Health and social care services for older male adults in prison: the identification of current service provision and piloting of an assessment and care planning model

Background

Older prisoners are the fastest growing subgroup in the English and Welsh prison estate. Existing research highlights that older prisoners have high health and social care needs and that, currently, these needs routinely remain unmet.

Objectives

(1) To explore the needs of men entering and leaving prison; (2) to describe current provision of services, including integration between health and social care services; and (3) to develop and pilot an intervention for identifying health and social care needs on reception into prison, ensuring that these are systematically addressed during custody.

Methods

The research programme was a mixed-methods study comprising four parts: (1) a study of all prisons in England and Wales housing older adult men, establishing current availability and degree of integration between health and social care services through a national survey and qualitative interviews; (2) establishing the health and social care needs of older men entering prison, including experiences of reception into custody, through structured (n = 100) and semistructured (n = 27) interviews; (3) the development and implementation of an intervention to identify and manage the health, social care and custodial needs of older men entering prison; and (4) exploration of the health and social care needs of older men released from prison into the community through qualitative interviews with older prisoners prior to and following discharge from prison. Descriptive statistics were produced for all quantitative data, and qualitative data were analysed using the constant comparison method.

Results

The number of older prisoner leads has increased in recent years but they do not all appear always to be active in their roles, nor in receipt of specialist training. Nearly half (44%) of establishments do not have an older prisoner policy. There is a lack of integration between health and social care services because of ambiguity regarding responsibility for older prisoners' social care. The responsible social service may be located a considerable distance from where the prisoner is held; in such instances, local social services do not co-ordinate their care. The most frequent unmet need on prison entry was the provision of information about care and treatment. Release planning for older prisoners was frequently non-existent.

Limitations

The study used a cut-off age of 60 years as the lower limit for the definition of an older prisoner; evidence has emerged that supports a redefinition of that cut-off to 50 years. Our study examined the care provided for men and this should be considered if contemplating using the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) with older women in prison.

Conclusion

The OHSCAP, developed as part of this study, provided a feasible and acceptable means of identifying and systematically addressing older prisoners' health and social care needs. Future work will include the conduct of a randomised controlled trial to examine the impact of the OHSCAP in terms of improving a range of outcomes, including economic impact.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Identification and management of prisoners with severe psychiatric illness by specialist mental health services

BACKGROUND

The prevalence of mental disorders among prisoners is considerably higher than in the general population. This is an important public health issue as the vast majority of prisoners stay in custody for less than 9 months and, when not in prison, offenders' lifestyles are frequently chaotic, characterized by social exclusion, instability and unemployment. Multi-disciplinary mental health inreach services were introduced to target care towards prisoners with severe mental illness (SMI) in a similar way to that provided by Community Mental Health Teams outside prison. The aim was to establish the proportion of prisoners with SMI who were assessed and managed by prison mental health inreach services. Method A two-phase prevalence survey in six prisons in England measured SMI upon reception into custody. Case-note review established the proportion of those with SMI subsequently assessed and treated by inreach services.

RESULTS

Of 3492 prisoners screened, 23% had SMI. Inreach teams assessed only 25% of these unwell prisoners, and accepted just 13% onto their caseloads.

CONCLUSIONS

Inreach teams identified and managed only a small proportion of prisoners with SMI. Prison-based services need to improve screening procedures and develop effective care pathways to ensure access to appropriate services. Improved identification of mental illness is needed in both the community and the Criminal Justice System to better engage with socially transient individuals who have chaotic lifestyles and complex needs.

Results of a two-center, before and after study of piperacillin-tazobactam versus ampicillin and gentamicin as empiric therapy for suspected sepsis at birth in neonates ≤ 1500 g

OBJECTIVE

We changed from ampicillin and gentamicin (AG) to piperacillin-tazobactam (PT) for routine treatment of suspected early-onset sepsis. The rationale for this change included ototoxic and renal toxic effects of gentamicin, resistance to gentamicin in late-onset infections and emergence of ampicillin resistant Escherichia coli. A before and after study was designed before the start of PT administration to monitor whether PT was associated with altered outcomes within the 501 to 1500 g birth weight (Very Low Birth Weight) population.

METHOD

Both unmatched and matched comparisons of AG (2007 to 2009) and PT (2010 to 2011) exposed infants are reported. Cohorts were evaluated for initial effectiveness for congenital infections, subsequent morbidities and mortality.

RESULTS

Data from 714 patients were collected (499 AG and 215 PT in the unmatched and 301 AG and 183 PT in the matched cohorts). No significant differences in demographics or initial Apgar scores were noted in the unmatched or matched comparisons. There were significant differences in many of the outcomes of interest in both the matched and unmatched comparisons including less necrotizing enterocolitis (NEC) and less diaper rash with PT versus AG. The only adverse finding with PT was a small, but statistically significant elevation in alkaline phosphatase.

CONCLUSIONS

Use of PT as the initial empiric antibiotic for very low birth weight infants was not associated with adverse microbiological outcomes. There was no increase in major morbidities. Although outcomes were superior in ≤ 1500 g infants treated with PT when compared with AG, the study design does not allow us to conclude that others will see a reduction in NEC or diaper rash if they implement this alternative.

Psychiatric in-patient care and suicide in England, 1997 to 2008: a longitudinal study

BACKGROUND

Psychiatric in-patients are at high risk of suicide. Recent reductions in bed numbers in many countries may have affected this risk but few studies have specifically investigated temporal trends. We aimed to explore trends in psychiatric in-patient suicide over time.

METHOD

A prospective study of all patients admitted to National Health Service (NHS) in-patient psychiatric care in England (1997-2008). Suicide rates were determined using National Confidential Inquiry and Hospital Episode Statistics (HES) data.

RESULTS

Over the study period there were 1942 psychiatric in-patient suicides. Between the first 2 years of the study (1997, 1998) and the last 2 years (2007, 2008) the rate of in-patient suicide fell by nearly one-third from 2.45 to 1.68 per 100,000 bed days. This fall in rate was observed for males and females, across ethnicities and diagnoses. It was most marked for patients aged 15-44 years. Rates also fell for the most common suicide methods, particularly suicide by hanging on the ward (a 59% reduction). Although the number of post-discharge suicides fell, the rate of post-discharge suicide may have increased by 19%. The number of suicide deaths in those under the care of crisis resolution/home treatment teams has increased in recent years to approximately 160 annually.

CONCLUSIONS

The rate of suicide among psychiatric in-patients in England has fallen considerably. Possible explanations include falling general population rates, changes in the at-risk population or improved in-patient safety. However, a transfer of risk to the period after discharge or other clinical settings such as crisis resolution teams cannot be ruled out.

Abstract P2-10-22: Phosphorylation of Steroid Receptor Coactivator 3 (SRC3) at Ser543 is a novel independent prognostic marker in breast cancer

Introduction: Steroid receptor coactivator 3 (SRC3) acts as a coactivator of nuclear receptors including estrogen receptor-alpha (ER). SRC3 has been implicated in the pathogenesis of breast cancer (BC) as well as in resistance to endocrine therapy. SRC3 is phosphorylated at a number of residues following the stimulation of growth factors or hormones. Tyr24 and Ser543 are both phosphorylated upon estrogen stimulation, while Tyr24 is modulated by JNK and Ser543 by both p38 and JNK. To date, the importance and potential role of phosphorylation at these residues has not been explored in BC. In this study we assessed the protein expression of SRC3, pTyr24 and pSer543 and association with clinico-pathological features and outcome in a well defined breast cancer series.

Methods: The expressions of SRC3, pTyr24 and pSer543 were assessed in the Nottingham Tenovus Primary Breast Cancer Series which consists of 1650 cases of primary invasive. SRC3, pTyr24 and pSer543 were correlated with clinico-pathological data as well as outcome.

Results: SRC3 expression was significantly associated with unfavourable clinicopathological features including ER -ve (p = 0.02), PR –ve (p = .038), HER2 overexpression (p < 0.0001), Triple negative phenotype (p = 0.001), high proliferation (p < 0.0001), high histological grade (p < 0.001), and lympho-vascular invasion. On contrast, the expression of pSer543 was significantly associated with a luminal phenotype, well differentiation, low proliferation (low mitotic index, low Ki67 and low SPAG5; p < 0.0001), hormonal receptors (ERα+ve/PR+ve/AR+ve), absence of both ER-B1 and ER-B5 (p < 0.01), high expression of ER-α associated proteins (cyclin D1 and Bcl2; p < 0.0001), high expression of c-jun (p < 0.0001), JNK (p < 0.0001), SRC3 (p < 0.0001), T24 (p < 0.001) and active p53 transcriptional pathways that regulate cell cycle progression and apoptosis (MDM2+ve, MDM4+ve and Bax+ve; p < 0.01) and absence of basal like phenotypes (p < 0.01). The absence of pSer543 was significantly associated with loss of expression of the key DNA repair proteins including XRCC1 (p < 0.0001), BRCA1 (p < 0.0001), ATM (p = 0.008) and TOP2A (p < 0.0001) reflecting a higher risk of genomic instability. Moreover, absence of pSer543 was more common in BC with a triple negative phenotype (p < 0.001). With regard to outcome, no association with outcome based on the expression of SRC3 either with or without tamoxifen was observed. However, expression of pSer543 was associated with significantly longer disease free survival (DFS) (p < 0.00001) and breast cancer specific survival (BCSS) (p = 0.0001). Furthermore, absence of pSer543 was associated with both a shorter DFS (p = 0.007) and BCSS (p = 0.01) in ER+ ve high risk BC. pSer534 was confirmed as an independent prognostic factor after adjustment for endocrine therapy and other validated prognostic factors and absent of pSer534 was associated with a two-fold increased risk of recurrence (HR = 1.9, CI 95%= 1.2–3.1). Data on Tyr24 will also be presented.

Conclusion: Phosphorylation at Ser543 is associated with a luminal phenotype, positive prognostic factors and sensitivity to tamoxifen. Furthermore, it is an independent prognostic factor. pS543 is a novel prognostic marker in BC and warrants further investigation.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-10-22.

Alterations in a hypothalamic GABA system in the spontaneously hypertensive rat

The density (Bmax) of muscimol and clonazepam binding to hypothalamic membranes from spontaneously hypertensive rats (SHR) was reduced compared to age-matched Wistar Kyoto (WKY) animals in the period 80 - 120 days. There were no significant differences in dissociation constant (Kd) for either ligand at this time. At 30 - 36 days, prior to development of pronounced hypertension, there were no differences in Kd or Bmax for either ligand in SHR and WKY animals. There were also deficits in endogenous hypothalamic GABA concentrations in SHR at 75 and 120 days as compared to WKY. The hypothesis is advanced, that there may be a dysfunction of a hypothalamic GABA system in the SHR rat as hypertension develops.

The role of oxidative stress in the prolonged inhibitory effect of ultrafine carbon black on epithelial cell function

Respired ultrafine particles induce a greater inflammation in rat lungs than fine particles; we have hypothesized that this is due to their comparatively huge number and surface area for the production of free radicals. We tested this hypothesis by studying the effects of fine and ultrafine (uf) carbon black (CB) particles in comparison with quartz on A549 human type II alveolar epithelial cells, particularly with respect to the oxidative properties of these particles. Treatment with fine CB (diameter 260nm), and quartz (up to 0.78mug/mm(2)) for 24 hours significantly (P<0.05) decreased the A549 cells metabolic competence, as measured by the ability to reduce MTT to a formazan product. The inhibitory effects of uf CB only became significantly different (P<0.05) relative to the control at 48 hours, by which time the effects of fine CB and quartz were no longer significant. The inhibition of MTT reduction by uf CB was prevented by the hydroxyl radical scavenger mannitol (2mm). In addition, measurement of reactive oxygen species production using supercoiled plasmid DNA showed that uf CB exhibited significantly more free radical activity than fine CB (P<0.05). In the absence of serum, uf CB depleted reduced glutathione at 6 hours (P<0.008). In contrast, CB did not significantly alter reduced or oxidized glutathione. Hence, compared with fine CB, uf CB exhibited greater free radical activity, greater inhibition of the reduction of MTT at 48 hours (prevented by mannitol) and a depletion of reduced glutathione. These results suggest that uf CB induces a greater oxidative stress than fine CB, and that this may play a role in the toxicological effects of this ultrafine particle.

Cross-reactive neutralizing antibody epitopes against Enterovirus 71 identified by an in silico approach

Currently, infections of hand, foot and mouth disease (HFMD) due to Human Enterovirus 71 (EV71) cannot be prevented or treated, as there are no suitable vaccines or antiviral drugs. This study aimed to identify potential vaccine candidates for EV71 using in silico analysis of its viral capsid proteins. A combined in silico approach utilizing computational hidden Markov model (HMM), propensity scale algorithm, and artificial learning, identified three 15-mer structurally conserved B-cell epitope candidates lying within the EV71 capsid proteins. Peptide vaccine candidates incorporating a target B-cell epitope and a promiscuous T-cell epitope from the related polio virus were synthesized using solid-phase Fmoc chemistry. Inbred BALB/C mice which were inoculated with two 10μg doses of the synthetic peptide, generated anti-peptide antibodies. Purified IgG isolated from pooled sera of the inoculated mice neutralized EV71 infections in vitro. Furthermore, these neutralizing antibodies were cross-reactive against other members of the Picornaviridae family, demonstrating greater than 50% virus neutralization. This indicates that the current approach is promising for the development of synthetic peptide-based vaccine candidates against Picornaviridae. Development of effective vaccines is of paramount importance in managing the disease in the Asia Pacific regions where this virus is endemic and has significant social, economic and public health ramifications.

Adrenoceptor responsiveness in bronchial asthma: effect of isoprenaline inhalation on plasma cyclic 3',5'-AMP levels

The effect of isoprenaline inhalation on plasma levels of cyclic AMP has been studied in a group of normal subjects and compared to a group of asthmatics. The normal subjects had a prompt rise in their plasma cyclic AMP level, and when compared to the asthmatic group, had a significantly greater percentage rise in plasma cyclic AMP from the basal levels. The markedly attenuated response to isoprenaline inhalation in the asthmatic group is consistent with the concept that asthmatics have a relative impairment of beta-adrenoceptor function. These results support the in vitro studies demonstrating that lymphocytes from asthmatic subjects incubated with isoprenaline produce less cyclic AMP than those from normal subjects.