Maintaining contact with people with severe mental illness: 5-year follow-up of assertive outreach

BACKGROUND

Assertive outreach is a central strand of Government mental health policy in England. Are different long-term models of mental health care which include assertive outreach associated with different service user outcomes and cost?

METHOD

We conducted a multi-site 5-year follow-up study of people with severe mental illness. From 0 to 18 months all three sites had Intensive Case Management (ICM) teams practising assertive outreach. From 18 to 60 months one team sustained ICM, one team merged and another was disbanded. All 131 original ICM team clients were the study participants. Outcome was measured in terms of sustained engagement with statutory mental health services, psychiatric symptoms, social functioning, resource use and cost.

RESULTS

All 120 live participants were traced. Only four people had no service contact; when contacted by a researcher they appeared to be coping well. No incidents of serious violence were discovered. No differences existed between teams in the mean total symptom or total social functioning change scores at follow-up, after controlling for baseline differences. No differences existed in mean cost between teams during the first 18 months. Mean (standard deviation) annualised costs varied considerably in the 18-60 month period: sustained team Pound Sterling13,734 (10,820); integrated team Pound Sterling11,037 (13,603); disbanded team Pound Sterling5,742 (7,007) (F=4.4, 105 df, p=0.015).

CONCLUSION

Continued specialist assertive outreach service models have higher costs than non-specialist services for no apparent benefit. In the long term new assertive outreach services should have procedures in place to transfer people to lower intensity and lower cost care.

Characterization of two evolutionarily conserved, alternatively spliced nuclear phosphoproteins, NFAR-1 and -2, that function in mRNA processing and interact with the double-stranded RNA-dependent protein kinase, PKR

We report here the isolation and characterization of two proteins, NFAR-1 and -2, which were isolated through their ability to interact with the dsRNA-dependent protein kinase, PKR. The NFAR proteins, of 90 and 110 kDa, are derived from a single gene through alternative splicing and are evolutionarily conserved nuclear phosphoproteins that interact with double-stranded RNA. Both NFAR-1 and -2 are phosphorylated by PKR, reciprocally co-immunoprecipitate with PKR, and colocalize with the kinase in a diffuse nuclear pattern within the cell. Transfection studies indicate that the NFARs regulate gene expression at the level of transcription, probably during the processing of pre-mRNAs, an activity that was increased in fibroblasts lacking PKR. Subsequent functional analyses indicated that amino acids important for NFAR's activity were localized to the C terminus of the protein, a region that was found to specifically interact with FUS and SMN, proteins also known as regulators of RNA processing. Accordingly, both NFARs were found to associate with both pre-mRNAs and spliced mRNAs in post-transcriptional studies, similar to the known splicing factor ASF/SF-2. Collectively, our data indicate that the NFARs may facilitate double-stranded RNA-regulated gene expression at the level of post-transcription and possibly contribute to host defense-related mechanisms in the cell.

Measurement of the branching ratio and form factor of K(L)-->mu(+)mu(-)gamma

We report on the analysis of the rare decay K(L)-->mu(+)mu(-)gamma the 1997 data from the KTeV experiment at Fermilab. A total of 9327 candidate events are observed with 2.4% background, representing a factor of 40 increase in statistics over the current world sample. We find that B(K(L)-->mu(+)mu(-)gamma) = (3.62 +/- 0.04(stat) +/- 0.08(syst)) x 10(-7). The form factor parameter alpha(K*) is measured to be alpha(K*) = -0.160(+0.026)(-0.028). In addition, we make the first measurement of the parameter alpha from the D'Ambrosio-Isidori-Portolés form factor, finding alpha = -1.54 +/- 0.10. In that model, this alpha measurement limits the Cabibbo-Kobayashi-Maskawa parameter rho>-0.2.

Comparison of tissue injury between laparosonic coagulating shears and electrosurgical scissors in the sheep model

STUDY OBJECTIVE

To compare laparosonic coagulating shears (LCS), which use ultrasonic energy, and unipolar diathermy scissors with respect to depth of tissue injury.

DESIGN

Prospective observational study (Canadian Task Force classification I).

SETTING

A reproduced surgical setting.

SUBJECTS

An anesthetized sheep.

INTERVENTION

We laparoscopically harvested uterine horn and bowel tissue.

MEASUREMENTS AND MAIN RESULTS

Tissue was transected while hemostasis was maintained. Two pathologists examined tissue independently, and each was blinded as to the instrument used for harvesting. Clinical characteristics and tissue injury created by the instruments were compared.

CONCLUSION

Subjectively, LCS appeared to produce less smoke plume than diathermy scissors. It also produced greater tissue damage than unipolar electrosurgery on settings of 35 W cut and 30 W coagulate.

Measurements of the rare decay K(L) --> e(+)e(-)e(+)e(-)

We observe 441 K(L)-->e(+)e(-)e(+)e(-) candidate events with a background of 4.2 events and measure B(K(L)-->e(+)e(-)e(+)e(-)) = [3.72+/-0.18(stat)+/-0.23(syst)]x10(-8) in the KTeV/E799II experiment at Fermilab. Using the distribution of the angle between the planes of the e(+)e(-) pairs, we measure the CP parameters beta(CP) = -0.23+/-0.09(stat)+/-0.02(syst) and gamma(CP) = -0.09+/-0.09(stat)+/-0.02(syst). We also present the first detailed study of the e(+)e(-) invariant mass spectrum in this decay mode.

Laparoscopic presacral neurectomy - retrospective series

A retrospective audit of medical records was conducted for one surgeon (AL). All patients who underwent laparoscopic presacral neurectomy for severe midline dysmenorrhoea were identified. Details of the preoperative symptoms, clinical findings and operative records were studied. Improvement of dysmenorrhoea was assessed according to a pain scale. Twelve patients who had a laparoscopic presacral neurectomy performed were identified. Eight patients reported significant improvement of symptoms, with a further two reporting mild improvement. Two patients failed to show any improvement of symptoms. We believe that the role of laparoscopic presacral neurectomy should be limited to patients with severe midline dysmenorrhoea not responding to the medical therapy. It may be a supplementary procedure to laparoscopic resection of endometriosis or adhesiolysis.

Measurement of the branching ratio and asymmetry of the decay Xi degrees -->Sigma degrees gamma

We have studied the rare weak radiative hyperon decay Xi degrees -->Sigma degrees gamma in the KTeV experiment at Fermilab. We have identified 4045 signal events over a background of 804 events. The dominant Xi degrees -->Lambdapi degrees decay, which was used for normalization, is the only important background source. An analysis of the acceptance of both modes yields a branching ratio of B(Xi degrees -->Sigma degrees gamma)/B(Xi degrees -->Lambdapi degrees ) = (3.34+/-0.05+/-0.09)x10(-3). By analyzing the final state decay distributions, we have also determined that the Sigma degrees emission asymmetry parameter for this decay is alpha(XiSigma) = -0.63+/-0.09.

Deeply infiltrating endometriosis: implications, diagnosis, and management

Deeply infiltrating endometriosis was described in the early part of the last century. Only recently, has there become a greater awareness and understanding of this form of endometriosis aided in part by advances in laparoscopic surgical technology in techniques. The clinical implications of the disease as well as diagnosis and current management are reviewed.

Laparoscopic presacral neurectomy: a review

Dysmenorrhea can be a severe and debilitating symptom in many women. Although most women may find adequate relief of symptoms from pharmacological approaches, there remain a few with resistant pain. Presacral neurectomy, although technically challenging, may be offered after other approaches are unsuccessful. The operation is now performed increasingly by the laparoscopic approach, which has revived this operation in some centers. The anatomy, technique, and indications as well as a review of the literature supporting this operation are reviewed. The potential complications of this operation are discussed also.

Study of the K(0)(L) --> pi(+)pi(-)gamma Direct Emission Vertex

We have performed studies of the K(0)(L)-->pi(+)pi(-)gamma direct emission ( DE) and inner Bremsstrahlung ( IB) vertices, based on data collected by KTeV during the 1996 Fermilab fixed target run. We find a(1)/a(2) = -0.737+/-0.034 GeV2 for the DE form-factor parameter in the rho-propagator parametrization, and report on fits of the form factor to linear and quadratic functions as well. We concurrently measure gamma(K(0)(L)-->pi(+)pi(-)gamma,E(*)(gamma)>20 MeV)/gamma(K(0)(L)-->pi(+)pi(-)) = (20.8+/-0.3)x10(-3), and a K(0)(L)-->pi(+)pi(-)gamma DE/(DE+IB) branching ratio of 0.683+/-0.011.

Xrel3 is required for head development in Xenopus laevis

The Rel/NF-kappa B gene family encodes a large group of transcriptional activators involved in myriad differentiation events, including embryonic development. We have shown previously that Xrel3, a Xenopus Rel/NF-kappa B-related gene, is expressed in the forebrain, dorsal aspect of the mid- and hindbrain, the otocysts and notochord of neurula and larval stage embryos. Overexpression of Xrel3 causes formation of embryonic tumours. We now show that Xrel3-induced tumours and animal caps from embryos injected with Xrel3 RNA express Otx2, Shh and Gli1. Heterodimerisation of a C-terminally deleted mutant of Xrel3 with wild-type Xrel3 inhibits in vitro binding of wild-type Xrel3 to Rel/NF-kappa B consensus DNA sequences. This dominant interference mutant disrupts Shh, Gli1 and Otx2 mRNA patterning and inhibits anterior development when expressed in the dorsal side of zygotes, which is rescued by co-injecting wild-type Xrel3 mRNA. In chick development, Rel activates Shh signalling, which is required for normal limb formation; Shh, Gli1 and Otx2 encode important neural patterning elements in vertebrates. The activation of these genes in tumours by Xrel3 overexpression and the inhibition of their expression and head development by a dominant interference mutant of Xrel3 indicates that Rel/NF-kappa B is required for activation of these genes and for anterior neural patterning in Xenopus.

Search for the decay KL --> pi(0)e+e-

We report on a search for the decay KL-->pi(0)e+e- carried out by the KTeV/E799 experiment at Fermilab. This decay is expected to have a significant CP violating contribution and the measurement of its branching ratio could support the Cabibbo-Kobayashi-Maskawa mechanism for CP violation or could point to new physics. Two events were observed in the 1997 data with an expected background of 1.06+/-0.41 events, and we set an upper limit B(KL-->pi(0)e+e-)<5.1 x 10(-10) at the 90% confidence level.

Search for the decay K(L) --> pi(0)&mgr;(+)&mgr;(-)

We report on a search for the decay K(L)-->pi(0)&mgr;(+)&mgr;(-) carried out as a part of the KTeV experiment at Fermilab. This decay is expected to have a significant CP violating contribution and a direct measurement will either support the Cabibbo-Kobayashi-Maskawa mechanism for CP violation or point to new physics. Two events were observed in the 1997 data with an expected background of 0.87+/-0.15 events, and we set an upper limit B(K(L)-->pi(0)&mgr;(+)&mgr;(-))<3. 8x10(-10) at the 90% confidence level.

Search for the weak decay of a lightly bound H0 dibaryon

We present results of a search for a new form of hadronic matter, a six-quark, dibaryon state called the H0, a state predicted to exist in several theoretical models. Analyzing data collected by experiment E799-II at Fermilab, we searched for the decay H0-->Lambdappi(-) and found no candidate events. We place an upper limit on [B(H0-->Lambdappi(-))dsigma(H)/dOmega]/(dsigma(Xi)/dOmega) and, in the context of published models, exclude the region of lightly bound mass states just below the LambdaLambda mass threshold, 2.194<M(H)<2.231 GeV/c(2), with lifetimes from approximately 5x10(-10) sec to approximately 1x10(-3) sec.

Mental health. Facing hard truths

A survey of 104 mental health units found that half did not have policies on treatment of detained patients from black and ethnic minority groups. Almost three-quarters had no policy for dealing with racial harassment of black and ethnic-minority patients. 11 percent of patients whose notes were examined had reported racial harassment.

Incisional hernia in a 5 mm laparoscopic port site incision

Herniation of omentum or bowel through laparoscopic incision sites is uncommon. Herniations through 5 mm ports sites are very rare, with less than a handful described in the literature. Undoubtedly however, with the increasing interest.

Observation of CP violation in K(L)-->pi(+)pi(-)e(+)e(-) decays

We report the first observation of a manifestly CP violating effect in the K(L)-->pi(+)pi(-)e(+)e(-) decay mode. A large asymmetry was observed in the distribution of these decays in the CP-odd and T-odd angle straight phi between the decay planes of the e(+)e(-) and pi(+)pi(-) pairs in the K(L) center of mass system. After acceptance corrections, the overall asymmetry is found to be [13.6+/-2. 5(stat)+/-1.2(syst)]%. This is the largest CP-violating effect yet observed when integrating over the entire phase space of a mode and the first such effect observed in an angular variable.

Mental health. As you don't like it

The publication of the national service framework for mental health provides a good opportunity to review acute psychiatric services, which are unpopular with patients and understaffed. The framework recommends a balance of hospital beds, community provision and home care. Planning should usually cover one or more primary care groups.