Mental health services for homeless: patient profile and factors associated with suicide and homicide

This study aimed to establish a profile of users of the mental health service for homeless in Cork, comparing this group with those attending a General Adult Service. The homeless group were significantly more likely to be male (89% v. 46%o), unemployed (96% v. 68%), unmarried (98% v. 75%) and under 65 (94% v. 83%). Diagnostically, there was a significantly higher prevalence of schizophrenia (50% v. 34%); personality disorder (37% v. 11%) and substance dependence (74% v. 19%) in the homeless service users. They were more likely to have a history of deliberate self harm (54% v. 21%) and violence (48% v. 10%). Severe mental illness has a high prevalence in the homeless population, with particularly high levels of factors associated with suicide and homicide. Poor compliance and complexity of illness lead to a requirement for significant input from multidisciplinary mental health teams members.

Multiple sclerosis, from referral to confirmed diagnosis: an audit of clinical practice

Background: The National Institute for Health and Clinical Excellence (NICE) guidelines recommend a timeline of 6 weeks from referral to neurology consultation and then 6 weeks to a diagnosis of multiple sclerosis (MS).

Objectives: We audited the clinical management of all new outpatient referrals diagnosed with MS between January 2007 and May 2010.

Methods: We analysed the timelines from referral to first clinic visit, to MRI studies and lumbar puncture (LP) (if performed) and the overall interval from first visit to the time the diagnosis was given to the patient.

Results: Of the 119 diagnoses of MS/Clinically Isolated Syndrome (CIS), 93 (78%) were seen within 6 weeks of referral. MRI was performed before first visit in 61% and within 6 weeks in a further 27%. A lumbar puncture (LP) was performed in 83% of all patients and was done within 6 weeks in 78%. In total, 63 (53%) patients received their final diagnosis within 6 weeks of their first clinic visit, with 57 (48%) patients having their diagnosis delayed. The main rate-limiting steps were the availability of imaging and LP, and administrative issues.

Conclusions: We conclude that, even with careful scheduling, it is difficult for a specialist service to obtain MRI scans and LP results so as to fulfil NICE guidelines within the optimal six-week period. An improved service would require MRI scans to be arranged before the first clinic visit in all patients with suspected MS.

Multiple sclerosis prevalence in Ireland: relationship to vitamin D status and HLA genotype

BACKGROUND

The relationship between prevalence of multiple sclerosis (MS) and latitude may be due to both genetic and environmental factors. The hypothesis that, in Ireland, MS prevalence is increasing and that north-south differences relate to variation in serum 25-hydroxyvitamin D (25(OH)D) levels was tested in this study.

PATIENTS AND METHODS

Patients and matched control subjects were identified in counties Donegal, Wexford and South Dublin through multiple sources. Prevalence was determined. Blood samples were taken for serum 25(OH)D and serum intact parathyroid hormone measurement, and DNA was extracted.

RESULTS

Prevalence in 2007 was significantly greater in Donegal (northwest) (290.3/105, 95% CI 262.3 to 321.7) compared with 2001 (184.6/105; 162 to 209.5). In Wexford (southeast), there was a non-significant increase in prevalence in 2007 compared with 2001. Prevalence was significantly higher in Donegal than in Wexford (144.8/105; 126.7 to 167.8, p<0.0001) and South Dublin (127.8/105; 111.3 to 148.2, p<0.0001). Overall, mean 25(OH)D levels were low and did not differ between patients (38.6 nmol/l) and controls (36.4 nmol/l) However, significantly more patients than controls had 25(OH)D levels <25 nmol/l (deficiency) (p=0.004). Levels of 25(OH)D (mean 50.74 nmol/l) were significantly higher in South Dublin (area with lowest prevalence) (p<0.0001) than in Donegal or Wexford. HLA DRB1*15 occurred most frequently in Donegal (greatest MS prevalence) and least frequently in South Dublin.

CONCLUSION

Vitamin D deficiency is common in Ireland. Latitudinal variation in MS probably relates to an interaction between genetic factors and environment (25(OH)D levels), and MS risk may be modified by vitamin D in genetically susceptible individuals.

Parturition induction two days prior to term decreases birth weight and lactational growth, but not piglet maturity, health or post-weaning growth

Premature parturition induction may adversely affect postnatal health and performance. The objective of this study was to evaluate the impact of cloprostenol induction 2 d prior to term on piglet maturity (liver glycogen), postnatal productivity (birth weight, growth rate), and health (morbidity, mortality, passive antibody, fecal Clostridium perfringens). Two hundred and sixteen pregnant sows and their progeny (2827 piglets) were assigned to the study. Induction decreased gestation length 2.1 d (P < 0.0001), birth weight 107.2 g pig-1 (P = 0.0004), lactational growth 10.1 g d-1 (P = 0.05), and day 16 weight 0.30 kg pig-1 (P < 0.05). Liver glycogen concentration was 71.2 µg g-1 higher in the stillborns of induced sows (P = 0.03), suggesting the pre-term sows were catabolic. No group differences in post-weaning growth rate, pre-weaning mortality or morbidity, passive antibody transfer or fecal Clostridium perfringens level were found. Reduced lactational growth appeared attributable to the reductions in gestation length and birth weight, rather than in piglet maturity. In spite of reducing lactational growth and body weight at 16 d of age, the administration of cloprostenol 2 d prior to term, under the conditions of this study, resulted in no measureable long-term health or performance consequences. Key words: Porcine, parturition-induction, cloprostenol, prostaglandin F2α, glycogen, Clostridium perfringens

Superselective intracerebral catheterization of a branch of the internal carotid artery coupled with magnetic resonance imaging

SUMMARY

We used fluoroscopic guidance and over-thewire techniques to superselectively place a microcatheter into a branch of the MCA of three macaques and MRI bolus tracking techniques to measure perfusion within the selected brain region. Such techniques are likely to be useful in the assessment and treatment of ischemic infarction, cerebral vasospasm, and monitoring local delivery of drugs into the brain.

Quantifying badger exposure and the risk of bovine tuberculosis for cattle herds in county Kilkenny, Ireland

The objectives of the study were to quantify the levels of badger exposure for cattle and to test the hypothesis that increased badger exposure does not increase the risk of bovine tuberculosis (BTB) in a herd. Information that became available from the targeted removal of badgers over the study period, and from a badger-removal project in county Kilkenny, during 1996-1999 was used. The specific location of cattle within each farm, and the length of time that cattle spent in each farm field during the grazing season, and in the barnyard during winter, was used to build an exposure coefficient to quantify the amount of badger exposure that cattle encountered either on pasture or in the barn. The study design was a matched case-control study in which the control herds were selected using incidence density sampling. During the 4-year study period, 543 badgers were removed and of these 96 badgers were classified as tuberculosis positive; 96 BTB herd breakdowns occurred. There was a significant association between case herds and having a higher badger sett exposure coefficient during 1996-1998. No significant association between case herds and having a higher exposure coefficient based on the number of badgers, or the number of tuberculous badgers, during September 1997-December 1999 was found.

Interferon treatment of multiple pulmonary malignancies associated with papilloma virus

Over a period of four years, beginning in spring 1988, a previously healthy man developed a primary squamous cell carcinoma of the tonsil, treated with radiotherapy, followed by 10 distinct, primary bronchial squamous cell carcinomas. Four of the cancers were surgically resected, all of which were positive by hybridization for human papilloma virus (type 16). Following the institution of alpha interferon, three smaller lesions disappeared and a larger one shrank in size, facilitating surgical resection. Over the following seven years no new ones have appeared. The finding of papilloma virus in malignancies should prompt consideration of antiviral therapy.

Spleen transplantation in miniature swine: surgical technique and results in major histocompatibility complex-matched donor and recipient pairs

BACKGROUND

Spleen transplantation (Tx) between some strains of rodents can lead to donor-specific tolerance either spontaneously or after a short course of immunosuppression. This study developed a surgical technique for spleen Tx in miniature swine to investigate its immunologic impact in a large animal model.

METHODS

The preferred surgical technique of spleen Tx (n=8) involved excision of the donor spleen with its vascular pedicle to the aorta and portal vein. Carrel patches of donor aorta and portal vein were anastomosed to the abdominal aorta and inferior vena cava, respectively, of the (splenectomized) recipient. The results in four major histocompatibility complex-matched pairs that were mismatched for the porcine allelic antigen are reported. Two recipients were untreated, one received a 12-day course of cyclosporine A (CsA) alone, and one received thymic irradiation (700 cGy) and CsA. Hematopoietic cell chimerism was followed by fluorescence-activated cell sorter, and graft survival was assessed by histology.

RESULTS

Spleen Tx was technically successful. In two untreated pigs, chimerism was detected in the blood (maximum 5% for 17 and 25 days) and lymph nodes (maximum 6% for 28 and 56 days), but both grafts showed histologic rejection by day 28. In two treated pigs, chimerism was present in the blood for 47 and 57 days, and rejection was prevented, with follow-up for 57 and 217 days, respectively.

CONCLUSION

Spleen Tx in major histocompatibility complex-matched pairs treated with CsA+/-thymic irradiation results in prolonged chimerism and is associated with the development of in vivo unresponsiveness to the transplanted spleen.

A comparison of biochemical and functional alterations of rat and human erythrocytes stored in CPDA-1 for 29 days: implications for animal models of transfusion

Animal models of transfusion are employed in many research areas yet little is known about the storage-related changes occurring in the blood used in these studies. This study assessed storage-related changes in red blood cell (RBC) biochemistry, function and membrane deformability in rat and human packed RBCs when stored in CPDA-1 at 4 degrees C over a 4-week period. Human blood from five volunteers and five bags of rat RBC concentrates (five donor rats per bag) were collected and stored at 4 degrees C. RBC function was assessed by post-transfusion viability and the ability to regenerate adenosine triphosphate (ATP) and 2,3-diphosphoglycerate (DPG) when treated with a rejuvenation solution. Membrane deformability was determined by a micropipette aspiration technique. ATP in rat RBCs declined more rapidly than human RBCs; after 1 week rat ATP fell to the same level as human cells after 4 weeks of storage (rat, 2.2 +/- 0.2 micromol g(-1) Hb; human, 2.5 +/- 0.3 micromol g(-1) Hb). Baseline DPG concentrations were similar in rat and human RBCs (16.2 +/- 2.3 micromol g(-1) Hb and 13.7 +/- 2.4 micromol g(-1) Hb) and declined very rapidly in both species. Human RBCs fully regenerated ATP and DPG when treated with a rejuvenation solution after 4 weeks of storage. Rat RBCs regenerated ATP but not DPG. Post-transfusion viability in rat cells was 79%, 26% and 5% after 1, 2 and 4 weeks of storage, respectively. In rats, decreased membrane deformability became significant (- 54%) after 7 days. Human RBC deformability decreased significantly by 34% after 4 weeks of storage. The rejuvenation solution restored RBC deformability to control levels in both species. Our results indicate that rat RBCs stored for 1 week in CPDA-1 develop a storage lesion similar to that of human RBCs stored for 4 weeks and underscores significant species-specific differences in the structure and metabolism of these cells.

Histologic study of patterns of cervical involvement in FIGO stage II endometrial carcinoma

The pathology of cervical involvement in endometrial carcinoma has not been fully defined previously. We reviewed the histopathology of 66 hysterectomies of women with stage II endometrial carcinoma. Cervical spread was categorized as macroscopic or microscopic; stage IIA or IIB; direct spread, surface or lymphvascular metastasis; and size, number, and location. The cervical tumor was macroscopically identified in 15 (23%) women and microscopically identified in 51 (77%). Twenty-one patients (32%) were stage IIA and 45 (68%) stage IIB. The method of spread was direct spread in 28 patients, surface metastases in 27, lymphovascular in 3, both direct spread and surface metastases in 7 and both direct spread and lymphovascular in 1. The cervical tumor had a mean horizontal dimension of 3 mm and a median of 2 mm. There were multiple sites of cervical tumor in 31 (47%) patients and single in 35 (53%). The sites of spread, including cases with multiple sites, were the endocervix in 60 women (90%), transformation zone in 24 (37%), and ectocervix in 3 (5%). Most patients had minimal microscopic cervical tumor. Small examples of direct spread may be an artifact of definition depending on the histology of the isthmian-endocervical junction and many surface metastases appear to follow dilatation and curettage. In 7 of 66, 11%, however, the cervical tumor was greater than 5 mm depth of invasion and/or the result of lymphvascular metastasis. Survival studies are required to compare minimal stage II endometrial carcinoma patients and those with larger and/or lymphvascular derived cervical tumor. Patients with minimal stage II and stage I patients should also be compared.

High dose alfentanil as sole anaesthetic induction agent for caesarean section in a patient with severe ischaemic heart disease

A 43-year-old woman presented at 34 weeks' gestation with pre-eclampsia and intra-uterine growth restriction. She had a past medical history of myocardial infarction and had angina on moderate effort. She also had non-insulin dependent diabetes mellitus, chronic obstructive airways disease and hypercholesterolaemia. The onset of unstable angina, cardiac failure and a deteriorating fetal condition necessitated urgent delivery by caesarean section. General anaesthesia was chosen. High dose alfentanil was used as sole induction agent resulting in minimal haemodynamic change and a successful maternal and fetal outcome.

Effects of inhaled nitric oxide in a rat model of Pseudomonas aeruginosa pneumonia

OBJECTIVE

Antimicrobial effects of nitric oxide (NO) have been demonstrated in vitro against a variety of infectious pathogens, yet in vivo evidence of a potential therapeutic role for exogenous NO as an antimicrobial agent is limited. Thus, we assessed the effects of inhaled NO on pulmonary infection, leukocyte infiltration, and NO synthase (NOS) activity in a rat model of Pseudomonas aeruginosa pneumonia.

DESIGN

Controlled animal study.

SETTING

Research laboratory of an academic institution.

SUBJECTS

Male Sprague-Dawley rats.

INTERVENTIONS

After intratracheal instillation of either P. aeruginosa or saline (sham), rats were randomly exposed to either 40 ppm of inhaled NO or room air (RA) for 24 hrs before they were killed.

MEASUREMENTS AND MAIN RESULTS

Inhaled NO in pneumonia rats markedly reduced pulmonary bacterial load (0.02+/-0.01% vs. 0.99+/-0.59% of bacterial input in pneumonia with room air, p < .05) and pulmonary myeloperoxidase activity, a marker of leukocyte infiltration (21.7+/-3.8 vs. 55.0+/-8.1 units in pneumonia with room air, p < .05), but had no effect on systemic hemodynamics or gas exchange. Pneumonia was associated with enhanced pulmonary NOS activity (8.8+/-2.4 vs. 0.2+/-0.1 pmol citrulline/min/mg protein in sham, p < .01) and increased plasma levels of nitrites/nitrates (NOx-; 45+/-7 vs. 16+/-3 micromol/L in sham, p < .01). Inhaled NO therapy attenuated the pneumonia-induced increase in pulmonary calcium-independent NOS activity (p < .05) and markedly increased plasma NOx- levels. Exposure of P. aeruginosa in culture to 40 ppm of ambient NO confirmed a delayed antibacterial effect of NO in vitro.

CONCLUSIONS

Inhaled NO has an important antibacterial effect both in vitro and in vivo against P. aeruginosa and is associated with reduced pulmonary leukocyte infiltration in vivo. These results in a rat model of P. aeruginosa pneumonia suggest that future studies should address the possible clinical effects of inhaled NO therapy in pneumonia.

Rethinking public health: new training for new times

The new public health agenda will require major changes in the way health authorities, local authorities, Trusts and Primary Care Groups organise and manage their activities. The requirement is for inter-agency co-ordination and inter-professional and inter-sectoral working to a shared agenda, yet the human and resources development planning to achieve these goals has not been done. This paper summarises the key training issues and argues for a collaborative, decentralised and quality assured approach to multidisciplinary public health management education and training. Only with such a joined up human resources plan can Our Healthier Nation succeed where The Health of the Nation signally failed.

Management of aggressive histologic variants of endometrial carcinoma at the Tom Baker Cancer Centre between 1984 and 1994

OBJECTIVE

The aim of this study was to determine the patient characteristics and outcome of patients with aggressive histologic variants (AV) of endometrial carcinoma, including uterine papillary serous carcinoma (UPSC), uterine clear cell carcinoma (UCCC), and mixed type.

METHODS AND MATERIALS

All cases with AV histological type of endometrial carcinoma from January 1984 to December 1994 at the Tom Baker Cancer Centre were identified using the Alberta Cancer Registry. Relevant data from the charts of these patients were entered into a study database (Microsoft Excel) and analyzed for presentation, demography, treatment parameters, and outcome of treatment. All pathology was reviewed at the time of diagnosis. Statistical analysis was performed using the S-plus statistics computer program. Univariate and multivariate analyses were used to assess independent prognostic factors using the Cox proportional hazards model.

RESULTS

A total of 103 patients with AV histological type were identified and analyzed; there were 61, 31, and 11 cases of UPSC, CCC, and mixed tumors, respectively. Sixty-three patients had Stage I, 11 had Stage II, 15 had Stage III, and 14 had Stage IV disease. The median age of patients was 67 years with a range of 36 to 86 years. Median follow-up was 60 months with a range of 36 to 156 months. The Cox proportional hazards model showed that lymphvascular space invasion and stage are the two independent prognostic factors affecting recurrence and survival. Forty six percent of all cases underwent surgery alone, 39% underwent treatment which included pelvic RT, and 17% underwent treatment which included chemotherapy. Pelvic recurrence was reduced significantly by radiotherapy in Stages I, II, and III (19% recurrence with no RT vs 7% recurrence with RT, P < 0.005). Chemotherapy improved overall survival, but made little difference in distant relapse rates.

CONCLUSIONS

Stage Ia cases treated by surgery alone have a low risk of relapse and need not be offered adjuvant systemic therapy or pelvic radiation. Patients with Ib, Ic, II, and III have significantly lower pelvic failure rates if treated with pelvic radiation, but still have a high distant failure rate. Systemic therapy did not significantly improve distant relapse-free survival, but did extend overall survival. Stage IV patients usually died within 6 months with a few responding to systemic chemotherapy. These results suggest that there is a need for randomized trials for these patients.

Quality care in an era of retrenchment

SOURCE AND PURPOSE: Constraints in the healthcare delivery system are resulting in unprecedented challenges to quality nursing care. In response to concerns expressed by readers in a JSPN survey, we solicited input from prominent SPN members.

CONCLUSIONS

Quality care can be sustained through nurses' creativity, flexibility, leadership, and collaboration. The context for quality care is an organizational environment with attention to critical analysis, careful resource utilization, and improved outcomes.

PRACTICE IMPLICATIONS

Nurses can not only maintain premium standards of quality care but, by assuming leadership, help shape the future of health care.

Adrenal failure in the critically ill

Three critically ill patients suffered multiple organ failure secondary to sepsis. Despite adequate supportive therapy and appropriate antibiotic cover, they failed to improve and required inappropriate inotrope support. They had not been treated with steroids or other drugs known to suppress adrenal function. Adrenal insufficiency was suspected. A random cortisol concentration and a short synacthen test demonstrated concentrations below the range expected in all three cases. High-dose steroid therapy was commenced with marked improvement in the short-term. However, in each case sepsis eventually caused death.

The role of surgery and laser ablation in oesophageal carcinoma

Between January 1990 and December 1994 oesophagectomy was carried out in 42 patients and comparison made with 38 who had palliative laser therapy. Apart from six patients referred after being unresectable at surgical exploration there were no agreed selection criteria, although the laser patients were in general older (mean 64 V 73 year) with a higher proportion of cardiorespiratory co-morbidity (14 per cent V 18 per cent). Lateral margins were involved in 14 per cent of known palliative resections with 50 per cent having positive nodes. The mean operating time was three hours and two chest drains inserted electively were removed after 3.6 days with mean drainage of 817 ml. The mean ICU stay was 5.4 days and 3 had radiological leaks; all but one settled conservatively. The 90 day mortality was 11.9 per cent for surgery and 34 per cent for laser patients. Twenty-three patients (61 per cent) required further courses of laser-therapy for benign anastomotic stenosis. Including the initial treatment of both groups 6.0 procedures per patient year were required in the laser groups compared with 1.1 for surgery. The 1, 2 and 3 year survival was 60 per cent, 31 per cent, 39 per cent for surgery compared with 24 per cent, 8 per cent, 3 per cent for laser--12 surgical patients are still alive and well at mean of 29 months (range 16-68). Surgery where possible with acceptable morbidity and mortality offers good palliation and long-term survival is possible; selection criteria for palliation only need to be defined.

Sarcoidosis of the pancreas: a case report

Sarcoidosis involving the pancreas is quite rare, having been reported only 10 times in the English language literature. Its clinical presentation is often similar to pancreatic cancer, with common presenting symptoms including abdominal pain, weight loss, jaundice, and anorexia. Diagnosis has been made in all cases at laparotomy, and in the majority of cases, no previous history of sarcoidosis was reported. Treatment has ranged from observation to pancreaticoduodenectomy for suspected malignancy. Prognosis is favorable with no significant morbidity or mortality reported postoperatively. The case we report is that of a patient with a prior history of sarcoidosis who presented with a clinical picture suggestive of pancreatic malignancy. However, the patient was found to have sarcoidosis involving the pancreas, with no evidence of malignancy at laparotomy.