Quality of English inpatient mental health services for people with anxiety or depressive disorders: Findings and recommendations from the core audit of the National Clinical Audit of Anxiety and Depression

BACKGROUND

Clinical audit is a sustained cyclical quality improvement process seeking to improve patient care and outcomes by evaluating services against explicit standards and implementing necessary changes. National audits aim to improve population-level clinical care by identifying unwarranted variations and making recommendations for clinicians, managers and service commissioners. The National Clinical Audit of Anxiety and Depression aimed to improve clinical care for people admitted to English hospitals for treatment of anxiety and depression, to provide comparative data on quality of care, and to support local quality improvement initiatives by identifying and sharing examples of best practice.

PROCEDURES

Thirteen standards were developed based on NICE guidelines, literature review and feedback from a steering committee and reference group of service users and carers. All providers of NHS inpatient mental health services in England were asked to submit details of between 20 and 100 eligible service users/patients admitted between April 2017 and September 2018. To ascertain data reliability, participating services re-audited 5 sets of case-notes with a second auditor, and the coordinating team checked 10 randomly-selected sets of case-notes from 3 services, also selected at random. The reference group and steering committee identified key findings and developed a series of recommendations, which were discussed in regional quality improvement workshops and on-line webinars.

FINDINGS

Data from 3795 case notes were analysed. A sizeable proportion of records indicated that at least one important aspect of initial assessment was not documented. Many service users/patients who could have benefited from an intervention targeted at optimising physical health did not receive it. Only a minority (39%) were referred for psychological therapy. Use of outcome measures varied considerably but no single outcome measure was being used routinely. Most individuals had a care plan recorded in the notes, but a review date was documented in only two-thirds, and almost half of individuals had not received a copy.

CONCLUSIONS

There was considerable variation between English mental health services across many variables, and much scope for improvement. Clinicians should ensure that care plans are developed collaboratively with service users/patients and identified carers should be provided with information about support services. Health services should investigate the reasons for low referral rates for psychological therapies. Clinicians should ensure all service users have jointly developed crisis plans in place at discharge. Service managers should agree outcome measures to evaluate the treatment provided and clinicians should use these measures at initial assessment and review appointments. The implementation of such changes provides an opportunity for collaborative research into mental health service delivery and quality.

Psychological interventions for acute psychiatric inpatients with schizophrenia-spectrum disorders: A systematic review and meta-analysis

BACKGROUND

Acute inpatient psychiatric wards are important yet challenging environments in which to implement psychological interventions for people with schizophrenia-spectrum disorders. No meta-analysis to date has evaluated whether psychological interventions are effective in this context.

METHODS

We systematically searched Embase, Medline and PsycInfo databases for randomised controlled trials (RCTs) of psychological interventions implemented in acute inpatient psychiatric settings with individuals with schizophrenia-spectrum disorders. We conducted random effects meta-analyses of between-groups outcomes at post-intervention and relapse/re-hospitalisation rates by follow-up.

RESULTS

Twenty-nine trials were suitable for meta-analysis. Psychological interventions improved post-intervention positive symptoms, social functioning and treatment compliance and reduced the risk of relapse/ re-hospitalisation, relative to control conditions. Analyses of specific intervention effects found positive effects of psychoeducation on several key outcomes (power > 80%) and preliminary evidence for positive effects of acceptance and commitment therapy (ACT), cognitive behaviour therapy (CBT) and metacognitive training (MCT) on some outcomes (power < 80%).

CONCLUSION

Psychological interventions can be helpful for acute inpatients with schizophrenia-spectrum disorders. However, risk of bias was often high or unclear, and some analyses were underpowered. Further research should use more rigorous RCT designs and publish meta-analysable data on positive symptoms, general psychopathology, relapse/ re-hospitalisation, social functioning and treatment compliance.

Patient-reported experience and quality of care for people with schizophrenia

BACKGROUND

Evidence is mounting that patient-reported experience can provide a valuable indicator of the quality of healthcare services. However, little is known about the relationship between the experiences of people with severe mental illness and the quality of care they receive. We conducted a study to examine the relationship between patient-reported experience and the quality of care provided to people with schizophrenia.

METHODS

We calculated a composite global rating of quality of care for people with schizophrenia using data from an audit of 64 mental health providers. We then examined associations between these ratings and mean patient satisfaction and patient-rated outcome using data from a survey of 5608 schizophrenic patients treated in these services.

RESULTS

Global rating of quality of care was positively correlated with patient-rated outcome (r = 0.33; p = 0.01) but not with patient satisfaction (r = 0.21, p = 0.10). Patient-rated outcome was also positively correlated with patient involvement (r = 0.26, p = 0.04) and the quality of prescribing practice (r = 0.31, p = 0.02). High patient satisfaction scores were significantly associated with the extent of use of care plans within each organisation (r = 0.27, p = 0.03).

CONCLUSIONS

Among people with schizophrenia, patient-rated outcome provides a better guide to the quality of care than patient-rated satisfaction. Greater use of patient-reported outcome measures should be made when assessing the quality of care provided to people with psychosis.

Psychiatric out-patients' views on talking about sex

Despite widespread acceptance that the sexual history is an important part of psychiatric assessment, concern continues to be raised that such questions are often neglected. It has been suggested that one reason for this is the belief of staff that patients do not want to discuss sexual matters. The response of 65 out-patients to a questionnaire concerning their attitudes and expectations to being asked questions about sex is reported. The majority of patients expected there to be some inquiry about sexual matters. While detailed enquiry was not anticipated, patients stated that most questions would not make them feel uncomfortable. This study does not support the view that patients are reluctant to give a sexual history.

Evaluation of a community based service for urgent psychiatric assessment

The Urgent Assessment Service (UAS) was set up to provide community based urgent psychiatric assessment to a range of referrers. The work of the service was assessed over a six month period. Results show that it was popular with a broad range of medical and non-medical professionals. Patients generally presented with depression or psychotic illnesses and those referred from non-medical sources were more likely to be suffering from schizophrenia and assessed as being at least as unwell as those referred by GPs and hospital based doctors. Rates or referral to hospital services were low with the vast majority of patients being referred back to their general practitioner after initial assessment and treatment.

Ethnicity as a predictor of detention under the Mental Health Act

BACKGROUND

There has been major concern about the 'over-representation' of Black and ethnic minority groups amongst people detained under the Mental Health Act (MHA). We explored the effect of patient ethnicity on detention following an MHA assessment, once confounding variables were controlled for.

METHOD

Prospective data were collected for all MHA assessments over 4-month periods in the years 2008, 2009, 2010 and 2011 each in three regions in England: Birmingham, West London and Oxfordshire. Logistic regression modelling was conducted to predict the outcome of MHA assessments - either resulting in 'detention' or 'no detention'.

RESULTS

Of the 4423 MHA assessments, 2841 (66%) resulted in a detention. A diagnosis of psychosis, the presence of risk, female gender, level of social support and London as the site of assessment predicted detention under the MHA. Ethnicity was not an independent predictor of detention.

CONCLUSIONS

There is no evidence for that amongst those assessed under the MHA, ethnicity has an independent effect on the odds of being detained.

Shifting effects in randomised controlled trials of complex interventions: a new kind of performance bias?

OBJECTIVE

Randomised controlled trials (RCTs) aim to provide unbiased estimates of treatment effects. However, the process of implementing trial procedures may have an impact on the performance of complex interventions that rely strongly on the intuition and confidence of therapists. We aimed to examine whether shifting effects over the recruitment period can be observed that might indicate such impact.

METHOD

Three RCTs investigating music therapy vs. standard care were included. The intervention was performed by experienced therapists and based on established methods. We examined outcomes of participants graphically, analysed cumulative effects and tested for differences between first vs. later participants. We tested for potential confounding population shifts through multiple regression models.

RESULTS

Cumulative differences suggested trends over the recruitment period. Effect sizes tended to be less favourable among the first participants than later participants. In one study, effects even changed direction. Age, gender and baseline severity did not account for these shifting effects.

CONCLUSION

Some trials of complex interventions have shifting effects over the recruitment period that cannot be explained by therapist experience or shifting demographics. Replication and further research should aim to find out which interventions and trial designs are most vulnerable to this new kind of performance bias.

Group art therapy as an adjunctive treatment for people with schizophrenia: a randomised controlled trial (MATISSE)

OBJECTIVE

To examine the clinical effectiveness and cost-effectiveness of referral to group art therapy plus standard care, compared with referral to an activity group plus standard care and standard care alone, among people with schizophrenia.

DESIGN

A three-arm, parallel group, single-blind, pragmatic, randomised controlled trial. Participants were randomised via an independent and remote telephone randomisation service using permuted blocks, stratified by study centre.

SETTING

Study participants were recruited from secondary care mental health and social services in four UK centres.

PARTICIPANTS

Potential participants were aged 18 years or over, had a clinical diagnosis of schizophrenia, confirmed by an examination of case notes, and provided written informed consent. We excluded those who were unable to speak sufficient English to complete the baseline assessment, those with severe cognitive impairment and those already receiving arts therapy.

INTERVENTIONS

Group art therapy was delivered by registered art therapists according to nationally agreed standards. Groups had up to eight members, lasted for 90 minutes and ran for 12 months. Members were given access to a range of art materials and encouraged to use these to express themselves freely. Activity groups were designed to control for the non-specific effects of group art therapy. Group facilitators offered various activities and encouraged participants to collectively select those they wanted to pursue. Standard care involved follow-up from secondary care mental health services and the option of referral to other services, except arts therapies, as required.

MAIN OUTCOME MEASURES

Our co-primary outcomes were global functioning (measured using the Global Assessment of Functioning Scale - GAF) and mental health symptoms (measured using the Positive and Negative Syndrome Scale - PANSS) at 24 months. The main secondary outcomes were level of group attendance, social functioning, well-being, health-related quality of life, service utilisation and other costs measured 12 and 24 months after randomisation.

RESULTS

Four hundred and seventeen people were recruited, of whom 355 (85%) were followed up at 2 years. Eighty-six (61%) of those randomised to art therapy and 73 (52%) of those randomised to activity groups attended at least one group. No differences in primary outcomes were found between the three study arms. The adjusted mean difference between art therapy and standard care at 24 months was -0.9 [95% confidence interval (CI) -3.8 to 2.1] on the GAF Scale and 0.7 (95% CI -3.1 to 4.6) on the PANSS Scale. Differences in secondary outcomes were not found, except that those referred to an activity group had fewer positive symptoms of schizophrenia at 24 months than those randomised to art therapy. Secondary analysis indicated that attendance at art therapy groups was not associated with improvements in global functioning or mental health. Although the total cost of the art therapy group was lower than the cost of the two comparison groups, referral to group art therapy did not appear to provide a cost-effective use of resources.

CONCLUSIONS

Referring people with established schizophrenia to group art therapy as delivered in this randomised trial does not appear to improve global functioning or mental health of patients or provide a more cost-effective use of resources than standard care alone.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 46150447.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 8. See the HTA programme website for further project information.

Medication prescribed to people with personality disorder: the influence of patient factors and treatment setting

OBJECTIVE

To examine the extent of use and clinical rationale for the prescribing of psychotropic drugs for people with personality disorder (PD) who are in contact with mental health services.

METHOD

Clinical records of 278 patients with a primary diagnosis of PD were examined.

RESULTS

Just over 80% (N = 225) of patients were being prescribed psychotropic medication. One in five was prescribed three or more drugs. People with comorbid mental disorders were more likely to receive psychotropic medication. Half those prescribed antidepressants had no record of depression in their records. While drug treatments were mostly prescribed for depressive and psychotic symptoms, they were also used to try to manage behavioural problems such as self-harm or given in response to patient requests for treatment. People receiving specialist PD services (OR = 0.35, 95% CI = 0.13-0.95) or other specialist services (OR = 0.24, 95% CI = 0.10-0.60) were less likely to be prescribed drug treatments.

CONCLUSION

Drug treatments are widely used for people with PD despite the relatively weak evidence base. Both the type of personality problem and the context in which treatment is delivered appear to have an impact on whether drug treatments are prescribed.

The effect of referral for brief intervention for alcohol misuse on repetition of deliberate self-harm: an exploratory randomized controlled trial

BACKGROUND

Referral for brief intervention among people who misuse alcohol is reported to be effective but its impact among those who present to services following deliberate self-harm (DSH) has not been examined.

METHOD

Consecutive patients who presented to an Emergency Department (ED) following an episode of DSH were screened for alcohol misuse. Those found to be misusing alcohol were randomly assigned to brief intervention plus a health information leaflet or to a health information leaflet alone. The primary outcome was whether the patient reattended an ED following a further episode of DSH during the subsequent 6 months. Secondary outcomes were alcohol consumption, mental health and satisfaction with care measured 3 and 6 months after randomization.

RESULTS

One hundred and three people took part in the study. Follow-up data on our primary outcome were obtained for all subjects and on 63% for secondary outcomes. Half those referred for brief intervention received it. Repetition of DSH was strongly associated with baseline alcohol consumption, but not influenced by treatment allocation. There was a non-significant trend towards the number of units of alcohol consumed per drinking day being lower among those randomized to brief intervention.

CONCLUSIONS

Referral for brief intervention for alcohol misuse following an episode of DSH may not influence the likelihood of repetition of self-harm. Longer-term interventions may be needed to help people who deliberately harm themselves and have evidence of concurrent alcohol misuse.

Effects of Gender and Age on Paediatric Headache

The aim of this study was to evaluate the impact of gender and age on headache characteristics and disability. Headache characteristics were assessed at an initial visit to a paediatric specialty care centre and five follow-up visits. A total number of 4121 patients were evaluated. Fifty-eight per cent of the sample was female. Boys were younger at their first headache and initial visit. They more frequently described headache pain as squeezing and location as top of the head. Girls reported more frequent and longer headaches. Girls more often described headache pain as sharp and location as back of the head. Age accounted for more variance than gender in headache severity, duration, frequency and disability. Gender differences exist in headache characteristics. Age is also an important factor in the variability in characteristics and disability. Longitudinal studies are needed to describe further the natural history of headaches in childhood and compare outcome between genders.

Cognitive behaviour therapy for violent men with antisocial personality disorder in the community: an exploratory randomized controlled trial

BACKGROUND

Little information exists on treatment effectiveness in antisocial personality disorder (ASPD). We investigated the feasibility and effectiveness of carrying out a randomized controlled trial of cognitive behaviour therapy (CBT) in men with ASPD who were aggressive.

METHOD

This was an exploratory two-centre, randomized controlled trial in a community setting. Fifty-two adult men with a diagnosis of ASPD, with acts of aggression in the 6 months prior to the study, were randomized to either treatment as usual (TAU) plus CBT, or usual treatment alone. Change over 12 months of follow-up was assessed in the occurrence of any act of aggression and also in terms of alcohol misuse, mental state, beliefs and social functioning.

RESULTS

The follow-up rate was 79%. At 12 months, both groups reported a decrease in the occurrence of any acts of verbal or physical aggression. Trends in the data, in favour of CBT, were noted for problematic drinking, social functioning and beliefs about others.

CONCLUSIONS

CBT did not improve outcomes more than usual treatment for men with ASPD who are aggressive and living in the community in this exploratory study. However, the data suggest that a larger study is required to fully assess the effectiveness of CBT in reducing aggression, alcohol misuse and improving social functioning and view of others. It is feasible to carry out a rigorous randomized controlled trial in this group.

Engagement and retention in specialist services for people with personality disorder

OBJECTIVE

To quantify levels of engagement and retention in specialist services for people with personality disorder (PD).

METHOD

Demographic and clinical data were collected on referrals to 10 specialist services for people with PD. Follow-up data on retention and drop-out from services were collected over the following 30 months.

RESULTS

Seven hundred and thirteen (60.1%) of 1186 people referred to services were taken by them, of whom 164 (23.0%) subsequently dropped out prior to the completion of an episode of care. Men, younger people and those with higher levels of personality disturbance were less likely to complete a package of care.

CONCLUSION

Specialist community-based services for adults with PD are able to engage most of those that are referred to them, but further efforts need to be made to find ways to engage younger people and men with PD.

Resuscitation room blood alcohol concentrations: one-year cohort study

OBJECTIVE

To clarify the relationship between presenting clinical condition and blood alcohol concentration (BAC) among adult patients admitted to a resuscitation room (RR) of an emergency department (ED) in order to help guide clinical practice.

METHOD

Single-site prospective cohort study of all patients admitted to the RR of an inner-city hospital over a one-year period. The study sample comprised all those aged 16 years and over from whom a blood sample was taken, with BAC (results not known to ED staff), pathology by International Classification of Diseases (ICD) version 10 coding, injury severity score for trauma, return visit to hospital and mortality during the subsequent 6-month period, being recorded.

RESULTS

291 (15%) of 1908 presentations had a positive BAC (ie, BAC >10 mg/100 ml) ranging from 11 to 574 mg/100 ml, of which almost 40% were over 240 mg/100 ml (ICD-10 code Y90.8). In addition to collapse from alcohol/drugs, almost half of those presenting following self-harm or assault had a positive BAC. Those with a positive BAC had a higher rate of ED re-attendance in the following 6 months. 10% of all presentations were due to trauma.

CONCLUSION

The following five presentations to the RR are associated with a positive BAC: collapse from alcohol/drugs, self-harm, trauma, gastrointestinal bleeding (ICD-10 code K92.2) and non-cardiac chest pain (ICD-10 code R07). Patients with a positive BAC demonstrate a very wide range of pathology, some with severe levels of misuse. This highlights the opportunity for prompt feedback when sober, to ensure all is done to encourage patients to contemplate change in order to reduce re-attendance.

Music therapy for depression

BACKGROUND

Depression is a highly prevalent disorder associated with reduced social functioning, impaired quality of life, and increased mortality. Music therapy has been used in the treatment of a variety of mental disorders, but its impact on those with depression is unclear.

OBJECTIVES

To examine the efficacy of music therapy with standard care compared to standard care alone among people with depression and to compare the effects of music therapy for people with depression against other psychological or pharmacological therapies.

SEARCH STRATEGY

CCDANCTR-Studies and CCDANCTR-References were searched on 7/11/2007, MEDLINE, PsycINFO, EMBASE, PsycLit, PSYindex, and other relevant sites were searched in November 2006. Reference lists of retrieved articles were hand searched, as well as specialist music and arts therapies journals.

SELECTION CRITERIA

All randomised controlled trials comparing music therapy with standard care or other interventions for depression.

DATA COLLECTION AND ANALYSIS

Data on participants, interventions and outcomes were extracted and entered onto a database independently by two review authors. The methodological quality of each study was also assessed independently by two review authors. The primary outcome was reduction in symptoms of depression, based on a continuous scale.

MAIN RESULTS

Five studies met the inclusion criteria of the review. Marked variations in the interventions offered and the populations studied meant that meta-analysis was not appropriate. Four of the five studies individually reported greater reduction in symptoms of depression among those randomised to music therapy than to those in standard care conditions. The fifth study, in which music therapy was used as an active control treatment, reported no significant change in mental state for music therapy compared with standard care. Dropout rates from music therapy conditions appeared to be low in all studies.

AUTHORS' CONCLUSIONS

Findings from individual randomised trials suggest that music therapy is accepted by people with depression and is associated with improvements in mood. However, the small number and low methodological quality of studies mean that it is not possible to be confident about its effectiveness. High quality trials evaluating the effects of music therapy on depression are required.

Alcohol: a missed opportunity. A survey of all accident and emergency departments in England

AIM

To determine the extent to which the recommendations of the alcohol harm reduction strategy for England and the Choosing Health white paper for the provision of screening and brief interventions for hazardous and harmful drinkers have been adopted by accident and emergency departments.

METHOD

Telephone/postal survey of all 191 Type 1 departments in England. The survey was part of a larger study investigating the impact of the changes in the licensing act (2004) on alcohol-related attendances.

RESULTS

4 departments use formal screening tools and 24 ask general questions about consumption (98.9% response rate). Blood alcohol levels were measured as required by 100 departments. No departments routinely measure blood alcohol, and 84 departments never assess blood alcohol levels. Alcohol-related attendances were formally recorded by 131 departments. Access to an alcohol health worker or a clinical nurse specialist was reported by 32 departments.

DISCUSSION

Although departments may be willing to address hazardous alcohol consumption, the low numbers of departments utilising formal screening tools suggests that patients who may benefit from help or advice remain undetected.

Can deficits in social problem-solving in people with personality disorder be reversed?

Research evidence is beginning to emerge that social problem-solving can improve the social functioning of people with personality disorder. This approach is particularly important because it may be relatively easy to train healthcare workers to deliver this intervention. However, the costs and cost-effectiveness of social problem-solving need to be established if it is to be made more widely available.

Conservation of Pitx1 expression during amphibian limb morphogenesis

In contrast to the pattern of limb emergence in mammals, chicks, and the newt N. viridescens, embryos such as Xenopus laevis and Eleutherodactylus coqui initiate pelvic limb buds before they develop pectoral ones. We studied the expression of Pitx1 in X. laevis and E. coqui to determine if this paired-like homeodomain transcription factor directs differentiation specifically of the hindlimb, or if it directs the second pair of limbs to form, namely the forelimbs. We also undertook to determine if embryonic expression patterns were recapitulated during the regeneration of an amputated limb bud. Pitx1 is expressed in hindlimbs in both X. laevis and E. coqui, and expression is similar in both developing and regenerating limb buds. Expression in hindlimbs is restricted to regions of proliferating mesenchyme.

Suicidal ideation and suicide attempts among ethnic minority groups in England: results of a national household survey

BACKGROUND

Socio-cultural factors impact on the extent of suicidal ideation and attempted suicide but the relative importance of these factors among people from different ethnic groups in Britain has not been explored. We examined the prevalence of suicidal ideation, the incidence of attempted suicide, and the extent of service utilization following attempted suicide among representative samples of White, Irish, Black Caribbean, Bangladeshi, Indian and Pakistani individuals living in England.

METHOD

We conducted a secondary analysis of data from the EMPIRIC study, a cross-sectional survey of 4281 adults aged 16-74 years, living in private households in England.

RESULTS

Lifetime suicidal ideation was generally lower in ethnic minority groups but higher among those born in the UK than those who migrated to England as adults. Risk factors for suicidal ideation have much in common across different ethnic groups; current symptoms of mental distress being the most important. White British and Irish respondents were twice as likely to receive medical attention following attempted suicide than those from other ethnic groups.

CONCLUSIONS

Services need to adapt in order to ensure that people from ethnic minorities receive appropriate psychological and medical care following attempted suicide.

Zero tolerance of violence by users of mental health services: the need for an ethical framework

Concerns about violent conduct of service users towards healthcare staff have prompted a ;zero tolerance' policy within the National Health Service. This policy specifically excludes users of mental health services. We attempt to challenge artificial distinctions between users of mental health and other services, and propose an ethical underpinning to the implementation of this policy.

Impact of health consequences feedback on patients acceptance of advice about alcohol consumption

OBJECTIVES

To demonstrate the impact of health consequences feedback on patients willingness to accept advice about drinking.

METHODS

281 patients identified as hazardous drinkers were offered advice about alcohol consumption. During the experimental period patients' were given feedback as to the health consequences.

RESULTS

Introduction of feedback led to a 23% increase in the proportion of patients who were willing to accept brief advice.

CONCLUSIONS

Feedback provision should be included as part of Screening and Brief intervention programmes to increase the number of patients that may benefit from an intervention.

User involvement in the planning and delivery of mental health services: a cross-sectional survey of service users and providers

OBJECTIVE

To identify methods for involving service users in the planning and delivery of psychiatric services and factors which may assist and impede this process.

METHOD

A cross-sectional postal survey of user groups and providers of psychiatric services throughout Greater London (UK).

RESULTS

Seventeen (94%) service providers and 29 (48%) user groups responded to the survey. Service providers employed a wide variety of different methods for involving users but none met national standards for user involvement (UI). Service providers stated that the main obstacle to UI was that users who took part were not representative of local patients. User groups highlighted staff resistance as a major obstacle and 80% stated that they were not satisfied with current arrangements for UI.

CONCLUSION

While users and providers of mental health services were able to identify changes resulting from UI the responsiveness of staff and the representativeness of service users may be impeding this process.

CAP1 expression is developmentally regulated in Xenopus

We have cloned and characterized a Xenopus member of the cyclase associated protein (CAP) gene family. xCAP1 is expressed as a maternal transcript, but is up-regulated prior to gastrulation and subsequently localizes to head mesenchyme, lens, otic vesicle, and trunk mesoderm including the pronephros. At different stages, the gene also appears to differentiate surface from deep (sensorial) ectoderm. As in Drosophila, Xenopus CAP1 is expressed in the developing eye, specifically in the differentiating lens. However, in distinction to Drosophila, Xenopus CAP1 does not express in periodically arrayed neural bands.

Xenopus adenine nucleotide translocase mRNA exhibits specific and dynamic patterns of expression during development

We report the isolation and characterization of the Xenopus homolog to human T1 ANT (adenine nucleotide translocase). The 1290-nucleotide sequence contains initiation and termination signals, and encodes a conceptual protein of 298 amino acids. The sequence shares high amino acid identity with the mammalian adenine translocases. The transcript is present in unfertilized eggs, and it is expressed at higher levels during formation of the antero-posterior dorsal axis in embryos. Although low levels are expressed constitutively except in endodermal cells, adenine nucleotide translocase (ANT) expression is dynamically regulated during neurulation. At this stage, expression in ectoderm rapidly diminishes as the neural folds form, and then ANT expression increases slightly in mesoderm. At the culmination of neurulation, the neural tube briefly expresses ANT, and thereafter its expression predominates in the somitic mesoderm and also the chordoneural hinge. In addition, ANT expression is particularly high in the prosencephalon, the mesencephalon, the branchial arches, eye, and the otic vesicle. Treatment of embryos with retinoic acid has the effect of diminishing constitutive expression of ANT, but microinjection studies demonstrate that immediate and local repression cannot be induced in dorsal structures.

British psychiatry in the 20th century--observations from a psychiatric journal

In order to investigate change and continuity in the concerns and practices of psychiatry in Britain during the 20th century we examined contents of the British Journal of Psychiatry. Specifically we sought to examine the paradigms used by psychiatry to conceptualize mental illness during this time. Back issues of the journal for 1 year at the mid-point of each decade were examined. We undertook a quantitative analysis categorising each article in terms of its form and content and a qualitative analysis in order to summarise the subjects that were covered. The results show that there has been continuous interest in biological aspects and treatments of mental illness with relatively little coverage of psychoanalysis or social psychiatry. Little support was found for the suggestion that major shifts have occurred in the explanatory paradigms used by psychiatry over the century. Modern interest in biological psychiatry is therefore not a new departure, but appears rather as the continuation of a long-standing inclination. The decline of the asylum-based system of care has been accompanied by a broadening in the scope of psychiatric concerns with a greater emphasis on milder mental disorders such as neurosis and depression.

Bcl-2 overexpression protects photooxidative stress-induced apoptosis of photoreceptor cells via NF-kappaB preservation

We recently showed that photooxidative stress on cultured photoreceptor cells results in down-modulation of NF-kappaB activity which then leads to apoptosis of cultured 661W photoreceptor cells. In an effort to further delineate the mechanism of photoreceptor cell death, we sought to determine the effects of Bcl-2 overexpression on cell survivability. Wild-type 661W cells were transfected with the plasmid construct pSFFV-neo-Bcl-2 and several clones were isolated. All clones demonstrated increased Bcl-2 mRNA and protein levels, with the B4 clone exhibiting the greatest enhancement. On exposure to visible light the B4 cells were protected from undergoing apoptosis when compared with the mock transfected cells, as ascertained by TUNEL apoptosis assay and formazan based estimation of cell viability. The Bcl-2 overexpressing cells also maintained a higher Bcl-2/Bax ratio, suggesting that this ratio is important in protection from photooxidative stress. Electrophoretic mobility shift assays for NF-kappaB demonstrated higher activity in both nuclear and cytosolic fractions of the B4 photoreceptors compared with the 661W wild-type cells at all light exposure time points. Furthermore, the findings of the gel shift assays were further supported by immunocytochemistry for NF-kappaB which revealed that protein levels of the RelA subunit of NF-kappaB were protected in the nucleus as well as in the cytoplasm of Bcl-2 overexpressing B4 cells exposed to light compared to the 661W cells. These results suggest that Bcl-2 overexpression protects NF-kappaB protein levels and activity in the nucleus, indicating that preservation of NF-kappaB binding activity in the nucleus may be essential for photoreceptor cells to survive photooxidative damage induced apoptosis.

Subcellular localization of acetyl-CoA carboxylase in the apicomplexan parasite Toxoplasma gondii

Apicomplexan parasites such as Toxoplasma gondii contain a primitive plastid, the apicoplast, whose genome consists of a 35-kb circular DNA related to the plastid DNA of plants. Plants synthesize fatty acids in their plastids. The first committed step in fatty acid synthesis is catalyzed by acetyl-CoA carboxylase (ACC). This enzyme is encoded in the nucleus, synthesized in the cytosol, and transported into the plastid. In the present work, two genes encoding ACC from T. gondii were cloned and the gene structure was determined. Both ORFs encode multidomain proteins, each with an N-terminal extension, compared with the cytosolic ACCs from plants. The N-terminal extension of one isozyme, ACC1, was shown to target green fluorescent protein to the apicoplast of T. gondii. In addition, the apicoplast contains a biotinylated protein, consistent with the assertion that ACC1 is localized there. The second ACC in T. gondii appears to be cytosolic. T. gondii mitochondria also contain a biotinylated protein, probably pyruvate carboxylase. These results confirm the essential nature of the apicoplast and explain the inhibition of parasite growth in cultured cells by herbicides targeting ACC.

xPitx1 plays a role in specifying cement gland and head during early Xenopus development

Xenopus Pitx1 is a homeobox gene whose family members are structurally and functionally conserved in organisms as diverse as Drosophila, chick, mouse, human, and frog. Present as a maternal transcript, the gene is zygotically expressed during gastrulation in a dorsal streak of cells. This streak restricts to a small circular domain underlying the center of presumptive neural plate. Shortly thereafter, a crescent of expression develops at the border of anterior neural ectoderm, and as the central plate domain diminishes, the crescent coalesces to define the presumptive cement gland. Expression remains high throughout cement gland development, and subsequently expands to include ectodermal cells involved in stomodeal invagination. During early organogenesis, expression ensues in developing eye, posterior lateral mesoderm, and first branchial arch derivatives. Ectopic expression of xPitx1 causes head deformities including enlarged cement gland, ectopic cement glands, and posterior deformities or, in extreme cases, inhibition of recognizable structures posterior to the cement gland. Expression of markers such as XCG-1, xOtx2, xPax6, neuralbeta tubulin, and xTwist suggest that increases in cement gland and lower mandibular size are likely at the expense of other head tissues. Paradoxically, overexpression is sufficient to partially rescue embryos that are axially perturbed by ultraviolet irradiation or retinoic acid administration. Ectopic expression of xPitx1 in ectodermal explants directly promotes cement gland development as there was no evidence that mesodermal or neural tissue was present in explants.

The plastid of Toxoplasma gondii is divided by association with the centrosomes

Apicomplexan parasites harbor a single nonphotosynthetic plastid, the apicoplast, which is essential for parasite survival. Exploiting Toxoplasma gondii as an accessible system for cell biological analysis and molecular genetic manipulation, we have studied how these parasites ensure that the plastid and its 35-kb circular genome are faithfully segregated during cell division. Parasite organelles were labeled by recombinant expression of fluorescent proteins targeted to the plastid and the nucleus, and time-lapse video microscopy was used to image labeled organelles throughout the cell cycle. Apicoplast division is tightly associated with nuclear and cell division and is characterized by an elongated, dumbbell-shaped intermediate. The plastid genome is divided early in this process, associating with the ends of the elongated organelle. A centrin-specific antibody demonstrates that the ends of dividing apicoplast are closely linked to the centrosomes. Treatment with dinitroaniline herbicides (which disrupt microtubule organization) leads to the formation of multiple spindles and large reticulate plastids studded with centrosomes. The mitotic spindle and the pellicle of the forming daughter cells appear to generate the force required for apicoplast division in Toxoplasma gondii. These observations are discussed in the context of autonomous and FtsZ-dependent division of plastids in plants and algae.

Kinematic analysis of shot-putting performed by wheelchair athletes of different medical classes

The aim of this study was to identify those kinematic characteristics that are most closely related to an athlete's medical classification and measured distance of a put. Two S-VHS camcorders (60 fields per second) were used to record the performance of 17 males of different classes. Each participant performed six trials and the best trial for each was selected for analysis. Three-dimensional kinematics of the shot and upper body segments at the instant of release and during the forward thrust (delivery) were determined. The average speeds and angles of the shot at release for different classes (5.3-7.8 m x s(-1) and 21.2 to 34.4 degrees, respectively) were smaller than those exhibited by elite male able-bodied throwers. The height of the shot at release, the angular speed of the upper arm at release, the range of motion of the shoulder girdle during the delivery, and the average angular speeds of the trunk, shoulder girdle and upper arm during the delivery, were all significantly correlated with both the classification and measured distance (P < 0.05). The results indicate the importance of achieving a high average angular speed for each upper body segment during the delivery.

Transport and trafficking: Toxoplasma as a model for Plasmodium

Like Plasmodium, the protozoan parasite Toxoplasma gondii is a member of the phylum Apicomplexa, and an obligate intracellular pathogen. Unlike Plasmodium, however, Toxoplasma is highly amenable to experimental manipulation in the laboratory. The development of molecular transformation protocols for T. gondii has provided both scientific precedent and practical selectable markers for Plasmodium. Beyond the feasibility of molecular biological experimentation now possible in both systems, the high frequency of stable transformation in Toxoplasma allows this parasite to be used for molecular genetic analysis. The ability to control homologous vs. non-homologous recombination in T. gondii permits gene knockouts/allelic replacements at previously cloned loci, and saturation insertional mutagenesis of the entire parasite genome (and cloning of the tagged loci). T. gondii also exhibits unusual ultrastructural clarity, facilitating cell biological analysis. The accessibility of Toxoplasma as an experimental system allows this parasite to be used as a surrogate for asking many questions that cannot easily be addressed in Plasmodium itself. T. gondii also serves as a model system for genetic exploration of parasite biology and host-parasite interactions. Success stories include: biochemical analysis of antifolate resistance mechanisms; pharmacological studies on the mechanisms of macrolide activity; genetic identification of nucleobase/nucleoside transporters and metabolic pathways; and cell biological characterization of the apicomplexan plastid. As with any model system, not all questions of interest to malariologists can be addressed in Toxoplasma; differentiating between sensible and foolish questions requires familiarity with the biological similarities and differences of these systems.

Increasing rates of suicide in young men in England during the 1980s: the importance of social context

Attempts to explain rising rates of suicide among young men in Britain and elsewhere during the 1980's have identified the characteristics of those people who kill themselves. Little, however, is known about the impact that changes in social context may have had on changing rates of suicide during this time. Changes in aggregate levels of unemployment, poverty, marriage and the proportion of adults living alone during the 1980s were derived from data collected in the UK National Census of 1981 and 1991. In an ecological analysis these changes were compared with changes in age-adjusted rates of suicide in men aged 15 to 44, in 364 county districts of England between the beginning and end of the 1980s. Areas experiencing the lowest increase in rates of suicide were those that experienced the smallest rise in the proportion of people living alone, the greatest increase in unemployment and highest levels of social deprivation. In addition to investigating the effect that characteristics of people have in determining the risk of suicide in individuals who kill themselves, further attention needs to be paid to the impact that social context may have on mediating these risks.

Origin, targeting, and function of the apicomplexan plastid

The discovery of a plastid in Plasmodium, Toxoplasma and related protozoan parasites provides a satisfying resolution to several long-standing mysteries: the mechanism of action for various surprisingly effective antibiotics; the subcellular location of an enigmatic 35 kb episomal DNA; and the nature of an unusual intracellular structure containing multiple membranes. The apicomplexan plastid highlights the importance of lateral genetic transfer in evolution and provides an accessible system for the investigation of protein targeting to secondary endosymbiotic organelles. Combining molecular genetic identification of targeting signals with whole genome analysis promises to yield a complete picture of organellar metabolic pathways and new targets for drug design.

Photo-oxidative stress down-modulates the activity of nuclear factor-kappaB via involvement of caspase-1, leading to apoptosis of photoreceptor cells

The mechanisms of photoreceptor cell death via apoptosis, in retinal dystrophies, are largely not understood. In the present report we show that visible light exposure of mouse cultured 661W photoreceptor cells at 4.5 milliwatt/cm2 caused a significant increase in oxidative damage of 661W cells, leading to apoptosis of these cells. These cells show constitutive expression of nuclear factor-kappaB (NF-kappaB), and light exposure of photoreceptor cells results in lowering of NF-kappaB levels in both the nuclear and cytosolic fractions in a time-dependent manner. Immunoblot analysis of IkappaBalpha and p50, and p65 (RelA) subunits of NF-kappaB, suggested that photo-oxidative stress results in their depletion. Immunocytochemical studies using antibody to RelA subunit of NF-kappaB further revealed the presence of this subunit constitutively both in the nucleus and cytoplasm of the 661W cells. Upon exposure to photo-oxidative stress, a depletion of the cytoplasmic and nuclear RelA subunit was observed. The depletion of NF-kappaB appears to be mediated through involvement of caspase-1. Furthermore, transfection of these cells with a dominant negative mutant IkappaBalpha greatly enhanced the kinetics of down modulation of NF-kappaB, resulting in a faster photo-oxidative stress-induced apoptosis. Taken together, these studies show that the presence of NF-kappaB RelA subunit in the nucleus is essential for protection of photoreceptor cells against apoptosis mediated by an oxidative pathway.

Not listening to patients--the use and misuse of patient satisfaction studies

Demand for the development of health services that are responsive to the views of users has led to a growing interest in the measurement of patient satisfaction. Initial reluctance to seek the views of users of mental health services focused on a debate about whether or not mentally disordered patients were able to make 'valid' comments about their treatment. More recently the development of questionnaires that claim to 'reliably measure' the views of patients have coincided with a greater acceptance of the role that such studies can play. However, it is argued that the use of these quantitative and often simplistic methods underestimate the dissatisfaction of many patients. Further exploration of the differing expectations of users and providers of services and a degree of willingness in both parties to change is required if services are to be developed that better meet the needs of patients.

Regulation of the Salmonella typhimurium flavohemoglobin gene. A new pathway for bacterial gene expression in response to nitric oxide

Flavohemoglobins, a family of two-domain proteins with homology to vertebrate hemoglobins, are found in a variety of prokaryotic and eukaryotic microorganisms. Recent studies suggest a role for these proteins in nitrogen oxide metabolism. We now show that nitric oxide donors positively regulate a chromosomal flavohemoglobin (hmp)/lacZ operon fusion in Salmonella typhimurium. hmp gene expression in the presence of NO. is independent of the SoxS, OxyR, and FNR transcription factors and instead relies on inactivation of the iron-dependent Fur repressor. Other Fur-repressed promoters in S. typhimurium are also activated by an NO. donor. In contrast to the wild-type strain, an hmp- mutant requires markedly lower concentrations of NO to induce the hmp/lacZ fusion, whereas its response to iron chelation is equivalent to wild type. These data unveil a new pathway for NO-dependent gene expression in S. typhimurium.

Role for the Salmonella flavohemoglobin in protection from nitric oxide

Hemoglobin homologs are being identified in an expanding number of unicellular prokaryotic and eukaryotic organisms. Many of these hemoglobins are twodomain proteins that possess a flavin-containing reductase in their C terminus. Determination of a function for these flavohemoglobins has been elusive. A Salmonella typhimurium strain harboring a deletion in the flavohemoglobin gene shows no difference in growth under oxidative stress conditions but displays an increased sensitivity to acidified nitrite and S-nitrosothiols, both of which produce nitric oxide. The effect is seen aerobically or anaerobically, indicating that oxygen is not required for flavohemoglobin function. These results suggest a role for the bacterial flavohemoglobins that is independent of oxygen metabolism and provide evidence for a bacterial route of protection from nitric oxide that is distinct from oxidative stress responses.