Pathways to community living in practice: Local development and adaptation within an older peoples mental health service

OBJECTIVE

To describe the local adaptation of the Pathways to Community Living (PCLI) program in an Older Peoples Mental Health (OPMH) service to guide other services.

METHOD

A retrospective observational study was conducted. Data were obtained from service planning meetings and newly developed documents, Clinical Advisory Committee meetings, and OPMH PCLI database.

RESULTS

The PCLI program was adapted for the local OPMH service through development of an assessment template, creating a Memorandum of Understanding with a partner Residential Aged Care Facility (RACF) and establishing processes for collaboration and regular review. Between 2019 and March 2023, 20 mental health consumers were referred to the OPMH PCLI program. Their demographic and clinical characteristics are described.

CONCLUSIONS

Adaptation of the PCLI program for OPMH consumers required consideration of specific older adult needs to develop a bespoke plan for assessment and partnership with the PCLI-funded RACF. The development phase and ongoing processes for review facilitated engagement of key stakeholders across health and RACF sectors, highlighting issues with consumer engagement. Similar models could be used by other health services to implement the PCLI in their local context.

Implementation and Evaluation of an Opioid Risk Questionnaire in the Outpatient Plastic Surgery Setting

Most patients undergoing plastic and cosmetic surgery are prescribed an opioid for postoperative pain control. With the advent of the opioid epidemic in our country, screening for opioid risk has become a topic of many health care discussions. However, there has been little mention of using an opioid risk questionnaire specific to the outpatient plastic surgery setting. This project consisted of distribution of an opioid risk questionnaire to adult patients undergoing outpatient plastic surgery. Data were collected at preoperative appointments from participating patients (n = 27). Although the sample size was small, two patients (7%) were identified as having a history of substance abuse, and both of those patients reported they had also received treatment for their substance abuse. In addition, six patients (22%) reported having a family history of substance abuse. Such findings suggest that clinicians working in outpatient plastic surgery should screen their patients for substance abuse and misuse.

Non-inferiority of minimally invasive oesophagectomy: an 8-year retrospective case series

BACKGROUND

The trend towards laparoscopic surgery seen in other specialties has not occurred at the same pace in oesophagectomy. This stems from concerns regarding compromised oncological clearance, and complications associated with gastric tube necrosis and anastomotic failure. We present our experience of minimally invasive oesophagectomy (MIO) compared to open and hybrid surgery. We aim to ascertain non-inferiority of MIO by evaluating impact on survival, oncological clearance by resection margin and lymph node harvest and post-operative complications.

METHODS

Data were sourced retrospectively 2008-2015. Three approaches were studied. MIO (3-stage Mckeown), hybrid (2-stage Ivor Lewis, laparoscopy, thoracotomy) and open (2-stage Ivor Lewis).

RESULTS

Five-year survival was 54.2%. Surgical approach had no significant impact on survival at any stage of disease (Stage 0/I p = 0.98; stage II p = 0.2; stage III p = 0.76). There was no statistically significant difference in oncological clearance by resection margins between procedures when compared by disease stage (p = 0.49). A higher number of nodes were harvested in hybrid [median 27.5 (6-65)] and open surgeries [median 26 (4-54)] than in MIO [median 20 (7-44)] (p > 0.01). Numbers of nodes resected did not impact risk of recurrence [recurrence, median 25 (6-54), no recurrence, 26 (4-65)] (p = 0.25). Anastomotic strictures (22.4%) and potential leaks (17.9%) were more common in MIO (strictures p > 0.01, leaks p = 0.08), although associated morbidity was lower. Respiratory complications were less common in MIO (2.9%) versus hybrid (13.3%) (p = 0.02). Wound infection and chyle leak were also lower (wound 1.5% MIO 3.5% open, p = 0.6; chyle leak 1.5% MIO, 6.7% hybrid, p = 0.2).

CONCLUSIONS

Our results show no negative impact of MIO on survival or oncological clearance. Respiratory and wound complications are lower in MIO, but rates of anastomotic strictures and potential anastomotic leaks are increased. This may be due to the longer length of conduit and subclinical ischaemia at the anastomosis and merits further evaluation.

Collaborative study for the establishment of the WHO 3(rd) International Standard for Endotoxin, the Ph. Eur. endotoxin biological reference preparation batch 5 and the USP Reference Standard for Endotoxin Lot H0K354

An international collaborative study was organised jointly by the World Health Organization (WHO)/National Institute for Biological Standards and Control (NIBSC), the United States Pharmacopeia (USP) and the European Directorate for the Quality of Medicines & HealthCare (EDQM/Council of Europe) for the establishment of harmonised replacement endotoxin standards for these 3 organisations. Thirty-five laboratories worldwide, including Official Medicines Control Laboratories (OMCLs) and manufacturers enrolled in the study. Three candidate preparations (10/178, 10/190 and 10/196) were produced with the same material and same formulation as the current reference standards with the objective of generating a new (3(rd)) International Standard (IS) with the same potency (10 000 IU/vial) as the current (2(nd)) IS, as well as new European Pharmacopoeia (Ph. Eur.). and USP standards. The suitability of the candidate preparations to act as the reference standard in assays for endotoxin performed according to compendial methods was evaluated. Their potency was calibrated against the WHO 2(nd) IS for Endotoxin (94/580). Gelation and photometric methods produced similar results for each of the candidate preparations. The overall potency estimates for the 3 batches were comparable. Given the intrinsic assay precision, the observed differences between the batches may be considered unimportant for the intended use of these materials. Overall, these results were in line with those generated for the establishment of the current preparations of reference standards. Accelerated degradation testing of vials stored at elevated temperatures supported the long-term stability of the 3 candidate preparations. It was agreed between the 3 organisations that batch 10/178 be shared between WHO and EDQM and that batches 10/190 and 10/196 be allocated to USP, with a common assigned value of 10 000 IU/vial. This value maintains the continuity of the global harmonisation of reference materials and unitage for the testing of endotoxins in parenteral pharmaceutical products. Based on the results of the collaborative study, batch 10/178 was established by the European Pharmacopoeia Commission as the Ph. Eur. Endotoxin Biological Reference Preparation (BRP) batch 5. The same batch was also established by the Expert Committee on Biological Standardisation (ECBS) of WHO as the WHO 3(rd) IS for Endotoxin. Batch 10/190 was adopted as the USP Endotoxin Reference Standard, lot H0K354 and vials from this same batch (10/190) will serve as the United States Food and Drug Administration (USFDA) Endotoxin Standard, EC-7.

Exploring experiences and understandings of pain in adults with intellectual disabilities

BACKGROUND

People with intellectual disabilities (ID) are at risk that their health problems, many of which cause pain, go unrecognised and untreated. Their understanding and personal experiences of pain have received little research attention.

METHOD

Information was collected from 15 adults with ID using semi-structured interviews about their experiences and understanding of pain. Transcripts were analysed using content analysis.

RESULTS

Participants described pain using negative meanings and strong imagery, with various causes of pain suggested, but said little about how they coped with pain. Participants varied in whether they reported pains to carers, some choosing to hide the experience. There seemed a general belief that others can tell when someone is in pain.

CONCLUSIONS

Conversations regarding pain with adults with ID are a real challenge; health-care staff need to think carefully about the questions they ask. Possessing verbal skills cannot be taken as an indication that pain will be communicated.

Monoclonal antibody TGN1412 trial failure explained by species differences in CD28 expression on CD4+ effector memory T-cells

BACKGROUND AND PURPOSE

In 2006, a life-threatening 'cytokine storm', not predicted by pre-clinical safety testing, rapidly occurred in all six healthy volunteers during the phase I clinical trial of the CD28 superagonist monoclonal antibody (mAb) TGN1412. To date, no unequivocal explanation for the failure of TGN1412 to stimulate profound cytokine release in vitro or in vivo in species used for pre-clinical safety testing has been established. Here, we have identified a species difference almost certainly responsible for this disparate immunopharmacology.

EXPERIMENTAL APPROACH

Polychromatic flow cytometry and intracellular cytokine staining were employed to dissect the in vitro immunopharmacology of TGN1412 and other therapeutic mAbs at the cellular level to identify differences between humans and species used for pre-clinical safety testing.

KEY RESULTS

In vitro IL-2 and IFN-γ release from CD4+ effector memory T-cells were key indicators of a TGN1412-type response. This mechanism of cytokine release differed from that of other therapeutic mAbs, which can cause adverse reactions, because these other mAbs stimulate cytokine release primarily from natural killer cells. In contrast to humans, CD28 is not expressed on the CD4+ effector memory T-cells of all species used for pre-clinical safety testing, so cannot be stimulated by TGN1412.

CONCLUSIONS AND IMPLICATIONS

It is likely that activation of CD4+ effector memory T-cells by TGN1412 was responsible for the cytokine storm. Lack of CD28 expression on the CD4+ effector memory T-cells of species used for pre-clinical safety testing of TGN1412 offers an explanation for the failure to predict a 'cytokine storm' in humans.

Volunteer stroke scheme revisited

A project with several strands was carried out with a local Volunteer Stroke Scheme (VSS) which evaluated current practice; identified gaps in practice on which a training programme was based: and then evaluated the outcome of this training in subsequent activities.

Mammary gland lactose, plasma progesterone and lactogenesis in the marsupial Macropus eugenii

Mammary gland lactose concentrations in pregnant tammar wallabies remained low at 115 +/- 24 (S.E.M.) micrograms/g wet weight of tissue until immediately before parturition, then increased to 1274 +/- 262 micrograms/g after birth. Concentrations in non-pregnant cyclic animals were generally low (143 +/- 36 micrograms/g), but were raised in three animals around the time of oestrus. Removal of the corpus luteum on day 18 of pregnancy or the oestrous cycle caused an increase in lactose concentrations in both lutectomized and sham-operated animals. This occurred despite a significant lowering of peripheral plasma progesterone concentration in only the lutectomized group. Plasma cortisol concentrations were high in some of these animals, but showed no consistent relationships with the raised lactose concentrations. The increased peripartum lactose concentration normally coincides with a sharp fall in peripheral plasma progesterone concentration, but artificial maintenance of high progesterone levels had no effect on the increase of mammary gland lactose at parturition. Mammary gland lactose concentrations in tammar wallabies are therefore a useful indicator of biosynthetic activity and as an index of lactogenesis but the role, if any, of progesterone withdrawal in lactogenesis remains unclear.

The mammary glands of the tammar wallaby (Macropus eugenii) during pregnancy and lactation

The 4 mammary glands of a nulliparous tammar wallaby differentiate during the 27-day pregnancy in preparation for lactation. Alveoli increase in size and number in the first half of gestation, and this increase continues slowly to term. At or soon after parturition the alveolar lumina enlarge as the gland to which the young is attached begins to secrete. The connective tissue stroma of the gland is progressively replaced throughout pregnancy and lactation with glandular tissue. Gross dimensions of the gland and alveolar size increase markedly in later lactation as the gland reaches maximum production. After parturition the other 3 glands simultaneously regress to a quiescent state until the next pregnancy. After weaning (Days 320-450 of lactation) the lactating gland involutes. This may occur concurrently with redifferentiation of the other glands for a new lactation. This pattern of differentiation is similar to that of the red kangaroo, and probably all macropodids.

Osteomyelitis of the spine following lumbar puncture

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Radiology in the diagnosis of hypertrophic pyloric stenosis

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Atelectatic or compensatory bronchiectasis

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Chlorotic Anæmia with Dwarfism and Rickets

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Massive (? Active) Pulmonary Collapse following Pneumonia

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Intrathoracic Tuberculous Abscess as a Sequel to Pleurisy with Effusion

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Congenital Shortening of the Œsophagus and the Thoracic Stomach Resulting Therefrom

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Jaw-Winking Phenomenon (Marcus Gunn). With Cinematographic Demonstration

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Microscopic Sections from Case of Gaucher's Disease

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