Continuity of care in mental health: understanding and measuring a complex phenomenon

BACKGROUND

Continuity of care is considered by patients and clinicians an essential feature of good quality care in long-term disorders, yet there is general agreement that it is a complex concept. Most policies emphasize it and encourage systems to promote it. Despite this, there is no accepted definition or measure against which to test policies or interventions designed to improve continuity. We aimed to operationalize a multi-axial model of continuity of care and to use factor analysis to determine its validity for severe mental illness.

METHOD

A multi-axial model of continuity of care comprising eight facets was operationalized for quantitative data collection from mental health service users using 32 variables. Of these variables, 22 were subsequently entered into a factor analysis as independent components, using data from a clinical population considered to require long-term consistent care.

RESULTS

Factor analysis produced seven independent continuity factors accounting for 62.5% of the total variance. These factors, Experience and Relationship, Regularity, Meeting Needs, Consolidation, Managed Transitions, Care Coordination and Supported Living, were close but not identical to the original theoretical model.

CONCLUSIONS

We confirmed that continuity of care is multi-factorial. Our seven factors are intuitively meaningful and appear to work in mental health. These factors should be used as a starting-point in research into the determinants and outcomes of continuity of care in long-term disorders.

Algorithms for intravenous insulin delivery

This review aims to classify algorithms for intravenous insulin infusion according to design. Essential input data include the current blood glucose (BG(current)), the previous blood glucose (BG(previous)), the test time of BG(current) (test time(current)), the test time of BG(previous) (test time(previous)), and the previous insulin infusion rate (IR(previous)). Output data consist of the next insulin infusion rate (IR(next)) and next test time. The classification differentiates between "IR" and "MR" algorithm types, both defined as a rule for assigning an insulin infusion rate (IR), having a glycemic target. Both types are capable of assigning the IR for the next iteration of the algorithm (IR(next)) as an increasing function of BG(current), IR(previous), and rate-of-change of BG with respect to time, each treated as an independent variable. Algorithms of the IR type directly seek to define IR(next) as an incremental adjustment to IR(previous). At test time(current), under an IR algorithm the differences in values of IR(next) that might be assigned depending upon the value of BG(current) are not necessarily continuously dependent upon, proportionate to, or commensurate with either the IR(previous) or the rate-of-change of BG. Algorithms of the MR type create a family of IR functions of BG differing according to maintenance rate (MR), each being an iso-MR curve. The change of IR(next) with respect to BG(current) is a strictly increasing function of MR. At test time(current), algorithms of the MR type use IR(previous) and the rate-of-change of BG to define the MR, multiplier, or column assignment, which will be used for patient assignment to the right iso-MR curve and as precedent for IR(next). Bolus insulin therapy is especially effective when used in proportion to carbohydrate load to cover anticipated incremental transitory enteral or parenteral carbohydrate exposure. Specific distinguishing algorithm design features and choice of parameters may be important to establish freedom from hypoglycemia, eliminate the need for administration of concentrated dextrose during euglycemia, control variability within the treatment course of individual patients, achieve adaptability to differing blood glucose targets, and minimize variability of glycemic control between treatment courses of different patients or patient populations. Areas for future work include the reduction of nursing burden, the development of a theory that will account for lag time of interstitial monitoring and pharmacodynamic delay of insulin action, and management strategies for the narrow euglycemic range. It is hoped that hypoglycemia and variability of control will become negligible problems, and that fear of hypoglycemia no longer will deflect investigators and caregivers from providing optimal glycemic management.

A review of instruments developed to measure outcomes for carers of people with mental health problems

OBJECTIVE

Community-based care for mental disorders places considerable burden on families and carers. Measuring their experiences has become a priority, but there is no consensus on appropriate instruments. We aimed to review instruments carers consider relevant to their needs and assess evidence for their use.

METHOD

A literature search was conducted for outcome measures used with mental health carers. Identified instruments were assessed for their relevance to the outcomes identified by carers and their psychometric properties.

RESULTS

Three hundred and ninety two published articles referring to 241 outcome measures were identified, 64 of which were eligible for review (used in three or more studies). Twenty-six instruments had good psychometric properties; they measured (i) carers' well-being, (ii) the experience of caregiving and (iii) carers' needs for professional support.

CONCLUSION

Measures exist which have been used to assess the most salient aspects of carers outcome in mental health. All require further work to establish their psychometric properties fully.

The therapeutic relationship in secondary mental health care: a conceptual review of measures

OBJECTIVE

The study aimed to determine the conceptual basis of measures of the patient-professional relationship used in routine mental health services research by reviewing their face, content and construct validity.

METHOD

A comprehensive literature search identified measures of the relationship used in mental health services research. The conceptual basis of each identified measure was identified by a review of measures' authors assessments of face, content and construct validity plus item analysis of the measures themselves.

RESULTS

The search identified 15 measures. The seven developed in psychotherapy were likely to be better validated conceptually; most were based on therapeutic alliance models. Measures developed specifically for mental health services were based on a wider range of models including global assessments of the relationship.

CONCLUSION

Most of the better validated measures originate in psychotherapy, but there is limited evidence for their validity in general mental health services. Four measures are recommended.

Hyponatremia in marathon runners due to inappropriate arginine vasopressin secretion

PURPOSE

Exercise-associated hyponatremia (EAH), as defined by a blood sodium concentration [Na+] less than 135 mmol/L, may lead to hypotonic encephalopathy with fatal cerebral edema. Understanding the pathogenetic role of antidiuresis may lead to improved strategies for prevention and treatment.

METHODS

Normonatremic marathon runners were tested pre- and post-race for creatine kinase, interleukin-6, cortisol, prolactin, and arginine vasopressin. Similar testing also was carried out in runners with encephalopathy caused by EAH, including 2 cases with fatal cerebral edema.

RESULTS

Normonatremic runners (n = 33; 2001) with a mean 3% decrease in body weight showed a 40-fold increase in interleukin-6 (66.6 +/- 11.9 pg/mL from 1.6 +/- 0.5 pg/mL, P = .001), which was significantly correlated with increases in creatine kinase (r = 0.88, P = <.0001), cortisol (r = 0.70, P = .0003), and prolactin (r = 0.67, P <.007), but not arginine vasopressin (r = 0.44, P = .07). Collapsed runners with EAH (n = 22; 2004) showed a mean blood urea nitrogen less than 15 mg/dL with measurable plasma levels of arginine vasopressin (>0.5 pg/mL) in 43% of cases. Two marathon runners with fatal cerebral edema additionally showed less than maximally dilute urines (>100 mmol/kg/H2O) and urine [Na+] greater than 25 mEq/L.

CONCLUSIONS

Cases of EAH fulfill the essential diagnostic criteria for the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Runners with hypotonic encephalopathy at subsequent races were treated with intravenous hypertonic (3%) saline on the basis of this paradigm, which resulted in rapid clinical improvement without adverse effects. Release of muscle-derived interleukin-6 may play a role in the nonosmotic secretion of arginine vasopressin, thereby linking rhabdomyolysis to the pathogenesis of EAH.

Better glycemic control in the hospital: beneficial and feasible

Hospitalized patients fare better if their blood glucose levels are strictly controlled. To manage blood glucose effectively, hospitals need to set up formal programs. Attending physicians, endocrinologists, and nurses need to work as a team. Standardized forms with management guidelines are valuable.

Intracellular residency is frequently associated with recurrent Staphylococcus aureus rhinosinusitis

AIM

The prevalence of intracellular Staphylococcus aureus organisms in the nasal mucosa of patients with recurrent infectious rhinosinusitis episodes was studied.

METHOD

Twenty-seven consecutive adult patients who failed medical management of chronic rhinosinusitis (CRS) of multiple origins, associated or not with nasal polyposis, were consecutively enrolled for endonasal sinus surgery (including partial middle turbinectomy, middle antrostomy, ethmoidectomy, sphenoidotomy) and followed for a 12-month post-operative period.

RESULTS

Seventeen of these patients showed the presence of intracellular S. aureus as detected by confocal laser scan immunofluorescence microscopy in epithelial cells of surgical intranasal biopsy specimens. Nine of the patients with and two without intracellular bacteria yielded S. aureus in endoscopically guided cultures of middle meatus secretions, despite the recent administration of prophylactic antibiotics. Eleven of the 17 patients with intracellular S. aureus relapsed for rhinosinusitis within the 12-month follow-up period. Molecular typing of sequential S. aureus isolates demonstrated the persistence of unique patient-specific S. aureus clonotypes in nine of the patients with intracellular bacteria during the 12-month follow-up.

CONCLUSION

The presence of intracellular S. aureus in epithelial cells of the nasal mucosa is a significant risk factor for recurrent episodes of rhinosinusitis due to persistent bacterial clonotypes, which appear refractory to antimicrobial and surgical therapy.

Embryonic and adult stem cell-derived cardiomyocytes: lessons from in vitro models

For years, research has focused on how to treat heart failure by sustaining the overloaded remaining cardiomyocytes. Recently, the concept of cell replacement therapy as a treatment of heart diseases has opened a new area of investigation. In vitro-generated cardiomyocytes could be injected into the heart to rescue the function of a damaged myocardium. Embryonic and/or adult stem cells could provide cardiac cells for this purpose. Knowledge of fundamental cardiac differentiation mechanisms unraveled by studies on animal models has been improved using in vitro models of cardiogenesis such as mouse embryonal carcinoma cells, mouse embryonic stem cells and, recently, human embryonic stem cells. On the other hand, studies suggesting the existence of cardiac stem cells and the potential of adult stem cells from bone marrow or skeletal muscle to differentiate toward unexpected phenotypes raise hope and questions about their potential use for cardiac cell therapy. In this review, we compare the specificities of embryonic vs adult stem cell populations regarding their cardiac differentiation potential, and we give an overview of what in vitro models have taught us about cardiogenesis.

[Non-invasive bi-level ventilation in paediatric status asthmaticus]

Invasive ventilation in status asthmaticus is associated with an increased mortality and morbidity. To avoid intubation associated complications, non-invasive bi-level ventilation is often used in adults and children. We report the clinical history of an 11-month old infant, which encountered intubation criteria but was treated successfully by full-face mask non-invasive bi-level ventilation. Despite difficulties in application due to young age and lack of age related material, non-invasive bi-level ventilation is a good tool in the treatment of children with status asthmaticus.

Subcutaneous Insulin Therapy in the Hospital Setting: Issues, Concerns, and Implementation

OBJECTIVE

To summarize issues and recommendations regarding subcutaneous insulin therapy in various clinical settings in the hospital.

RESULTS

The inpatient insulin regimen must be tailored to the specific clinical circumstance of the individual patient. Because nutritional intake is not necessarily provided as discrete meals in the hospital, the insulin dose requirement can be subclassified into "basal" and "nutritional" needs. In addition, the insulin requirement is generally increased in the presence of acute illness and stress. Thus, components of the insulin requirement are divided into basal, nutritional, and correction insulin. When the physician writes insulin orders, the basal and nutritional components are written as programmed or scheduled insulin, and the correction-dose insulin is written as an algorithm to supplement the scheduled insulin. Total insulin requirements may vary widely. Practical guidelines and suggestions are presented for selection of appropriate insulins, the delivery route, and the logical apportionment to programmed and correction insulin doses for hospitalized patients who are eating or not eating. Moreover, the role of bedside blood glucose monitoring in the hospital setting is discussed.

CONCLUSION

Strict glycemic management in hospitalized patients has been shown to improve outcomes. Development and implementation of specific strategies for insulin delivery and improved methods for blood glucose monitoring should help to achieve target blood glucose levels safely.

Guidelines for glycemic control

Glycemic control in diabetes patients continues to evolve as new medications are introduced and clinical trial data become available. The American Diabetes Association (ADA) guidelines for 2004, for the first time, provide targets for both preprandial and postprandial glucose levels. The ADA, however, does not provide guidelines regarding specific medication therapy. This paper provides a detailed treatment algorithm that is easy to follow for nurse practitioners as well as primary care providers. Progress in our understanding of diabetes and new therapeutic agents will dictate modifications of treatment targets and guidelines, with the goal of making euglycemia achievable for all patients with diabetes.

Oral modified insulin (HIM2) in patients with type 1 diabetes mellitus: results from a phase I/II clinical trial

An effective, orally administered insulin product would be of substantial benefit in the treatment of patients with diabetes mellitus. This phase I/II clinical trial was the first to investigate the safety and effectiveness of a single oral dose of a modified human insulin in controlling postprandial plasma glucose levels in patients with type 1 diabetes mellitus who were receiving basal continuous subcutaneous insulin infusion (CSII) therapy. Fourteen patients with type 1 diabetes mellitus were evaluated in an open-label, 2-center, dose-escalation, nonrandomized study of oral hexyl-insulin monoconjugate 2 (HIM2). After an overnight fast and prior to receiving a standardized meal (50% carbohydrates, 30% fat, 20% proteins; 650 calories), the patients received either no additional insulin (day 1), or 0.5 to 1.0 mg/kg of HIM2 (day 2). All patients received a basal insulin regimen by CSII throughout the study. Blood samples were collected for determination of glucose and insulin levels for 240 minutes post-dose. The postprandial glucose excursion versus time curves showed clear reductions in glucose values after both HIM2 doses (day 2) relative to no treatment (day 1), although the differences in the reductions were not statistically significant. When the data for both HIM2 doses were pooled, a statistically significant effect of HIM2 on glucose excursion (as measured by AUCex(30-240)) was observed. Mean +/- SD values for AUCex(30-240) were 501.35 +/- 124.1 mg. h/dL after no treatment and 375.81 +/- 215.5 mg. h/dL after HIM2 (Wilcoxon signed-rank test, P =.042). The results of this study suggest that oral HIM2, when added to a basal insulin regimen, was safe and may prove effective in controlling postprandial hyperglycemia in patients with type 1 diabetes mellitus. Further clinical investigation is necessary.

Transvaginal ultrasound in pregnancy: its acceptability to women and maternal psychological morbidity

OBJECTIVES

To assess the acceptability to women of antenatal transvaginal ultrasound scans; to compare the characteristics of women who accept the offer of a transvaginal scan with those who decline; to establish the prevalence of any psychological morbidity associated with the scan.

METHODS

The study was a cross-sectional questionnaire survey. Women were recruited from two hospitals in South London. The sample consisted of 755 pregnant women who had a transvaginal scan at 23 weeks' gestation to assess the risk of preterm delivery and 167 women who were offered the transvaginal scan but declined. Women completed a questionnaire at home. Those who reported finding the scan a difficult experience were sent a questionnaire 4 weeks post-scan to assess its longer term impact. The main outcomes were acceptability (assessed by individual questionnaire items); anxiety before and during the scan (Spielberger State-trait Anxiety Inventory); pain during the scan (Present Pain Intensity Scale of the McGill Pain Questionnaire); psychological trauma (Impact of Event Scale).

RESULTS

Over half (55.2%) of women accepted the offer of a transvaginal scan, according to hospital records. The majority of study participants who had transvaginal ultrasound reported finding the experience acceptable. Women experienced some anxiety before and during the scan and over a third experienced some (usually mild) pain during the procedure. Twelve women (1.6%) reported clinically significant levels of psychological trauma in relation to the scan.

CONCLUSIONS

Antenatal transvaginal ultrasound for assessing the risk of preterm delivery is an acceptable procedure for the majority of women. A significant minority decline the scan. The procedure has some psychological sequelae for some women.

Oral insulin product hexyl-insulin monoconjugate 2 (HIM2) in type 1 diabetes mellitus: the glucose stabilization effects of HIM2

This study was designed to determine plasma glucose and insulin levels after administration of three escalating doses of the oral insulin product hexyl-insulin monoconjugate 2 (HIM2) in fasting, insulin-deprived adult patients with type 1 diabetes. The study was also designed to assess the safety of the product. Sixteen patients with daily insulin requirements of 27-60 units and glycosylated hemoglobin levels of 5.8-11.1% completed the study. Patients' regular insulin regimens were discontinued at bedtime, and they fasted overnight. Blood glucose levels were stabilized overnight by intravenous insulin infusion. In the morning, intravenous insulin was discontinued 30 min prior to an oral dose of HIM2 (0.6, 0.8, or 1.0 mg/kg). A second oral dose of HIM2 was administered 120 min later. Plasma glucose and insulin levels were measured during a 240-min evaluation period after the first HIM2 dose. Identical HIM2 dosing and study procedures were repeated 1 week later with the same patients. Stable or declining plasma glucose levels were observed on 31 out of a total of 32 dosing days beginning at 20 min after the initial administration of HIM2. After plasma glucose levels declined or were stable for 30 min to 2 h, increases were observed for some patients. However, for the majority of patients (68.8%), plasma glucose levels were <150% of predose levels throughout the postdose evaluation period. Similar results were observed after repeating the study procedures 1 week later. Also, plasma glucose area under the concentration-time curves (AUCs) were inversely correlated with plasma insulin AUCs. HIM2 appeared to be safe and well-tolerated in this study; no episodes of symptomatic hypoglycemia were observed. Thus, HIM2 prevented the expected rise in plasma glucose concentrations in insulin-deprived adult patients with type 1 diabetes. The lack of hypoglycemic events in this exploratory study is encouraging and suggests that there may be less risk of severe hypoglycemia associated with HIM2 when compared with injectable insulin. The promising data in this study support the hypothesis that oral HIM2 reproduces the physiological pathway of insulin secreted by the pancreas - through the portal vein directly to the liver - suggesting a therapeutic advantage in the management of type 1 diabetes mellitus.