[Somatic care in psychiatry : barriers perceived by patients and health professionals]

Disparities in access to, use of and delivery of somatic health care contribute to widening gaps in morbidity and mortality between psychiatric patients and the general population. We conducted a qualitative semi-structured interview study with psychiatric patients and health professionals from different psychiatric care settings to understand these poor physical health outcomes. Optimal somatic follow-up of patients with severe mental illness seems to be hampered by (1) provider-related elements (attitude, training, experiences); (2) organisational aspects (equipment, infrastructure, staff, pharmacy, communication networks); (3) psychiatric patient-related elements and (4) financial barriers.There is an urgent need for integrated somatic and psychiatric health care systems and for cultural change. Psychiatrists and somatic health care providers continue to view the mental and physical health of their patients as mutually exclusive responsibilities. A range of system changes will improve the quality of somatic health care for these vulnerable patients.

Silicone adhesive multilayer foam dressings as adjuvant prophylactic therapy to prevent hospital-acquired pressure ulcers: a pragmatic noncommercial multicentre randomized open-label parallel-group medical device trial

Background

Silicone adhesive multilayer foam dressings are used as adjuvant therapy to prevent hospital‐acquired pressure ulcers (PUs).

Objectives

To determine whether silicone foam dressings in addition to standard prevention reduce the incidence of PUs of category 2 or worse compared with standard prevention alone.

Methods

This was a multicentre, randomized controlled medical device trial conducted in eight Belgian hospitals. At‐risk adult patients were centrally randomized (n = 1633) to study groups based on a 1 : 1 : 1 allocation: experimental groups 1 (n = 542) and 2 (n = 545) – pooled as the treatment group – and the control group (n = 546). The experimental groups received PU prevention according to hospital protocol, and a silicone foam dressing on the relevant body sites. The control group received standard of care. The primary endpoint was the incidence of a new PU of category 2 or worse at the studied body sites.

Results

In the intention‐to‐treat population (n = 1605), PUs of category 2 or worse occurred in 4·0% of patients in the treatment group and 6·3% in the control group [relative risk (RR) 0·64, 95% confidence interval (CI) 0·41–0·99, P = 0·04]. Sacral PUs were observed in 2·8% and 4·8% of the patients in the treatment group and the control group, respectively (RR 0·59, 95% CI 0·35–0·98, P = 0·04). Heel PUs occurred in 1·4% and 1·9% of patients in the treatment and control groups, respectively (RR 0·76, 95% CI 0·34–1·68, P = 0·49).

Conclusions

Silicone foam dressings reduce the incidence of PUs of category 2 or worse in hospitalized at‐risk patients when used in addition to standard of care. The results show a decrease for the sacrum, but no statistical difference for the heel and trochanter areas.

What is already known about this topic?

The incidence of hospital‐acquired pressure ulcers (PUs) remains high despite the implementation of best‐practice recommendations.

The concept of using silicone foam dressings as an additional prophylactic strategy in PU prevention has been investigated in previous studies but with some limitations.

Most RCTs were monocentric studies, restricted to either critically ill or acute care patients and did not observe more than two anatomical at‐risk skin sites, which limited the generalizability of the findings.

What does this study add?

This large pragmatic RCT suggests that it is beneficial to use silicone adhesive multilayer foam dressings on the sacrum, in addition to standard of care, to help prevent hospital‐acquired PUs.

Clinical decision making for heel dressings should be based on the clinical effectiveness of the intervention weighed against the potential risk of falling.

Linked Comment: F. Coyer. Br J Dermatol 2021; 185:4–5.

Postmenopausal hormone use and cutaneous melanoma risk: A French prospective cohort study

Cutaneous melanoma has been suspected to be influenced by female hormones. Several studies reported a positive association between menopausal hormone therapy (MHT) use and melanoma risk; however, previous findings were conflicting. We sought to explore the associations between MHT use and melanoma risk in a prospective cohort of women in France, where a particularly wide variety of MHT formulations are available. E3N is a prospective cohort of 98,995 French women aged 40-65 years in 1990. MHT use was assessed through biennial self-administered questionnaires. We used Cox proportional hazards regression models adjusted for age and skin cancer risk factors. Over 1990-2008, 444 melanoma cases were ascertained among 75,523 postmenopausal women. Ever use of MHT was associated with a higher melanoma risk (hazard ratio (HR) = 1.35, 95% confidence intervals (CI) = 1.07-1.71). The association was strongest among past users (HR = 1.55, CI = 1.17-2.07, homogeneity for past vs. recent use: p = 0.11), and users of MHT containing norpregnane derivatives (HR = 1.59, CI = 1.11-2.27), although with no heterogeneity across types of MHT (p = 0.13). Among MHT users, the association was similar across durations of use. However, a higher risk was observed when treatment onset occurred shortly after menopause (<6 months: HR = 1.55, CI = 1.16-2.07 vs. ≥2 years). Associations between MHT use and melanoma risk were similar after adjustment for UV exposure, although MHT users were more likely to report sunscreen use than nonusers. Our data do not support a strong association between MHT use and melanoma risk. Further investigation is needed to explore potential effect modification by UV exposure on this relationship.

Oral contraceptive use and cutaneous melanoma risk: a French prospective cohort study

Cutaneous melanoma has been suspected to be influenced by female hormones. Several studies reported a positive association between oral contraceptive (OC) use and melanoma risk. However, findings were conflicting and data from large prospective studies are lacking. E3N is a prospective cohort of 98,995 French women aged 40-65 years at inclusion in 1990. Exposure to lifetime OC use was assessed in 1992 and through biennial questionnaire updates. To assess the association between OC use and melanoma risk, we used Cox models adjusted for age, pigmentary traits, residential ultraviolet (UV) exposure in county of birth and at inclusion and family history of skin cancer. Over 1992-2008, 539 melanoma cases were ascertained among 79,365 women. In age-adjusted models, we found a modest positive association between ever use of OCs and melanoma risk (hazard ratio (HR) = 1.18, 95% confidence intervals (CIs) = 0.98-1.42), which was reduced after adjustment (HR = 1.14, 95% CI = 0.95-1.38). The association was stronger in long-term users (duration ≥10 years: HR = 1.33, 95% CI = 1.00-1.75) and in women who used high-estrogen OCs (HR = 1.27, 95% CI = 1.04-1.56). Among users, there was an inverse association with age at first use (ptrend < 0.01), but no evidence of an association with age at last use or time since last use. OC use was positively associated with tanning bed use (OR = 1.14, CI = 1.01-1.29), sunburns (ptrend = 0.5) and sunscreen use (OR = 1.13, CI = 1.00-1.28) since age 25. Overall, our findings do not support a strong association between OC use and melanoma risk and suggest intentional UV exposure in OC users, which supports a potential confusion by UV exposure in this relationship.

A quantitative genetic study of cephalometric variables in twins

This study aimed at determining the relative genetic and environmental impact on a number of well-known cephalometric variables in twins. In order to find a clue in the heritability pattern of some dentofacial characteristics and on the expected limits of the therapeutic impact on the dentofacial subparts they are representing. Cephalograms were collected from 33 monozygotic and 46 dizygotic twins, who did not undergo any orthodontic treatment. Nineteen linear and four angular variables were selected all representing a different definite subpart of the dentofacial complex. The reproducibility of the measurement of most of the linear variables was very high. A genetic analysis using model fitting and path analysis was carried out. First, data were checked on the fulfilment of the conditions for genetic analysis in twins reared together. The results show that the genetic determination is significantly higher for vertical (72%) than for horizontal (61%) variables. As far as the genetic component is concerned, all variables selected seem to be inherited by additive genes, except for mandibular body length, which was determined by dominant alleles. Sex differences in genetic determination were found for the anterior face height, showing a significantly higher genetic component for boys (91%) than for girls (68%). For the angular measurements, no genetic influence was found: only environmental influences common to both members of each pair could be demonstrated.

A genetic study of anteroposterior and vertical facial proportions using model-fitting

Genetic model-fitting was used to determine the heritability of anteroposterior and vertical facial proportions in twins. Lateral headplates of 33 monozygotic and 46 dizygotic twins, none of whom had undergone orthodontic treatment, were used. Five proportions, based on four vertical and five horizontal measurements, were assessed: lower facial height, anterior- to posterior-facial height, total facial height to face depth, sella-A-point to sella-B-point, and sella-upper incisal edge to sella-lower incisal edge. Reproducibility was high for all variables. Model-fitting indicated that all the facial proportions were controlled by additive genes and the specific environment. The genetic component was 71% for upper-to lower-facial height, 66% for anterior- to posterior-facial height, 62% for total facial height, and 66% for sella-A-point to sella-B-point and sella-upper incisal edge to sella-lower incisal edge.