Variation in the clinical management of self-harm by area-level socio-economic deprivation: findings from the multicenter study of self-harm in England

BACKGROUND

We investigated disparities in the clinical management of self-harm following hospital presentation with self-harm according to level of socio-economic deprivation (SED) in England.

METHODS

108 092 presentations to hospitals (by 57 306 individuals) after self-harm in the Multicenter Study of Self-harm spanning 17 years. Area-level SED was based on the English Index of Multiple Deprivation. Information about indicators of clinical care was obtained from each hospital's self-harm monitoring systems. We assessed the associations of SED with indicators of care using mixed effect models.

RESULTS

Controlling for confounders, psychosocial assessment and admission to a general medical ward were less likely for presentations by patients living in more deprived areas relative to presentations by patients from the least deprived areas. Referral for outpatient mental health care was less likely for presentations by patients from the two most deprived localities (most deprived: adjusted odd ratio [aOR] 0.77, 95% CI 0.71-0.83, p < 0.0001; 2nd most deprived: aOR 0.80, 95% CI 0.74-0.87, p < 0.0001). Referral to substance use services and 'other' services increased with increased SED. Overall, referral for aftercare was less likely following presentations by patients living in the two most deprived areas (most deprived: aOR 0.85, 95% CI 0.78-0.92, p < 0.0001; 2nd most deprived: aOR 0.86, 95% CI 0.79-0.94, p = 0.001).

CONCLUSIONS

SED is associated with differential care for patients who self-harm in England. Inequalities in care may exacerbate the risk of adverse outcomes in this disadvantaged population. Further work is needed to understand the reasons for these differences and ways of providing more equitable care.

964 Cheques and Balances: A Five-Year Review of Surgical Settlements

Aim

The litigious burden in the NHS has been increasing yearly, costing an estimated £2.5 billion per year in financial settlements. We investigated the causes of general surgical settlements and attributed costs at a district general hospital over a five-year period.

Method

A retrospective analysis of all general surgical claims between 2016–2021 using the NHS Resolutions Case Management System. Selected cases were those which resulted in out of court financial settlements; whilst these claims have been settled, the trust admitted no negligence in each case.

Results

A total of 12 settlements were made with a total cost of £249,918 (£8000-£60,000, mean £20,827). Eight of the claims (67%) related to elective cases with four (33%) emergency cases. Of the total cases, 41% and 33% related to management of gallstones and appendicitis respectively.

The majority of claims (58%) related to delays in treatment with a total cost of £103,500 (£8000-£35,000), accounting for 41% of total settlement costs. Five cases (42%) were due to harm with a combined total of £146,418 (£9000-£60,000), 59% of the total settlement. Of the claims due to harm, 80% suffered recognised complications of the procedure.

Conclusions

Increasing litigation in the NHS over the last decade now accounts for 2% of the total NHS budget. The majority of settlements reviewed here were for avoidable delays in elective treatment, with higher financial settlements for well documented surgical complications related to the consent process. Better access to investigations, earlier clinical review, and reductions in delays to elective surgeries may reduce the financial burden of litigation.

Cost-effectiveness of psychosocial assessment for individuals who present to hospital following self-harm in England: a model-based retrospective analysis

Background

Guidance in England recommends psychosocial assessment when presenting to hospital following self-harm but adherence is variable. There is some evidence suggesting that psychosocial assessment is associated with lower risk of subsequent presentation to hospital for self-harm, but the potential cost-effectiveness of psychosocial assessment for hospital-presenting self-harm is unknown.

Methods

A three-state four-cycle Markov model was used to assess cost-effectiveness of psychosocial assessment after self-harm compared with no assessment over 2 years. Data on risk of subsequent self-harm and hospital costs of treating self-harm were drawn from the Multicentre Study of Self-Harm in England, while estimates of effectiveness of psychosocial assessment on risk of self-harm, quality of life, and other costs were drawn from literature. Incremental cost-effectiveness ratios (ICERs) for cost per Quality Adjusted Life Year (QALY) gained were estimated. Parameter uncertainty was addressed in univariate and probabilistic sensitivity analyses.

Results

Cost per QALY gained from psychosocial assessment was £10,962 (95% uncertainty interval [UI] £15,538–£9,219) from the National Health Service (NHS) perspective and £9,980 (95% UI £14,538–£6,938) from the societal perspective. Results were generally robust to changes in model assumptions. The probability of the ICER being below £20,000 per QALY gained was 78%, rising to 91% with a £30,000 threshold.

Conclusions

Psychosocial assessment as implemented in the English NHS is likely to be cost-effective. This evidence could support adherence to NICE guidelines. However, further evidence is needed about the precise impacts of psychosocial assessment on self-harm repetition and costs to individuals and their families beyond immediate hospital stay.

796 Chronic Pneumoperitoneum: Cause or Consequence of Pneumatosis Cystoides Intestinalis

Pneumatosis cystoides intestinalis (PCI), ‘gas cysts’ in the wall of the bowel, is a rare sign that can be found as a result of many different conditions, ranging from benign and asymptomatic, to life threatening. Its pathogenesis is not yet fully understood, and patients found to have PCI are treated in a heterogeneous manner. Pneumoperitoneum, however, is much more commonly seen by the General Surgeons, and most often occurs as a result of a perforated viscus; usually necessitating an emergent surgical intervention. Spontaneous pneumoperitoneum occurs very rarely, although it is seen more frequently with small bowel PCI, compared to large bowel PCI.

We present here an unusual case of a patient with acute-on-chronic pneumoperitoneum and subsequently subacute small bowel obstruction associated with small bowel pneumatosis cystoides intestinalis. The patient also had extensive pan colonic and jejunal diverticulosis, although the area of perforation and PCI was discrete and located in the mid-ileum. It is unclear whether the patient had chronic pneumoperitoneum secondary to perforated PCI, or if the PCI developed secondary to an ileum perforation of unknown origin (fitting with the bacterial or mechanical theory of pathogenesis). The patient went onto to have an emergency laparotomy and small bowel resection 28 months after initial presentation and a trial of conservative management.

A Prospective, Placebo-Controlled Pilot Evaluation of the Effect of Omeprazole on Serum Calcium, Magnesium, Cobalamin, Gastrin Concentrations, and Bone in Cats

BACKGROUND

Chronic proton pump inhibitor administration has been associated with electrolyte and cobalamin deficiency, disrupted bone homeostasis, hypergastrinemia, and rebound acid hypersecretion in humans. It is unknown if this occurs in cats.

OBJECTIVES

Prolonged oral omeprazole results in altered bone mineral density or content, serum calcium, magnesium, cobalamin, and gastrin concentrations in healthy cats.

ANIMALS

Six healthy adult DSH cats.

METHODS

In a within subjects, before and after design, cats received placebo followed by omeprazole (0.83-1.6 mg/kg PO q12h) for 60 days each. Analysis of serum calcium, magnesium, cobalamin, and gastrin concentrations was performed on days 0, 30, and 60. Bone density and content were evaluated on days 0 and 60 of each intervention. Continuous data were analyzed using a two-way ANOVA (α = 0.006). On day 60 of omeprazole administration, continuous intragastric pH monitoring was performed in 2 cats to evaluate the effects of abrupt withdrawal of omeprazole.

RESULTS

No significant changes were detected between treatments for any variables, except serum gastrin, which was significantly higher during omeprazole treatment in comparison to placebo (P = 0.002). Evidence of gastric hyperacidity was seen in both cats in which intragastric pH monitoring was performed following cessation of omeprazole.

CONCLUSIONS AND CLINICAL IMPORTANCE

Although further studies with larger populations of cats will be needed to draw any definitive conclusions, these preliminary results suggest that prolonged PPI treatment results in hypergastrinemia and abrupt PPI withdrawal might result in RAH in cats.

Suicide in bipolar disorder in a national English sample, 1996-2009: frequency, trends and characteristics

BACKGROUND

Bipolar disorder (BD) has been reported to be associated with high risk of suicide. We aimed to investigate the frequency and characteristics of suicide in people with BD in a national sample.

METHOD

Suicide in BD in England from 1996 to 2009 was explored using descriptive statistics on data collected by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI). Suicide cases with a primary diagnosis of BD were compared to suicide cases with any other primary diagnosis.

RESULTS

During the study period 1489 individuals with BD died by suicide, an average of 116 cases/year. Compared to other primary diagnosis suicides, those with BD were more likely to be female, more than 5 years post-diagnosis, current/recent in-patients, to have more than five in-patient admissions, and to have depressive symptoms. In BD suicides the most common co-morbid diagnoses were personality disorder and alcohol dependence. Approximately 40% were not prescribed mood stabilizers at the time of death. More than 60% of BD suicides were in contact with services the week prior to suicide but were assessed as low risk.

CONCLUSIONS

Given the high rate of suicide in BD and the low estimates of risk, it is important that health professionals can accurately identify patients most likely to experience poor outcomes. Factors such as alcohol dependence/misuse, personality disorder, depressive illness and current/recent in-patient admission could characterize a high-risk group. Future studies need to operationalize clinically useful indicators of suicide risk in BD.

Self-poisoning suicide deaths in England: could improved medical management contribute to suicide prevention?

BACKGROUND

Suicide by self-poisoning is a major cause of death worldwide. Few studies have investigated the medical management of fatal self-poisoning.

AIM

To describe the characteristics and management of a national sample of individuals who died by intentional self-poisoning in hospital and assess the quality of care that they received.

DESIGN

National population-based descriptive study and confidential inquiry.

METHODS

Adults (aged ≥ 16 years) who had died by self-poisoning in English hospitals in 2005 and received a coroner's verdict of suicide or undetermined death at inquest were included. Socio-demographic and clinical data were collected through detailed questionnaires sent to clinicians at the treating hospitals. A panel of three expert assessors rated each case with respect to quality of care and likely contribution to the fatal outcome.

RESULTS

We obtained information on 121 cases (response rate for questionnaires 77%). Expert assessors rated 41/104 cases [39% (95% CI 30-49%)] as having received inadequate care; in the majority (38/41-93%) of these, this poor care was felt to have potentially contributed to the patient's death. The most common reason for a rating of inadequate care was poor airway management (recorded in over half of inadequate care cases). In three cases, the receipt of inadequate care was associated with the presence of some form of advance directive.

CONCLUSION

In as many as 39% of in-hospital self-poisoning fatalities, the care received may be in some way sub-optimal. The challenge for clinical services is to ensure that optimal management strategies are implemented in practice.

Glucose-induced pathways for actin tyrosine dephosphorylation during Dictyostelium spore germination

In the presence of germination signals, dormant spores of Dictyostelium discoideum rapidly germinate to start a new life cycle. Previously we have shown that half of the actin molecules in spores are maintained in a tyrosine-phosphorylated state, and a decline of the actin phosphorylation levels is a prerequisite for spore swelling. In this study, we have established d-glucose as a trigger molecule for the actin dephosphorylation. Present in a nutrient germination medium, d-glucose both may act as a trigger molecule and/or may serve as a substrate within a pathway for actin dephosphorylation depending upon spore age. However, the glucose-induced actin dephosphorylation was insufficient for spores to swell. Other factors in the nutrient medium were required for complete germination of young spores aged 1 to 5 days. In contrast, dispersion in nonnutrient buffer was necessary and sufficient for a decline of actin phosphorylation levels and even the emergence of amoebae in older spores (6 days and beyond). Moreover, the dephosphorylation pathway in the older spores was independent of energy production. We propose that the diversification of the actin dephosphorylation pathway may enable spores to increase their probability of germination upon spore aging.

High levels of actin tyrosine phosphorylation: correlation with the dormant state of Dictyostelium spores

Upon removal of nutrients, the amoebae of the cellular slime mold Dictyostelium discoideum differentiate into dormant spores which survive starvation stress. In this study, we demonstrate that half of the actin molecules in the spores are tyrosine-phosphorylated. The phosphorylated actin is distributed around immobile crenate mitochondria and vesicles, as well as in the cytoplasm of the spores. The actin isolated from spore lysates contains phosphorylated and unphosphorylated forms at the same molar ratio as that of the original whole spore lysate. Under actin polymerizing conditions they form actin filaments and then they are completely depolymerized under actin depolymerizing conditions, indicating that tyrosine phosphorylation of actin may not prohibit actin polymerization nor stimulate depolymerization. The phosphorylation levels increase at the end of the culmination stage when spores have matured morphologically and physiologically, and reach maximum levels after an additional 12 hours of development. The levels are stable for 20 days following spore maturation, and decline to undetectable levels within the next 10 days. Spores having high levels of phosphorylation show high viability, and vice versa. Following activation of spores with nutrient medium containing spore germination promoters, the phosphorylation levels quickly decrease with a half-life of about 5 minutes. After 20 minutes spores begin to swell. At this later time, most of the phosphorylated actin already has been dephosphorylated. Also, in heat-activated spores actin dephosphorylation occurs prior to spore swelling. However, addition of phosphatase inhibitors following heat-activation, prevented spore swelling and dephosphorylation of actin. Our data indicate that the high levels of actin tyrosine phosphorylation, specific to the spore stage, may be required for maintaining dormancy to withstand starvation stress. The rapid dephosphorylation of actin leads to a reactivated dynamic actin system which participates in spore swelling, vesicle movement, and mitochondrial shape changes during the spore germination process.

Genotoxicity of select herbicides in Rana catesbeiana tadpoles using the alkaline single-cell gel DNA electrophoresis (comet) assay

Pesticides are broadly used for pest control in agriculture despite possible negative impacts they may pose to the environment. Thus, we examined the DNA damage caused by five herbicides commonly used in southern Ontario (Canada). Erythrocytes from Rana catesbeiana (bullfrog) tadpoles were evaluated for DNA damage following exposure to selected herbicides, using the alkaline single-cell gel DNA electrophoresis (SCG) or "comet" assay [Singh et al. (1988): Exp Cell Res 175:184-191; Ralph et al. (1996): Eviron Mol Mutagen 28:112-120]. This approach involves detection, under alkaline conditions, of DNA fragments that upon electrophoresis migrate from the nuclear care, resulting in a comet formation. The herbicides tested, along with their active ingredients, were AAtrex Nine-O (atrazine), Dual-960E (metalochlor), Roundup (glyphosate), Sencor-500F (metribuzin), and Amsol (2,4-D amine). Tadpoles were exposed in the laboratory for a 24-hr period to several concentrations of the herbicides dissolved in dechlorinated water. Methyl methanesulphonate was used as a positive control. The herbicides AAtrex Nine-O-, Dual-960E-, Roundup-, and Sencor-500F-treated tadpoles showed significant DNA damage when compared with unexposed control animals, whereas, Amsol-treated tadpoles did not. Unlike the other responding herbicides, Sencor-500F did not show a relationship between dosage and DNA damage. In summary, the results indicate that at least some of the herbicides currently used in southern Ontario are capable of inducing DNA damage in tadpoles.

Memory functioning in Lyme borreliosis

BACKGROUND

To objectively measure memory functioning in patients with Lyme borreliosis and examine the relationship between subjective reports of memory dysfunction and actual impairment.

METHOD

A prospective pretreatment study of patients with Lyme borreliosis (N = 21), a patient control group (osteomyelitis, N = 21), and healthy controls (N = 21) was conducted by using tests of verbal memory functioning (California Verbal Learning Test) and self-reported depression (Beck Depression Inventory-Cognitive Index), fatigue (Fatigue Severity Scale), and subjective ratings of memory abilities (Self-Rating Scale of Memory Functions).

RESULTS

Patients with Lyme borreliosis performed worse than healthy controls on verbal memory testing, but did not perform significantly differently from patient controls. Lyme borreliosis patients reported increased fatigue, which was correlated with poorer memory performance. Although the Lyme borreliosis patients rated their memory as more impaired, subjective complaints were not correlated with objective memory scores.

CONCLUSION

These findings suggest impaired memory performance is not specific to Lyme borreliosis and may be a result of evaluating cognitive functioning in patients with physical illness and somatic complaints. Fatigue is a prominent presenting complaint in patients with Lyme borreliosis and needs to be controlled for since it is known to influence neuropsychological performance. Subjective complaints are not correlated with objective memory assessment, so self-report of memory impairment should not be the criterion for inclusion in studies investigating cognitive manifestations of Lyme borreliosis.

Implicit memory bias for threat in panic disorder: application of the 'white noise' paradigm

We employed Jacoby's white noise paradigm to investigate implicit memory bias for threat in panic disorder and in normal control subjects. Subjects heard a series of neutral sentences (e.g. "The shiny apple sat on the table") and panic sentences (e.g. "The anxious woman panicked in the supermarket"). Implicit memory for this prior exposure was then tested by having subjects rate the volume of white noise accompanying the presentation of 'old' sentences intermixed with 'new' sentences. Implicit memory for old sentences is revealed when subjects rate the white noise accompanying these sentences as less loud than noise accompanying new sentences. Results revealed that under low noise level, panic patients demonstrated an implicit memory bias for threat information, whereas control subjects did not. This differential priming effect suggests that information about threat may be automatically accessed in these patients.

Photo CD in practice

Kodak Photo CD is an optical disc-based storage system for recording still photographs. This article explores some of the practical aspects of Photo CD for the medical user. Some potential applications are described, along with hardware and software requirements for the effective use of the medium.

Forensic psychiatry and applied clinical ethics: theory and practice

The authors briefly describe and then apply a new method--applied clinical ethics--for identifying and working with ethical problems. This method, starting from the clinical context, develops ethical constructs that may be tested in clinical practice and revised if required. The work was done in the context of a combined university-county forensic psychiatric service. The authors discuss three of the identified ethical issues: effects of deinstitutionalization, countertransference with forensic populations, and prediction of dangerousness. They discuss the basis for developing ethical norms from clinical experience and suggest ethical guidelines for medical practice.

Family or individual therapy: the ethics of modality choice

The authors examine the ethical issues in choosing between individual and social unit (marital and family) therapies. Although usually neglected in the literature, these ethical questions are important and complex. A general systems perspective is used to provide a framework for ethical analysis. The core of the ethical problem is shown to be the interdependence and irreducible conflict inherent between the individual and social unit levels. The authors outline a general systems approach to identification and consideration of these ethical issues in clinical practice.

Psychiatry's contribution to medical ethics education

Two recent trends in medical education, the growth of interest in biomedical ethics and the examination of psychiatry's status in medicine, have important implications for psychiatry. Educators are needed to bring a clinical perspective to bear on ethics instruction, yet psychiatrists risk missing this opportunity. Psychiatrists are uniquely suited to contribute because of their expertise in three areas: an understanding of the affective, nonrational components in ethical thought and behavior, a developmental perspective regarding personal morality, and an appreciation of the rootedness of ethics in the social ethos. Problems with contemporary ethical models of informed consent illustrate the value of psychiatry's contribution.

Fluorescein angiography in borderline diabetics

Fluorescein angiography was performed in twenty three men with impaired oral glucose tolerance (borderline diabetics) and sixteen matched, normoglycaemic controls. Retinal abnormalities (microaneurysms and leakage of dye) were observed in 18.7% of the controls, 41.6% of sustained borderline diabetics and 54.4% of initially borderline diabetics who subsequently "worsened to diabetes". Qualitatively the abnormalities were similar in each group. Although the difference in frequency between the sustained borderline diabetics and the controls does not achieve conventional statistical significance, other studies quoted support the conclusion that moderate impairment of glucose tolerance is associated with a raised frequency of minor retinal abnormalities. The significance of these remains to be determined.

Long term follow-up study of a trachoma vaccine trial in villages of Northern India

A field trial of two high titer bivalent trachoma vaccines was done in a rural area of Northern India in children under the age of 6 years. Three months later 310 of the original 451 children in the study received a booster vaccination of either of the two vaccines or a placebo. Both the sucrose gradient purified and the Genetron purified vaccine protected against trachoma infection for one year. Significant protection for two years was found only with the gradient vaccine. A 12-year follow-up study located and examined 201 subjects that had received booster vaccine. It was found that 31, 27, and 28% of the individuals in each of the three groups (two vaccine and placebo) had evidence of mostly minimally active trachoma. Additionally, from 6 to 10% of the subjects in each group had signs of mild to moderate potentially blinding sequelae. The results showed no protection by either vaccine, and there was no evidence of adverse effects from the vaccines.