Developing Specialist Perinatal Mental Health Services: the door of opportunity

The development of Specialist Perinatal Mental Health Services in Ireland in recent years (2018-2021) is described. The paper highlights the role of unexpected opportunity in advancing this much needed service for women, infants and their families. It also emphasises the need for funding combined with an implementation mechanism to ensure that the service emerging is true to the Model of Care designed and is available in a uniform manner to women nationally.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Determinants of self-efficacy among persons with spinal cord injuries

The purpose of this study was to determine the factors affecting self-efficacy among persons with spinal cord injury (SCI). The study population consisted of 105 persons with SCI who were discharged from one of eight hospitals in north central Alabama between October 1989 and September 1992. Data were derived from a retrospective acute-care medical record review and 12-month annual follow-up telephone interviews. The findings indicate that high self-efficacy is significantly associated with less severe neurological impairment, being white, employed at injury, having a high-school education or beyond, and having an unintentional injury. In terms of marital status our data indicate the odds of divorced persons having high self-efficacy are 8.2 (CL = 0.919, 74.1) times those of married persons. In addition, 64% of those who were divorced during the 12 months after injury had high self-efficacy compared to 50% of those who were divorced prior to injury.

Factors associated with awareness of vocational rehabilitation services after traumatic brain injury

OBJECTIVES

To determine the characteristics of persons with traumatic brain injury (TBI) who were aware of vocational rehabilitation (VR) services 1 year after hospital discharge.

DESIGN

Medical record and longitudinal survey data on persons with TBI were analyzed using logistic regression and bivariate analyses.

SETTING

The study sample was drawn from a population-based sample of persons hospitalized in 1 of 8 hospitals in north-central Alabama.

PARTICIPANTS

Criteria for inclusion were: (1) being at least 18 years of age or older when injured; (2) having sustained a TBI; (3) being discharged alive after a hospital stay of at least 3 days; (4) residing and having been injured in the state of Alabama; (5) participation in a 12-month follow-up interview.

MAIN OUTCOME MEASURE

Patients' awareness of VR service programs and benefits.

RESULTS

Awareness of VR service programs was associated with: (1) being Caucasian; (2) being more often employed at the time of injury; (3) being more often severely injured; and (4) more frequently receiving outpatient rehabilitation.

CONCLUSION

Interventions should target non-Caucasians, those who were unemployed when injured, those less severely injured, and those not receiving outpatient rehabilitation services after hospital discharge. Periodic review of VR benefits with patients and their families should be undertaken by health care and VR professionals.

A study of aggression among referrals to a community-based psychiatry of old age service

OBJECTIVE

The aims of the study were to examine the prevalence of aggressive behaviour in a non-selected community-based population, to identify clinical and sociodemographic variables associated with aggression and to examine the relationship between aggression and outcome at 2-year follow-up.

DESIGN

Case series, using the Ryden Aggression Scale as a retrospective measure of aggression.

SETTING

A community-based specialist psychiatry of old age service.

PARTICIPANTS

All referrals to the service over a 3-month period.

RESULTS

Of the 42 subjects included in the study, 25-patients had a diagnosis of dementia. Aggressive behaviour was reported in 18 patients, this being verbal only in nine cases and both verbal and physical in nine cases. Sexual aggression and self-injurious behaviour were each reported in one case only. Aggression was found to be positively associated with a diagnosis of dementia and high physical dependency but was not found to be associated with age, sex, physical illness or the use of psychotropic medication. At 2-year follow-up, aggressive patients were found to have a higher rate of admission to psychiatric inpatient or residential care and tended to have a higher use of neuroleptic drugs.

CONCLUSIONS

These findings suggest that aggression is a significant problem for community-based elderly people and their carers, may increase the likelihood of admission into long-term care and that a reliable instrument to measure aggression would be useful in the clinical assessment of this population.

Explaining quality of life for persons with traumatic brain injuries 2 years after injury

OBJECTIVE

To model the complex effects of demographic, psychosocial, physical, and rehabilitation variables on quality of life 2 years after hospital discharge.

DESIGN

Medical record and longitudinal survey data on traumatic brain injury (TBI) survivors who did or did not receive formal rehabilitation services after being injured were analyzed.

SETTING

The study sample was selected from a representative sample of hospitals in north-central Alabama.

PARTICIPANTS

Criteria for inclusion were: (1) 18 years and older with TBI; (2) discharged after hospital stay of 3 or more days; and (3) resided and injured in Alabama. There were 293 persons eligible for the 24-month follow-up survey, 186 (63%) of whom participated; the focus was on the 116 persons (of 186) who responded to the surveys themselves.

MAIN OUTCOME MEASURE

A causal model of hypothesized direct and indirect effects of several variables on quality of life outcomes.

RESULTS

Employment was the strongest contributor of improved quality of life. Persons unable to pay for health care showed less improvement in functional independence 12 to 24 months postinjury and reported a poorer quality of life. The psychosocial variables of self-blame and family support improved quality of life by reducing impairments and increasing the likelihood of employment. Family support also improved quality of life by increasing functional independence. Fewer physical impairments and gains in functional independence directly improved quality of life.

CONCLUSION

The interrelationships between psychosocial and physical variables are important when examining quality of life. Interventions are recommended targeting psychosocial variables and functional independence in efforts to improve quality of life.

Factors relating to return to work after burn injury

This study examined the influence of various factors on the probability that 225 persons with severe burns would return to work 12 months after being discharged from the acute care setting. By use of multivariate analysis, 4 out of 15 variables significantly increased the probability of being employed: (1) being white, (2) not blaming oneself, (3) receiving workmen's compensation, and (4) being employed before the injury. With controls for burn severity and other variables, premorbid employment accounted for a person being 171 times more likely to return to work than one who was not employed before injury. Our findings suggest that some traditionally held impressions regarding factors related to return to work after a severe burn should be revisited. Moreover, despite earlier reports concluding that burn severity was the primary predictor of return to work, we found no factors in the acute care environment or patient characteristics that were statistically significant. Instead, findings from this series underscore the importance of the preinjury environment--especially being employed at the time of injury--as the strongest predictor of return to work after a severe burn.

Late paraphrenia

Late paraphrenia is one of a group of paranoid disorders arising in the elderly. The distinctive clinical and social features of this disorder are highlighted in this article together with the possible aetiological causes.

Alcohol related problems in elderly people--a prospective study

Alcohol related problems in elderly people are often difficult to diagnose because of denial and non specific presentation in this age group. This study examines the factors related to alcohol abuse in elderly people referred to a psychiatry of old age service over a six month period. Patients were specifically screened for alcohol related psychiatric, physical and social problems. Of the 150 patients referred, 23 (15%) had alcohol related problems, with 12 (52%) denying any history of alcohol abuse/dependence. The majority were female (15/23, 65%), of which 10 were late-onset drinkers. Loneliness was found to be a contributory factor in 10 (43%) patients. A large proportion of patients had physical, psychiatric and social problems related to alcohol. Twenty one patients (91%) required psychiatric follow-up. In conclusion, this study confirms elderly peoples vulnerability to the destructive effects of alcohol.

Delusional infestation in an elderly population

The clinical features of delusional infestation are outlined and six elderly patients who presented with this condition are described. Their presentation and clinical features are discussed in relation to other case reports. Management issues, particularly in relation to aetiology, are outlined.

The Sparklet carbon dioxide resuscitator

The use of carbon dioxide in resuscitation was advocated in the 1920s and 1930s. A device, the Sparklet Resuscitator, was marketed to allow the administration of carbon dioxide gas. This piece of equipment is described and the indications for its use in resuscitation reviewed. The use of carbon dioxide appeared to have a degree of support and success as a 'universal' aid to resuscitation.

Should motorcycles be operated within the legal alcohol limits for automobiles

A motorcycle simulator was used to assess operating performance of 14 experienced motorcyclists with varying breath alcohol concentrations. Riding error scores in three defensive and evasive maneuvers plus distance traveled in a standard time period were documented at baseline and at predetermined intervals following controlled alcohol consumption. The results revealed a positive correlation between total errors and breath alcohol concentrations within a range well below the commonly accepted legal limit of intoxication of 0.10 mg/dL. There was a highly significant increase (p < 0.0055) in an operator's tendency to leave the roadway (an error that is frequently fatal for motorcyclists), as well as a reduction in ability to complete a timed course. Moreover, performance errors increased while operators were "sobering up," a dramatic finding not heretofore established in previous studies. Since the present definition of the legal limit of intoxication for motorcyclists is based on automobile studies, noted increases in reaction time and performance errors support the hypothesis that "legal alcohol levels" should be lowered for motorcycle operators.

Consultation-liaison referrals to the north Dublin old age psychiatry service

107 elderly acute hospital in-patients were referred to the North Dublin Old Age Psychiatry Service during an eighteen month period. Cognitive impairment was present in 54%, 25% had functional psychiatric disorders and 19% had no psychiatric diagnosis. The main reason for referral in 47% of cases was advice on placement. This reflects the deficiency in residential care in North Dublin and supports other recently compiled data. The implications of this situation for both elderly people and the acute hospitals are discussed.

Abuse of elderly people--"pathological" carers

Abuse of elderly people is now recognised as a problem deserving attention because of the suffering incurred by the victim. Forms of abuse and characteristics of potential victims are described. An awareness of the existence of such abuse coupled with good social and medical services for elderly people would reduce the carer stress which most commonly results in such abuse. A second much rarer group of abusing carers, "pathological" carers, is highlighted and it is suggested that a specific procedure possibly similar to that used in child abuse cases is required to protect the victim.

Psychosocial factors and admission for poor glycaemic control: a study of psychological and social factors in poorly controlled insulin dependent diabetic patients

Psychological and social factors were investigated in 89 poorly controlled insulin-dependent diabetic admissions matched with out-patient controls. Those admitted were found to suffer greater current and past psychiatric morbidity, to report more social problems and chronic difficulties and to experience more life events in the six months before interview. The occurrence of significantly more independent events and chronic difficulties among admissions suggests that social stress can lead to poor control. These results emphasize the importance of global assessment of diabetic admissions to include psychological and social aspects as well as medical status.

Psychological distress in carers of dementia sufferers

This study compares dementia sufferers and their carers referred to an old age psychiatry service with a non-referred group from the same community. It examines the level of stress in the carer with the age and sex of the carer, and with the degree of physical disability and cognitive impairment in the person with dementia. There was no difference between the two groups in the prevalence of stress but overall 65% of carers experienced significant levels of stress. Females and younger carers were more likely to experience stress. Stress in the carer was associated with high levels of physical disability but not with the degree of cognitive impairment. This study shows that considerable psychological distress occurs among carers of those with dementia in the community. If government policy of maintaining people with dementia in the community is to be pursued, measures to relieve carers must be included when planning services for this vulnerable group.

Comparison of four local extradural anaesthetic solutions for elective caesarean section

We have examined a combination of two local anaesthetics to see if the resultant solution is superior to the agents individually. This study shows that a mixture of bupivacaine and lignocaine provided an excellent alternative to bupivacaine alone, and was superior to 2% lignocaine with adrenaline for elective Caesarean section. By reducing the dose of bupivacaine used, the combination may reduce the risk of cardiotoxicity.