledge." In this context "Health" involves not only clinical procedures but covers the whole range of information from molecular level (genetic and proteomic information) over cells and tissues, to the individual and finally the population level (social healthcare). Grid technology offers the opportunity to create a common working backbone for all different members of this large "health family" and will hopefully lead to an increased awareness and interoperability among disciplines. The first HealthGrid conference led to the creation of the Healthgrid association, a non-profit research association legally incorporated in France but formed from the broad community of European researchers and institutions sharing expertise in health grids. After the second Healthgrid conference, held in Clermont-Ferrand on January 29th-30th, 2004, the need for a "white paper" on the current status and prospective of health grids was raised. Over fifty experts from different areas of grid technologies, eHealth applications and the medical world were invited to contribute to the preparation of this document.