Survey of mental health nurses' attitudes towards risk assessment, risk assessment tools and positive risk

WHAT IS KNOWN ON THE SUBJECT?: Risk assessment and safety planning are a core aspect of the role of the mental health nurse. Conflicting views exist on the value of risk assessment tools. Few studies have examined mental health nurses' attitudes towards risk, including use of tools and the role of positive risk in recovery. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Mental health nurses view risk assessment as a core dimension of their role and not merely an exercise to fulfil organizational clinical safety and governance obligations. The majority of nurses hold positive attitudes towards therapeutic or positive risk, and consider creative risk taking as vital to people's recovery. The majority of nurses believe that risk assessment tools facilitate professional decision making, however, some are concerned that tools may negatively impact upon therapeutic relationships. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Ongoing education on the use of risk assessment tools is required to minimize views that their use is incompatible with therapeutic engagement, and to enable nurses to develop confidence to engage with positive risk and to allow service users make decisions and take responsibility.

ABSTRACT

Introduction Risk assessment and safety planning are considered core components of the role of the mental health nurse; however, little is known about nurses' attitudes towards risk assessment, use of tools to assess risk or therapeutic risk taking. Aim This study aimed to explore mental health nurses' attitudes towards completing risk assessments, use of tools as an aid, and therapeutic or positive risk. Method An anonymous survey which included 13 attitudinal statements, rated on a five-point Likert scale, was completed by 381 mental health nurses working in adult services in Ireland. Findings Findings indicate strong support for the practice of risk assessment in mental health practice. The vast majority of nurses believe that risk assessment tools facilitate professional decision making; however, there is concern that the use of these tools may negatively impact upon therapeutic engagement with service users. The majority of participants have positive attitudes towards therapeutic risk, believing that service users have the right to take informed risks in the context of recovery-orientated care. Discussion The provision of education on the use of risk assessment tools within the context of engagement may help minimize views that the use of assessment tools are incompatible with therapeutic engagement.

The noncalcemic analogue of vitamin D, 22-oxacalcitriol, suppresses parathyroid hormone synthesis and secretion

OCT, a non-calcemic analogue of 1,25(OH)2D3 has been found to have a more potent activity than that of 1,25(OH)2D3 regarding cell differentiation and immunopotentiation activity, and to prolong the average life span of MRL/l mice. Recently, we found that OCT effectively suppressed the secretion and synthesis of PTH without inducing hypercalcemia. In primary cultures of bovine parathyroid cells, OCT was capable of suppressing PTH release in a dose-dependent manner. OCT was also active in vivo, and, like 1,25(OH)2D3, decreased the pre-pro(PTH) mRNA levels. In a group of rats with CRF, daily administration of OCT, 8 ng i.p. for 2 weeks returned PTH levels to normal without changes in serum calcium. Preliminary results in dogs with CRF indicated that after the administration of OCT 5 micrograms i.v., N-terminal PTH decreased by 76% without changes in Ca. In conclusion, OCT may provide a unique contribution to the treatment of secondary hyperparathyroidism.

'We have got the tools': Qualitative evaluation of a mental health Wellness Recovery Action Planning (WRAP) education programme in Ireland

In recent years, there has been a consistent drive to incorporate Recovery principles into the Irish mental health services. A group of Irish mental health service providers came together and delivered a 5-day Wellness Recovery Action Planning (WRAP) facilitator's programme. The programme was developed and delivered by key stakeholders including people with self-experience of mental health problem. This paper presents the qualitative findings from an evaluation of these facilitator's programmes. Three focus groups were held with 22 people, the majority of who described themselves as mental health professionals and/or people with self-experience of mental health problems. Data were analysed using a thematic approach and yielded four themes. Although the participants were positive about the programme and felt that their knowledge of Recovery and WRAP had improved, they felt that they still lacked confidence in terms of the presentation skills required for facilitating Recovery and WRAP programmes. The findings suggest that mental health service providers who wish to develop service users and clinicians as WRAP facilitators need to put more emphasis on the provision of facilitation and presentation skills in the programmes they develop.

The non-classical ArsR-family repressor PyeR (PA4354) modulates biofilm formation in Pseudomonas aeruginosa

PyeR (PA4354) is a novel member of the ArsR family of transcriptional regulators and modulates biofilm formation in Pseudomonas aeruginosa. Characterization of this regulator showed that it has negative autoregulatory properties and binds to a palindromic motif conserved among PyeR orthologues. These characteristics are in line with classical ArsR-family regulators, as is the fact that PyeR is part of an operon structure (pyeR-pyeM-xenB). However, PyeR also exhibits some atypical features in comparison with classical members of the ArsR family, as it does not harbour metal-binding motifs and does not appear to be involved in metal perception or resistance. Hence, PyeR belongs to a subgroup of non-classical ArsR-family regulators and is the second ArsR regulator shown to be involved in biofilm formation.

Endoglucanase activities and growth of marine-derived fungi isolated from the sponge Haliclona simulans

AIMS

The conversion of cheap cellulosic biomass to more easily fermentable sugars requires the use of costly cellulases. We have isolated a series of marine sponge-derived fungi and screened these for cellulolytic activity to determine the potential of this unique environmental niche as a source of novel cellulase activities.

METHODS AND RESULTS

Fungi were isolated from the marine sponge Haliclona simulans. Phylogenetic analysis of these and other fungi previously isolated from H. simulans showed fungi from three phyla with very few duplicate species. Cellulase activities were determined using plate-based assays using different media and sea water concentrations while extracellular cellulase activities were determined using 3,5-dinitrosalicylic acid (DNSA)-based assays. Total and specific cellulase activities were determined using a range of incubation temperatures and compared to those for the cellulase overproducing mutant Hypocrea jecorina QM9414. Several of the strains assayed produced total or relative endoglucanase activities that were higher than H. jecorina, particularly at lower reaction temperatures.

CONCLUSIONS

Marine sponges harbour diverse fungal species and these fungi are a good source of endoglucanase activities. Analysis of the extracellular endoglucanase activities revealed that some of the marine-derived fungi produced high endoglucanase activities that were especially active at lower temperatures.

SIGNIFICANCE AND IMPACT OF THE STUDY

Marine-derived fungi associated with coastal marine sponges are a novel source of highly active endoglucanases with significant activity at low temperatures and could be a source of novel cellulase activities.

Validation of the Quick Confusion Scale for mental status screening in the emergency department

OBJECTIVE

The Mini-Mental Status Exam (MMSE) is a commonly used assessment of cognitive status; however, it has been considered somewhat unwieldy for use in the emergency department (ED). An alternate test, the Quick Confusion Scale (QCS), has been compared against the MMSE in a single centre. We hypothesised that the QCS would strongly correlate with the MMSE in the ED, but could be administered more quickly.

METHODS

Trained research assistants administered both the QCS and the MMSE to a convenience sample of 666 patients and visitors in an urban academic ED. Patients were randomised as to which test would be administered first.

RESULTS

The QCS required less time to complete than the MMSE (2.7+/-1.3 vs. 5.1+/-1.9 min, p<0.0001). Nine patients could not complete the MMSE because they could not use their hands to write and four because of vision impairment. Correlation of QCS and MMSE scores was fair, with Pearson's r=0.61 (95% CI, 0.56-0.66).

CONCLUSIONS

The QCS can be administered more quickly than the MMSE, and is easier to administer in the ED because it does not require the subject to read, write or draw. There is a fair correlation between QCS and MMSE scores.

Activity of micafungin (FK463) against an itraconazole-resistant strain of Aspergillus fumigatus and a strain of Aspergillus terreus demonstrating in vivo resistance to amphotericin B

We compared the activity of four doses of micafungin (FK463) with that of amphotericin B, liposomal amphotericin B and itraconazole in a murine model of disseminated aspergillosis. Temporarily neutropenic mice were infected with a lethal dose of either an itraconazole-resistant Aspergillus fumigatus isolate or Aspergillus terreus, a species that is less susceptible to amphotericin B. Treatment was started 24 h after infection and lasted for 7 days. Mice were treated with either amphotericin B (0.5 or 5 mg/kg), liposomal amphotericin (5 or 25 mg/kg), itraconazole (25 or 75 mg/kg) or FK463 (either 1, 2, 5 or 10 mg/kg). Treatment of the A. fumigatus model with either amphotericin B, liposomal amphotericin or FK463 prolonged survival. Doses of FK463 5 and 10 mg/kg had a 100% survival. Treatment of A. terreus infection with either itraconazole or FK463, but not amphotericin B, also prolonged survival. Doses of liposomal amphotericin of 5 and 25 mg/kg were ineffective against A. terreus infection. No treatment regime was able to totally clear the liver or kidneys in either model. The data indicate that FK463 may have a clinical role in the treatment of life-threatening invasive aspergillosis.

Intra-articular tissue factor/factor VII complex induces chronic arthritis

OBJECTIVE

Fibrin accumulation in the joint cavity is a common feature of chronic arthritides, such as rheumatoid arthritis (RA). Complex formation between tissue factor (TF) and factor VII (FVII) is the initial step in such a fibrin formation.

METHODS

To assess the role of the TF/FVII complex in the pathogenesis of joint inflammation, 1) the levels of TF/FVII complex were measured in synovial fluid of RA patients; 2) the complex was injected to healthy mice intra-articularly.

RESULTS

Morphological analysis of the joints 4 days after TF/FVII injection revealed influx of CD4-Mac1+ mononuclear leukocytes into synovial tissue followed by cartilage and bone destruction. Inflammation induced by TF/FVII complex was more profound than that caused by each of the proteins separately, both with respect to frequency, severity and duration of arthritis. Interaction between macrophages and lymphocytes in sustaining joint inflammation was proved by the requirement of the combined lymphocyte/ monocyte depletion to abolish TF/FVII induced arthritis. Induction of monocyte attracting chemokines (MIP-1 alpha and RANTES) was shown to be one of the potential mechanisms for TF/FVII complex triggered inflammatory cell influx. Interestingly, TF/FVII complexes were detected in synovial fluid of 20/40 patients with RA.

CONCLUSIONS

Altogether these findings indicate that TF/FVII complexes, frequently found intra-articularly in joints of RA patients, may be an important component in both induction and progression of chronic destructive arthritis.

Characterization of rural mental health service systems

This paper explores two mental health systems in rural North Carolina that provide services to people with severe mental disorders. Recent findings show rural people with mental disorders receive less mental health care than their urban counterparts. This study asks whether rural service systems differ from urban systems in the way that their services are coordinated and structured. A popular conception is that public mental health systems in the United States are uncoordinated with many services provided outside the mental health sector. Rural service providers are seen as even more dependent on nonspecialized mental health providers than their urban counterparts. While many rural service barriers are attributed to the rural environment, little is known about rural service systems and how their organization might contribute to or negate barriers to care. Social network methods were used in this study to compare two rural with four urban systems of care. Findings confirm that mental health systems fit the de facto hypothesis, but that rural systems differ in ways not anticipated by the hypothesis. Rather than being more dependent on nonmental health agencies, rural mental health agencies are more interdependent.

Towards in vivo monitoring of neutron distributions for quality control of BNCT

Dose delivery in boron neutron capture therapy (BNCT) is complex because several components contribute to the dose absorbed in tissue. This dose is largely determined by local boron concentration, thermal neutron distribution and patient positioning. In vivo measurements of these factors would considerably improve quality control and safety. During therapy, a y-ray telescope measures the y-rays emitted following neutron capture by hydrogen and boron in a small volume of the head of a patient. Scans of hydrogen y-ray emissions could be used to verify the actual distribution of thermal neutrons during neutron irradiation. The method was first tested on different phantoms. These measurements showed good agreement with calculations based on thermal neutron distributions derived from a treatment planning program and from Monte Carlo N-particle (MCNP) simulations. Next, the feasibility of telescope scans during patient irradiation therapy was demonstrated. Measurements were reproducible between irradiation fractions. In theory, this method can be used to verify the positioning of the patient in vivo and the delivery of thermal neutrons in tissue. However, differences between measurements and calculations based on a routine treatment planning program were observed. These differences could be used to refine the treatment planning. Further developments will be necessary for this method to become a standard quality control system.

Just a little bit. Breathing room slight in extended deadline for HIPAA claims processing rule

Lawmakers have given the healthcare industry another year to comply with the electronic-billing mandates of HIPAA, but that doesn't mean time is on hospitals' side. In return for more time, legislators have introduced a timeline to keep everyone on track.

On the upswing. Leaner JCAHO makes cuts and draws up plans to pave way to new success

Revenue has been slipping for years, but the Joint Commission on Accreditation of Healthcare Organizations is rolling in record profits to develop a slew of new programs. At the same time the group is under great industry scrutiny as it decides how to spend its financial cushion.

CD antigens 2001

This paper reviews the Seventh Human Leucocyte Differentiation Antigen (HLDA7) workshop. Due to the limitations of "blind" antibody screening, which had been evident at the previous meeting in 1996, participants at HLDA7 adopted a more selective approach to the choice of antibodies by identifying new CD specificities. This resulted in the addition of more than 80 new CD specificities. Plans for the eighth and subsequent workshops are also previewed.

agr expression precedes escape of internalized Staphylococcus aureus from the host endosome

Staphylococcus aureus is a versatile pathogen capable of causing life-threatening infections. Many of its cell wall and exoproduct virulence determinants are controlled via the accessory gene regulator (agr). Although considered primarily as an extracellular pathogen, it is now recognized that S. aureus can be internalized by epithelial and endothelial cells. Traditional experimental approaches to investigate bacterial internalization are extremely time-consuming and notoriously irreproducible. We present here a new reporter gene method to assess intracellular growth of S. aureus in MAC-T cells that utilizes a gfp-luxABCDE reporter operon under the control of the Bacillus megaterium xylA promoter, which in S. aureus is expressed in a growth-dependent manner. This facilitates assessment of the growth of internalized bacteria in a nondestructive assay. The dual gfp-lux reporter cassette was also evaluated as a reporter of agr expression and used to monitor the temporal induction of agr during the MAC-T internalization process. The data obtained suggest that agr induction occurs prior to endosomal lysis and that agr-regulated exoproteins appear to be required prior to the release and replication of S. aureus within the infected MAC-T cells.

Service delivery and community: social capital, service systems integration, and outcomes among homeless persons with severe mental illness

OBJECTIVES

This study evaluated the influence of features of community social environment and service system integration on service use, housing, and clinical outcomes among homeless people with serious mental illness.

STUDY SETTING

A one-year observational outcome study was conducted of homeless people with serious mental illness at 18 sites.

DATA SOURCES

Measures of community social environment (e.g., social capital) were based on local surveys and voting records. Housing affordability was assessed with housing survey data. Service system integration was assessed through interviews with key informants at each site to document interorganizational transactions. Standardized clinical measures were used to assess clinical and housing outcomes in face-to-face interviews.

RESEARCH DESIGN

Structural equation modeling was used to determine the relationship between (1) characteristics of the social environment (social capital, housing affordability); (2) the level of integration of the service system for persons who are homeless in each community; (3) access to and use of services by individual clients; and (4) successful exit from homelessness or clinical improvement.

PRINCIPAL FINDINGS

Social capital was associated with greater service systems integration, which was associated in turn with greater access to assistance from a public housing agency and to a greater probability of exiting from homelessness at 12 months. Housing affordability also predicted exit from homelessness. Neither environmental factors nor systems integration predicted outcomes for psychiatric problems, substance abuse, employment, physical health, or income support.

CONCLUSION

Community social capital and service system integration are related through a series of direct and indirect pathways with better housing outcomes but not with superior clinical outcomes for homeless people with mental illness. Implications for designing improved service systems are discussed.

Modern Healthcare celebrates the 25th anniversary of the magazine's ownership by Crain Communications

In many ways it's been a quarter-century of change. But in some ways it's been just the opposite. To mark Modern Healthcare's silver anniversary under its current ownership, the magazine's staff took a trip through time, looking at pivotal events in healthcare during the past 25 years and the people who helped shape the industry.

Contributions of angiotensin II and tumor necrosis factor-alpha to the development of renal fibrosis

Angiotensin II upregulates tumor necrosis factor-alpha (TNF-alpha) in the rat kidney with unilateral ureteral obstruction (UUO). In a mouse model of UUO, we found that tubulointerstitial fibrosis is blunted when the TNF-alpha receptor, TNFR1, is functionally knocked out. In this study, we used mutant mice with UUO in which the angiotensin II receptor AT(1a) or the TNF-alpha receptors TNFR1 and TNFR2 were knocked out to elucidate interactions between the two systems. The contribution of both systems to renal fibrosis was assessed by treating TNFR1/TNFR2-double knockout (KO) mice with an angiotensin-converting enzyme inhibitor, enalapril. The increased interstitial volume (Vv(int)) in the C57BI/6 wild-type mouse was decreased in the AT(1a) KO from 32.8 +/- 4.0 to 21.0 +/- 3.7% (P < 0.005) or in the TNFR1/TNFR2 KO to 22.3 +/- 2.1% (P < 0.005). The Vv(int) of the TNFR1/TNFR2 KO was further decreased to 15.2 +/- 3.7% (P < 0.01) by enalapril compared with no treatment. The induction of TNF-alpha mRNA and transforming growth factor-beta1 (TGF-beta1) mRNA in the kidney with UUO was significantly blunted in the AT(1a) or TNFR1/TNFR2 KO mice compared with the wild-type mice. Treatment of the TNFR1/TNFR2 KO mouse with enalapril reduced both TNF-alpha and TGF-beta1 mRNA and their proteins to near normal levels. Also, alpha-smooth muscle actin expression and myofibroblast proliferation were significantly inhibited in the AT(1a) or TNFR1/TNFR2 KO mice, and they were further inhibited in enalapril-treated TNFR1/TNFR2 KO mice. Incapacitating the angiotensin II or the TNF-alpha systems individually leads to partial blunting of fibrosis. Incapacitating both systems, by using a combination of genetic and pharmacological means, further inhibited interstitial fibrosis and tubule atrophy in obstructive nephropathy.

Susceptibility testing of Aspergillus flavus: inoculum dependence with itraconazole and lack of correlation between susceptibility to amphotericin B in vitro and outcome in vivo

We have attempted to validate in Aspergillus flavus the main in vitro methodologies that have been used to detect resistance in Aspergillus fumigatus. We developed a murine model with two A. flavus isolates, one that was apparently resistant in vitro to amphotericin B (AFL5) and another that was resistant to itraconazole (AFL8). No correlation was found for amphotericin B in AFL5, since the in vivo response was compatible with a susceptible isolate. Modification of the in vitro susceptibility test methodology for amphotericin B was unsuccessful. Although AFL8 was apparently resistant to itraconazole in vitro, it was found to be susceptible in vivo. Additional in vitro work has detected weaknesses in the in vitro susceptibility methodology validated for A. fumigatus when applied to A. flavus. The principal problems are that changes in the inoculum have a large effect on the MICs of itraconazole for some A. flavus strains and that a trailing end point and spore sediment often appear when an inoculum with a higher colony count is used. We propose a modified method using a final inoculum of 2.5 x 10(4) CFU per ml of RPMI 1640 medium with 2% glucose buffered to pH 7.0 in a microtiter format, incubated for 48 h with no growth end point. Validation of this methodology requires one or more itraconazole-resistant A. flavus isolates, which have yet to be identified.

p21(WAF1) and transforming growth factor-alpha mediate dietary phosphate regulation of parathyroid cell growth

BACKGROUND

The parathyroid (PT) hyperplasia induced by renal failure can be further enhanced by high dietary phosphate (P) or completely abolished by P restriction. To identify potential mechanisms mediating these opposing effects of dietary P on PT growth, this study first focused on p21(WAF1) (p21) because high P reduces while low P enhances serum 1,25-dihydroxyvitamin D, whose potent antiproliferative properties result from the induction of p21. In addition to reducing p21, high P-induced PT growth could result from increased PT expression of the growth promoter transforming growth factor-alpha (TGF-alpha), known to be elevated in hyperplastic and adenomatous human PT glands.

METHODS

The time course for dietary P regulation of PT expression of TGF-alpha and p21 was assessed for seven days after 5/6 nephrectomy in rats and correlated with the degree of PT hyperplasia and secondary hyperparathyroidism.

RESULTS

In P-restricted 5/6 nephrectomized rats, PT-p21 mRNA and protein increased by day 2, independent of changes in serum 1,25-dihydroxyvitamin D, and remained higher than in the high P counterparts for up to seven days. The PT hyperplasia of the high P group could not be attributed to a reduction of PT-p21 expression from normal control values. Instead, PT-TGF-alpha protein was higher in uremic rats compared with normal controls and increased further with high dietary P intake. PT levels of proliferating cell nuclear antigen (PCNA), an index of cell mitoses, correlated inversely with p21 and directly with TGF-alpha. Consistent with these findings, PT gland size and serum PT hormone levels, similar in both dietary groups at day 2, were higher in the high P group by day 5. Induction of p21 by low P and of TGF-alpha by high P was specific for the PT glands. Dietary P had no effect either on intestinal growth or p21 or TGF-alpha protein content.

CONCLUSIONS

These findings suggest that low P induction of p21 could prevent PT hyperplasia in early uremia, whereas high P enhancement of TGF-alpha may function as an autocrine signal to stimulate growth further.