The birth of a specialty: the first ten thousand patients of an old age psychiatry service

BACKGROUND

Old age psychiatry as a clinical specialty emerged in the 1970s and modern, open-access multidisciplinary services started in the mid-1980s in South London. There are few accounts of referrals to old age psychiatry services and no quantitative accounts of the referral patterns to such teams. We report on the first 10,000 patients newly referred to the first such service in the world.

METHODS

Observational study on routinely gathered data on age, gender, referral source, discipline of team member involved, diagnosis and duration of contact. Data validation was by iterative feedback to clinicians.

RESULTS

Ten thousand patients were referred between December 1983 and March 2000. Missing data rates were low. The overall referral rate was 21.0 per 1000 population over 65 per annum, with the highest rate in those 85+ years old, in whom there was a marked rise over time. The rise in referral rate compensated for a decline in the population over 65 so that the numbers of referrals rose. Although there was a rise in the rate of referral of people with an organic diagnosis over time, this was not statistically significant. Organic patients constituted 50-60% of referrals but had shorter contact times than functional ones. Cause for concern included a low rate of referral from care homes, and a high proportion of possibly inappropriate referrals from medical and general psychiatry services. We were pleased to see no excess of such referrals from open-access sources, confirming earlier work.

CONCLUSIONS

Descriptive data on referrals and workload of the first open-access multidisciplinary old age psychiatry service have generated cause for both celebration and concern.

Developing empathy as a foundation of client-centred practice: evaluation of a university curriculum initiative

BACKGROUND

The foundation of client-centred practice is the therapist's capacity to view the world through the client's eyes and to develop an understanding of the lived experience of disability.

PURPOSE

This paper describes the evaluation of an educational initiative promoting student empathy to the lived experience of disability.

METHODS

Pairs of first-year occupational therapy students visited adults with disabilities who shared their knowledge and experience of living with a disability. Students reflected on their visits in journals, which were later analyzed using pattern matching.

FINDINGS

Students appeared to appreciate the co-existence of health and disorder and demonstrated a holistic understanding of living with a disability. Little attention was focused on cultural and institutional environments. Students struggled to define the nature of their relationship with their tutors. Practice Implications. The evaluation confirmed our belief that this educational initiative could facilitate student empathy, consistent with critical features of client-centred practice.

Platelets adhered to endothelial cell-bound ultra-large von Willebrand factor strings support leukocyte tethering and rolling under high shear stress

Leukocyte rolling on vascular endothelium is mediated by an interaction between P-selectin expressed on endothelial cells and P-selectin glycoprotein ligand-1 on leukocytes. This interaction reduces the velocity of leukocyte movements to allow subsequent firm adhesion and transmigration. However, the interaction has so far been observed only under low venous shear stress and cannot explain the accumulation of monocytes in atherosclerotic plaques found in arteries, where shear stress is much higher. We have previously shown that newly released ultra-large von Willebrand factor (ULVWF) forms extremely long string-like structures to which platelets tether. Here, we investigated whether platelets adhered to ULVWF strings are activated and form aggregates. We also determined whether activated platelets on ULVWF strings can support leukocyte tethering and rolling under high shear stresses. We found that platelets adhered to ULVWF expressed P-selectin and bound PAC-1, suggesting their rapid activation. We also found that leukocytes tethered to and rolled on these platelet-decorated ULVWF strings, but not directly on endothelial cells, under high shear stresses of 20 and 40 dyn/cm(2) in a P-selectin dependent manner. These results suggest that the endothelial cell-bound ULVWF provide an ideal matrix to aggregate platelets and recruit leukocytes to endothelial cells under high shear stress. The observed phenomenon delineates a mechanism for leukocytes to be tethered to arterial endothelial cells under high shear, providing a potential link between inflammation and thrombosis.

Variations among normal individuals in the cleavage of endothelial-derived ultra-large von Willebrand factor under flow

von Willebrand factor (VWF) freshly released from endothelial cells is normally cleaved by the ADAMTS-13 metalloprotease to prevent the direct release of these ultra-large (UL) and hyper-reactive multimers into plasma. The balance of ULVWF proteolysis may be regulated by the amount of ULVWF released and the processing capacity of ADAMTS-13. The former associates with the size of ULVWF storage pool, sensitivity of vascular endothelial cells to stimulation, and the type of agonists, whereas the latter associates with the activity of ADAMTS-13. These parameters may vary significantly among individuals. We have determined the variations of ADAMTS-13 activity in 68 normal individuals by a flow-based assay and a static assay using ULVWF strings and recombinant VWF A2 domain as substrates, respectively. We found that the levels of ADAMTS-13 activity required to cleave the platelet-decorated ULVWF strings under flow is significantly higher than that of static assays. Normal plasma diluted to 25% significantly reduced its ability to cleave ULVWF strings under flow, whereas 2% plasma retained 48% enzyme activity in static assay. ADAMTS-13 activity varied from 33 to 100% among individuals and the variations were greater at shorter incubations of plasma with the substrate. Furthermore, the production of ULVWF from endothelial cells also varied among individuals. These results suggest that the commonly used static assays may underestimate the ADAMTS-13 activity required to cleave newly released ULVWF. They also demonstrated that the proteolysis of ULVWF may vary significantly among individuals, potentially contributing to the individual's vulnerability to thrombosis so that measurement of ADAMTS-13 may serve as a marker for TTP and other thrombotic diseases.

Medium-term results of cementless hydroxyapatite-coated primary total hip arthroplasty: a clinical and radiological review

PURPOSE

To evaluate the clinical and radiological outcomes following cementless primary hydroxyapatite-coated total hip arthroplasty.

METHODS

A retrospective study of 69 patients (82 hips) who underwent uncemented hydroxyapatite-coated Anatomic Benoist Girard total hip replacement between October 1991 and October 1995 at our institution was conducted. Patient records were reviewed. All patients were evaluated clinically using the Merle D'Aubigne hip score, and osteointegration was assessed radiographically by analysing the bone implant interface in the 7 zones of Gruen on followup review.

RESULTS

The mean follow-up period was 7.3 years. Clinical results were excellent with an improvement seen in clinical score from 9.9 preoperatively to 16.5 at last review. A total of 15% of patients recorded some thigh discomfort, which was intermittent and not functionally limiting, except in 2 cases. There were 3 cases of severe acetabular osteolysis and loosening requiring revision surgery, and 4 cases of localised proximal femoral osteolysis around well-ingrown implants. There were few perioperative complications, with the exception of 5 dislocations of which 3 were recurrent and required a revision procedure.

CONCLUSION

Clinical and radiological outcomes following cementless hydroxyapatite-coated total hip arthroplasty were seen to be favourable in this medium-term retrospective study.

Endogenous interleukin-10 is required for the defervescence of fever evoked by local lipopolysaccharide-induced and Staphylococcus aureus-induced inflammation in rats

We tested the hypothesis that endogenous interleukin (IL)-10 limits the fever induced by a Gram-negative bacterial toxin (Escherichia coli lipopolysaccharide, LPS) and a Gram-positive bacterial toxin (Staphylococcus aureus), when these toxins are injected into a subcutaneous air pouch (I.PO.) in rats. Injection of LPS or S. aureus caused fevers that were reduced in amplitude and duration by simultaneous administration of rat recombinant IL-10. The inhibition of fever by IL-10 was accompanied by a significant reduction in the toxin-evoked increases in concentrations of immunoreactive IL-6 at the site of inflammation and of IL-6 and IL-1 receptor antagonist in the circulation. Conversely, neutralisation of endogenous IL-10 in the pouch increased the amplitude and dramatically increased the duration of toxin-evoked fever, and augmented toxin-induced increases in pouch tumour necrosis factor-alpha, IL-1beta, and especially IL-6. Our data support a crucial regulatory role for endogenous IL-10 in limiting the fever responses during both Gram-negative and Gram-positive infections.

Exploring psychological abuse in childhood: I. Developing a new interview scale

Definitions of psychological abuse are reviewed and a new definition proposed, operationalized as an extension of an existing measure of childhood, the Childhood Experience of Care and Abuse (CECA). This semistructured, investigator-based interview is designed for use with adults to collect retrospective accounts of childhood adverse experience. The CECA extension identifies nine subtypes of psychological abuse, with a single global severity rating. The definition is clearly differentiated from other adverse experiences with emotionally abusive elements such as parental antipathy (hostile parenting), neglect, and role reversal. Examples are given. A community-based series of 301 women were interviewed using the extended CECA to gather a range of experiences of childhood maltreatment on which to devise the new measure. Interrater reliability was satisfactory, and several features of psychological abuse were examined, including its prevalence, frequency, and the characteristics of the abused child and perpetrator. The new scale is discussed in terms of its potential use not only by researchers but also by practitioners such as clinicians and social workers in the child protection field in order to more accurately identify and assess multiples of abuse in childhood. A companion article (Bifulco, Moran, Baines, Bunn, & Stanford, 2002) examines the relationship of psychological abuse to adult major depression.

Childhood adversity, parental vulnerability and disorder: examining inter-generational transmission of risk

BACKGROUND

An investigation of intergenerational factors associated with psychiatric disorder in late adolescence/early adulthood was undertaken to differentiate influences from maternal disorder, maternal poor psychosocial functioning and poor parenting, on offspring.

METHOD

The sample comprised an intensively studied series of 276 mother-offspring pairs in a relatively deprived inner-city London area with high rates of lone parenthood and socio-economic disadvantage. The paired sample was collected over two time periods: first a consecutively screened series of mothers and offspring in 1985-90 (n = 172 pairs) and second a 'vulnerable' series of mothers and offspring in 1995-99 (n = 104 pairs). The vulnerable mothers were selected for poor interpersonal functioning and/or low self-esteem and the consecutive series were used for comparison. Rates of childhood adversity and disorder in the offspring were examined in the two groups. Maternal characteristics including psychosocial vulnerability and depression were then examined in relation to risk transmission.

RESULTS

Offspring of vulnerable mothers had a fourfold higher rate of yearly disorder than those in the comparison series (43% vs. 11%, p < .001). They were twice as likely as those in the comparison series to have experienced childhood adversity comprising either severe neglect, physical or sexual abuse before age 17. Physical abuse, in particular, perpetrated either by mother or father/surrogate father was significantly raised in the vulnerable group. Analysis of the combined series showed that maternal vulnerability and neglect/abuse of offspring provided the best model for offspring disorder. Maternal history of depression had no direct effect on offspring disorder; its effects were entirely mediated by offspring neglect/abuse. Maternal childhood adversity also had no direct effect.

CONCLUSIONS

Results are discussed in relation to psychosocial models of risk transmission for disorder. Maternal poor psychosocial functioning needs to be identified as a factor requiring intervention in order to stem escalation of risk across generations.

Alagille syndrome associated with angiographic moyamoya

We describe the case of a 13-year-old boy with Alagille syndrome in whom intracranial imaging was performed following a seizure. The MRI and MRA revealed changes of angiographic moyamoya within both the anterior and posterior circulation. This very rare manifestation of the systemic vasculopathy in Alagille syndrome has not been previously documented in a patient without a focal neurological deficit. We discuss the potential role of routine intracranial imaging in patients with Alagille syndrome.

Adult attachment style. II: Its relationship to psychosocial depressive-vulnerability

BACKGROUND

A range of studies show adult attachment style is associated with depressive-vulnerability factors such as low self-esteem, poor support and childhood adversity. However, there is wide inconsistency shown in the type of insecure style most highly associated. Few studies have examined attachment style in relation to clinical depression together with a range of such factors in epidemiological series. The present study uses an interview measure of adult attachment which differentiates type of attachment style and degree of insecurity of attachment, to see: (a) if it adds to other vulnerability in predicting depression and (b) if there is specificity of style to type of vulnerability.

METHOD

Two hundred and twenty-two high-risk and 80 comparison women were selected from questionnaire screenings of London GP patient lists and intensively interviewed. The Attachment Style Interview (ASI) differentiated five styles (Enmeshed, Fearful, Angry-dismissive, Withdrawn and Standard) as well as the degree to which attitudes and behaviour within such styles were dysfunctional ('non-standard'). Attachment style was examined in relation to low self-esteem, support and childhood experience of neglect or abuse, and all of these examined in relation to clinical depression in a 12-month period.

RESULTS

The presence of any 'non-standard' style was significantly related to poor support, low self-esteem and childhood adversity. Some specificity of type of style and type of vulnerability was observed. Logistic regression showed that non-standard Enmeshed, Fearful and Angry-dismissive styles, poor support and childhood neglect/abuse provided the best model for clinical depression.

CONCLUSION

Non-standard attachment in the form of markedly Enmeshed, Fearful or Angry-dismissive styles was shown to be associated with other depressive-vulnerability factors involving close relationships, self-esteem and childhood adversity and added to these in modelling depression.

Adult attachment style. I: Its relationship to clinical depression

BACKGROUND

Although there are an increasing number of studies showing an association of adult attachment style to depressive disorder, such studies have rarely utilised epidemiological approaches with large community-based series and have relied heavily on brief self-report measurement of both attachment style and symptoms. The result is a wide inconsistency in the type of insecure style shown to relate to disorder. The present study examined adult attachment style in a high-risk community sample of women in relation to clinical depression. It utilised an interview measure of adult attachment which allowed for an assessment of both type of attachment style and the degree of insecurity of attachment. A companion paper examines its relationship with other depressive-vulnerability (Bifulco et al. 2002).

METHOD

Two hundred and twenty-two high-risk and 80 comparison women were selected from questionnaire screenings of London GP patient lists and intensively interviewed. A global scale of attachment style based on supportive relationships (with partner and very close others) together with attitudes to support-seeking, derived the four styles paralleling those from self-report attachment assessments (Secure, Enmeshed, Fearful, Avoidant). In order to additionally reflect hostility in the scheme, the Avoidant category was subdivided into 'Angry-dismissive' and 'Withdrawn'. The degree to which attitudes and behaviour within such styles were dysfunctional ('non-standard') was also assessed. Attachment style was examined in relation to clinical depression in a 12-month period. For a third of the series this was examined prospectively to new onset of disorder.

RESULTS

The presence of any insecure style was significantly related to 12-month depression. However, when controls were made for depressive symptomatology at interview, only the 'non-standard' levels of Enmeshed, Fearful or Angry-dismissive styles related to disorder. Withdrawn-avoidance was not significantly related to disorder.

CONCLUSION

The relationship of attachment style to clinical depression is increased by differentiating the degree of insecurity of style and differentiating hostile and non-hostile avoidance.

Paediatric antiretroviral therapy audit in South London

OBJECTIVES

To audit clinical and surrogate marker outcome data following the introduction of combination antiretroviral therapy to HIV-infected children in South London.

METHODS

We performed a retrospective cohort study of 110 HIV-infected children under the care of the Paediatric HIV in South London Network (PHILS-NET) from January 1996 to September 1999. The following were identified: type of antiretroviral therapy used; duration of therapy; toxicity; impact on viral load and CD4 count; reasons for changing therapy; and clinical progression.

RESULTS

Ninety-one (83%) of the 110 children (55 females; median age 6.3 years) received 166 antiretroviral therapy regimens. Sixty per cent of the regimens were triple therapy: either two nucleoside reverse transcriptase inhibitors (NRTIs) and one protease inhibitor (58; 34.9%) or two NRTIs and one non-nucleoside reverse transcriptase inhibitor (39; 23.5%). The mean duration of completed therapy was 46 weeks for first line therapy with a standard deviation (SD) of 38 weeks and 40 weeks in third line therapy with an SD of 22 weeks. Changes in antiretroviral regimens were owing to virological failure in 60% and toxicity in 10%. Overall, 46% of children on first line and 37% on second line antiretroviral therapy achieved an undetectable viral load of < 400 HIV-1 RNA copies/mL. Clinical progression for the whole cohort fell from 3.7% per year for children on dual therapy to 0.7% per year for children on highly active antiretroviral therapy.

CONCLUSIONS

This audit shows the clinical benefit of antiretroviral therapy use in a cohort of children with moderately advanced HIV disease. The surrogate outcome data seen for the viral load and CD4 count are similar to those of reports from clinical trials. Antiretroviral therapy regimens were sequenced rapidly, mainly owing to virological failure.

Predicting onset of depression: the Vulnerability to Depression Questionnaire

OBJECTIVES

The development of a self-report questionnaire capable of assessing cognitive and interpersonal vulnerability factors for clinical depression is described. The Vulnerability to Depression Questionnaire (VDQ) was developed to provide a brief, economical alternative to the Self-Evaluation and Social Support interview (SESS; O'Connor & Brown, 1984), assessing negative evaluation of self, negative interaction with partner or child and lack of a support figure.

DESIGN

The VDQ was tested in a prospective study of community-based women who were contacted on three occasions over the course of approximately 1 year, to: (i) compare the VDQ's capacity to categorize vulnerability compared with the SESS interview, and (ii) to test the VDQ's prediction of onset of clinical depression during the follow-up.

METHOD

Selected nondepressed respondents completed the VDQ and were interviewed to determine their vulnerability using the SESS. They were re-interviewed on two further occasions during the follow-up period, and the VDQ was also re-administered at the time of first follow-up. Onset of clinical depression during the follow-up was assessed by interview at each contact.

RESULTS

Comparison of VDQ and SESS interview classification of participants' vulnerability at first contact indicated that the questionnaire had good sensitivity and specificity. Test-retest scores for the VDQ indicated satisfactory levels of reliability. VDQ scores also predicted onset of clinical depression in the follow-up period.

CONCLUSIONS

Results suggest that the VDQ is an economical and effective means of screening large populations for the purposes of risk assessment, to aid future research into clinical depression and to facilitate the implementation of intervention strategies.