Scotland's national approach to improving mental health services: integrated care pathways as tools for redesign and continuous quality improvement

National Health Service (NHS) Scotland is taking a national approach to improving the quality and safety of mental health services. This programme relies on implementing integrated care pathways (ICPs) for people with mental health conditions across the whole journey of care.

This long-term improvement programme has started with the publication of national standards by NHS Quality Improvement Scotland (NHS QIS), setting out the framework of what needs to be developed in each local area.

The emphasis of development and implementation of the ICPs lies with local NHS Boards to ensure they are developed with local ownership and to meet the needs of the local population. However, to ensure accreditation by NHS QIS, the local ICPs must incorporate the national standards and evidence improvement to the quality of care provided.

A concerted effort has been made to ensure good involvement of service users, social work colleagues and NHS staff in order to get buy-in from all stakeholders.

NHS QIS is also supporting local boards and their partner agencies in their implementation of ICPs through a team of National ICP Coordinators and has developed a web-based toolkit to act as an electronic resource: www.icptoolkit.org . This supportive and facilitative approach helped to ensure that person-centred care was driving service redesign.

This is the beginning of a long-term improvement programme that has been carefully staged and is being facilitated in order to give it the best chance for success. In Scotland, ICPs for mental health are being used as a tool for service redesign and continuous quality improvement and a way to focus on meeting service user needs.

Development, implementation and evaluation of a pilot project to deliver interventions on alcohol issues in community pharmacies

Objective

The aim was to evaluate the feasibility and acceptability of the provision of brief interventions on alcohol misuse in community pharmacies. The objectives were to: train community pharmacists to initiate discussion of alcohol consumption with targeted pharmacy clients and screen, intervene or refer as appropriate; and to explore with pharmacists and clients the feasibility, acceptability and perceived value of screening and delivering the intervention.

Setting

Eight community pharmacies in Greater Glasgow.

Method

After a two-day training course for pharmacists (n = 9) and one day for pharmacy assistants (n = 13), the eight pharmacies recruited clients over 3 months. Standardised protocols were prepared to screen clients for hazardous or harmful drinking using the Fast Alcohol Screening Tool (FAST) and to guide the intervention. Clients were recruited from specific target groups and via posters highlighting the service. Following completion of the recruitment phase, pharmacists and clients were followed up by the research team, using a combination of focus groups and semi-structured telephone interviews.

Key findings

During the study period 70 clients were recruited, 30 screened as drinking hazardously (42.9%) and 7 (10%) screened positive for harmful drinking. Interventions commonly included explanation of sensible drinking and units in clients' preferred drinks (n = 33), feedback on screening and risks to health (n = 27) and discussion of pros and cons of current drinking pattern and link with presenting issue (n = 23). Of the 40 clients agreeing to be followed up, 19 could be contacted and most were generally positive about the experience. On follow-up the pharmacists were positive and felt the project worthwhile and, importantly, noted no strong negative reactions from clients.

Conclusion

This project has been successful in training community pharmacists to discuss alcohol with 70 clients. Further work is required to test the generalisability of our findings and to measure the impact on alcohol consumption.

5-Aminomethylbenzimidazoles as potent ITK antagonists

Benzamide 1 demonstrated good potency as a selective ITK inhibitor, however the amide moiety was found to be hydrolytically labile in vivo, resulting in low oral exposure and the generation of mutagenic aromatic amine metabolites. Replacing the benzamide with a benzylamine linker not only addressed the toxicity issue, but also improved the cellular and functional potency as well as the drug-like properties. SAR studies around the benzylamines and the identification of 10n and 10o as excellent tools for proof-of-concept studies are described.

The statistical inevitability of stability-diversity relationships in community ecology

In this article, we explain an often overlooked process that may significantly contribute to positive correlations between measures of species diversity and community stability. Empirical studies showing positive stability-diversity relationships have, for the most part, used a single class of stability (or, more accurately, instability) measures: the temporal variation in aggregate community properties such as biomass or productivity. We show that for these measures, stability will essentially always rise with species diversity because of the statistical averaging of the fluctuations in species' abundances. This simple probabilistic process will operate in the absence of any strong species interactions, although its strength is driven by the relative abundances of species, as well as by the existence of positive or negative correlations in the fluctuations of species. To explore the possible importance of this effect in real communities, we fit a simple simulation model to Tilman's grassland community. Our results indicate that statistical averaging might play a substantial role in explaining stability-diversity correlations for this and other systems. Models of statistical averaging can serve as a useful baseline for predictions of community stability, to which the influences of both negative and positive species interactions may then be added and tested.

PIRAMHIDS - Positive and Innovative Resources. A Mental Health Interactive Database (Scotland) National Resource for Sharing Evidence Based Practice

PIRAMHIDS is a multidisciplinary, multi agency database designed as a vehicle to promote and support the sharing of positive and innovative practice in mental health that is evidence based and quality assured. The use of technology as an information-sharing tool contributes to improved patient care by promoting an improved equitable service throughout Scotland and beyond.

The resource promotes a culture of local ownership of a national resource and encourages contribution from statutory and non statutory services. Consideration is given to the quality of submission in terms of identifying underpinning evidence and quality assurance processes. Networking opportunities are also promoted by encouraging contact with contributors from those considering adopting the examples of practice or developing services.

The Practice Development Unit of NHS Quality Improvement Scotland is leading this work following recommendation from the National Review of Mental Health Nursing in Scotland, ‘Rights, Relationships and Recovery’ (2006). The database ensures sharing of evidence based practice in a manner which is useful, accessible and user friendly with open access to all. Initial response is enthusiastic from service users, clinicians and educators. This model of sharing practice may be adopted across any national service and have value when sharing practice on an international plane. A process of evaluation including impact on care outcomes is considered and ongoing.

Successful Surgical Treatment of Protein-Losing Enteropathy Complicating Rheumatic Tricuspid Regurgitation

Protein-losing enteropathy may uncommonly complicate cardiac disease. While well described as a complication for patients having undergone previous Fontan surgery for congenital heart disease, pericardial and valvular aetiologies are much less frequent. We report a 35-year-old female presenting with marked hypoalbuminaemia and peripheral oedema on a background of known rheumatic valvular heart disease. After extensive investigation for gastrointestinal, hepatic and renal causes of protein loss, echocardiography demonstrated severe tricuspid valve incompetence. Subsequent invasive testing confirmed severe tricuspid valve regurgitation in the absence of pericardial constriction. The patient proceeded to tricuspid valve repair with resolution of the protein-losing state and correction of hypoalbuminaemia. While cardiac causes of gastrointestinal protein loss are uncommon, they should be considered when initial diagnostic work up is negative. The importance of correction of haemodynamic precipitants of protein-losing enteropathy is also discussed.

Vision screening of older people

A recent systematic review found that between 20% and 50% of older people in the UK have undetected reduced vision and in most cases this is caused by refractive error or cataracts, and is correctable. Two approaches to improve the detection of these problems are to better publicise optometric services and to carry out community-based vision screening of older people. Screening programmes should pass the Wilson criteria and a consideration of these highlights three inter-related questions: 'Is vision screening effective at detecting correctable low vision in older people?'; 'Which tests should be included?' and 'Which venues are most appropriate?' We carried out a systematic review to investigate these questions. For the first question, only one study was found which met our selection criteria. The 'gold standard' eye examination in this study lacked several important components, and the vision screening method that was used was not found to be very effective. The review revealed other studies, which, although not meeting our selection criteria, included relevant information. The screening studies highlight the lack of agreement on the content of a gold standard eye examination and of the test(s) that should be used to screen vision. Visual function in older people is not adequately described by high contrast visual acuity (VA), nor by self-reports of visual difficulties. Other tests that may be relevant include visual field testing, low contrast VA, contrast sensitivity and stereo-acuity. The pinhole test has often been used in attempts to detect uncorrected refractive errors, but results from this test can be problematic and possible reasons for this are discussed. Appropriate venues for vision screening are contingent upon the format of the vision screening programme. There is still uncertainty over the battery of vision tests that are most appropriate. This, and optimum venues for screening, require further research before it can be fully determined whether vision screening of older people meets the Wilson criteria. If a vision screening programme using a battery of vision tests, perhaps computerised, can be established, then this should be tested to determine the sensitivity and specificity for detecting the target conditions. Ultimately, longitudinal studies are necessary to determine whether such a screening programme will lead to improved visual performance and quality of life in older people.

Discovery and SAR study of novel dihydroquinoline-containing glucocorticoid receptor agonists

We have recently reported the discovery of a novel class of glucocorticoid receptor (GR) antagonists, exemplified by 3, containing a 1,2-dihydroquinoline molecular scaffold. Further SAR studies of these antagonists uncovered chemical modifications conveying agonist functional activity to this series. These agonists exhibit good GR binding affinity and are selective against other nuclear hormone receptors.

Results of a multicenter randomized study to evaluate the safety and efficacy of combined immunotherapy with interleukin-2, interferon-{alpha}2b and histamine dihydrochloride versus dacarbazine in patients with stage IV melanoma

BACKGROUND

The safety and efficacy of immunotherapy with histamine dihydrochloride (HDC), interleukin-2 (IL-2) and interferon-alpha2b (IFN) compared with dacarbazine (DTIC) in adult patients with stage IV melanoma was evaluated.

PATIENTS AND METHODS

Two hundred and forty-one patients were randomized to either receive repeated 4-week cycles of IFN [3 MIU, s.c., once daily for 7 days], IL-2 (2.4 MIU/m(2), s.c., twice a day for 5 days) and HDC (1 mg, s.c., twice a day for 5 days) or DTIC 850 mg/m(2) i.v. every 3 weeks. The primary endpoint was overall survival.

RESULTS

Median survival was longer for patients receiving HDC/IL-2/IFN (271 days) than for patients receiving DTIC (231 days), but this did not achieve statistical significance. Four patients receiving HDC/IL-2/IFN and nine receiving DTIC experienced at least one grade 4 adverse event. Striking differences in overall survival were observed between countries participating in the study.

CONCLUSION

Treatment with HDC/IL-2/IFN was safely administered on an outpatient basis, but this immunotherapeutic regimen did not improve upon the response rate and overall survival seen with DTIC.

Reprocessing flexible gastrointestinal endoscopes after a period of disuse: is it necessary?

BACKGROUND

Gastrointestinal endoscopy is an integral tool in the evaluation and management of many gastrointestinal and hepatobiliary conditions. Although rare, media reports of infectious complications following gastrointestinal endoscopy persist in this new millennium. With only limited data available, society guidelines continue to suggest that endoscopes undergo a reprocessing cycle before the first patient of the day. This preliminary study aimed to assess the microbiological stability of gastrointestinal endoscopes after high-level disinfection.

METHODS

In this multiphase study, four endoscopic retrograde cholangiopancreatography (ERCP) scopes and three colonoscopes were evaluated. In phase 1, endoscopes were assayed after initial high-level disinfection and daily for a period of 2 weeks. In phase 2, this procedure was repeated to confirm phase 1 results. In phase 3, endoscopes were assayed after high-level disinfection and again following a 7-day storage period.

RESULTS

In phase 1, 6 of 70 (8.6 %) assays were positive. This involved 4 of 7 (57 %) endoscopes (2 colonoscopes and 2 ERCP scopes) and was limited to the first 5 days of the study. No cultures were positive in phase 2. In phase 3, one endoscope had a positive culture. Positive cultures grew only STAPHYLOCOCCUS EPIDERMIDIS, a low-virulence skin organism.

DISCUSSION

With proper disinfection and storage, it appears that reprocessing of gastrointestinal endoscopes is unnecessary after periods of disuse of at least 7 days and possibly up to 2 weeks. Despite recent media reports of infectious complications, society guidelines that recommend more frequent reprocessing seem to lack scientific merit and need to be revisited.

Identification of dissociated non-steroidal glucocorticoid receptor agonists

A new series of ligands for the glucocorticoid receptor (GR) is described. SAR development was guided by docking 3 into the GR active site and optimizing an unsubstituted phenyl ring for key interactions found in the steroid A-ring binding pocket. To identify compounds with an improved side effect profile over marketed steroids the functional activity of compounds was evaluated in cell based assays for transactivation (aromatase) and transrepression (IL-6). Through this effort, 36 has been identified as a partial agonist with a dissociated profile in these cell based assays.

Final results of a phase I study of daily PI-88 as a single agent and in combination with dacarbazine (D) in patients with metastatic melanoma

8532

Background: PI-88 is a heparan sulfate mimetic that inhibits angiogenesis and metastasis directly and via release of tissue factor pathway inhibitor (TFPI). PI-88 has shown some efficacy in an intermittent dosage regimen (250 mg/day 4 days/week) in melanoma (Thomson et al, ASCO 2005). This study tested PI-88 7 days per week alone (group 1) and in combination with 3 weekly D (group 2). Methods: Eligibility included inoperable metastatic melanoma, no prior chemotherapy, PS 0–1, adequate organ function, no recent use of heparin, negative anti-heparin antibody (AHA), no concurrent use of anti-coagulants or anti-platelet agents, no history of GI bleeding. Group 1 cohorts received daily PI-88 in doses of 140 mg, 190 mg and 250 mg. Group 2 received PI-88 commencing at the level below the single agent MTD plus D 1,000 mg/m2 every 21 days. Group 1 pts who had PD could continue PI-88 with the addition of D. FDG-PET scans were performed prior to and after 6 weeks PI-88 in Group 1. Free TFPI was measured in serum prior to and up to 2hr post first dose PI-88 in group 1. Results: Group 1 - DLT occurred in 0/3 (140 mg), 0/3 (190 mg) and 2/3 (250 mg) pts. Group 2 - DLT occurred in 1/6 (140 mg) and 0/4 (190 mg) pts. All DLTs were AHA positive grade III/IV thrombocytopenia with in 1 pt (250 mg) cerebral venous sinus thrombosis. No other major toxicities and no increase in expected DTIC toxicities were observed. 4 group 1 pts had pre/post PET scans. One pt had 50% fall in SUVmax with radiologic SD for 4 months. No radiologic responses occurred with PI-88 alone. 3/9 pts in group 2 had radiologic PR. 2/5 group1 pts who had D added to PI-88 had PR. Free TFPI increased from 6.9 ± 1.9 ng/ml just prior PI-88 to 56.1 ± 19.4 30 min post PI-88. The elevated levels were maintained at 60 and 120 min. Elevation of free TFPI did not correlate with PI-88 dose. Conclusion: The recommended phase II dose of continuous daily PI-88 is 190mg alone and in combination with D 1,000 mg/m2 every 3 weeks. An ongoing randomised study is comparing D 1,000 mg/m2 plus PI-88 190mg/day to single-agent D.

No significant financial relationships to disclose.

Melanoma incidence and mortality in Scotland 1979-2003

We studied 12,450 cases of invasive melanoma diagnosed in Scotland in 1979-2003, by thickness, pathological type, and body site at ages under 40, 40-59, and 60 years and over. Melanoma incidence trebled in males from 3.57 to 10.93/10(5) per year, and increased 2.3-fold in females from 5.60 to 12.96/10(5) per year. The rate of increase fell in each successive 5-year period. The greatest increase was in males aged 60 years and over at diagnosis. Significant incidence increases were seen in melanomas < 1 mm in all three age groups, but those > 4 mm only increased significantly at ages 60 years and over. All histological types increased significantly at ages 60 years and over, and in this age group the greatest increase was seen on the head and neck. Five-year disease-free survival improved steadily. Survival figures for 1994-1998 ranged from 93.6% for males and 95.8% for females with tumours < 1 mm, to 52.4 and 48.3%, respectively, for those with tumours > 4 mm. Over the 25 years, melanoma mortality doubled in males from 1.1 to 2.4/10(5) per year, but was unchanged in females at 1.5/10(5) per year. Public education on melanoma is required both for primary prevention and earlier diagnosis, particularly for older males.

Micrometer size polarization independent depletion-type photonic modulator in Silicon On Insulator

The trend in silicon photonics, in the last few years has been to reduce waveguide size to obtain maximum gain in the real estate of devices as well as to increase the performance of active devices. Using different methods for the modulation, optical modulators in silicon have seen their bandwidth increased to reach multi GHz frequencies. In order to simplify fabrication, one requirement for a waveguide, as well as for a modulator, is to retain polarisation independence in any state of operation and to be as small as possible. In this paper we provide a way to obtain polarization independence and improve the efficiency of an optical modulator using a V-shaped pn junction base on the natural etch angle of silicon, 54.7 deg. This modulator is compared to a flat junction depletion type modulator of the same size and doping concentration.

Agonist versus antagonist induce distinct thermodynamic modes of co-factor binding to the glucocorticoid receptor

The glucocorticoid receptor (GR) is involved in the transcriptional regulation of genes associated with inflammation, glucose homeostasis, and bone turnover through the association with ligands, such as corticosteroids. GR-mediated gene transcription is regulated or fine-tuned via the recruitment of co-factors including coactivators and corepressors. Current therapeutic approaches to targeting GR aim to retain the beneficial anti-inflammatory activity of the corticosteroids while eliminating negative side effects. Towards achieving this goal the experiments discussed here reveal a mechanism of co-factor binding in the presence of either bound agonist or antagonist. The GR ligand binding domain (GR-LBD(F602S)), in the presence of agonist or antagonist, utilizes different modes of binding for coactivator versus corepressor. Coactivator binding to the co-effector binding pocket of GR-LBD(F602S) is driven both by favorable enthalpic and entropic interactions whereas corepressor binding to the same pocket is entropically driven. These data support the hypothesis that ligand-induced conformational changes dictate co-factor binding and subsequent trans-activation or trans-repression.