The benefits of index telephone consultations in patients referred on the two-week wait colorectal cancer pathway

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic led to hospitals in the UK substituting face-to-face (FtF) clinics with virtual clinic (VC) appointments. We evaluated the use of virtual two-week wait (2-ww) lower gastrointestinal (LGI) clinic appointments, conducted using telephone calls at a district general hospital in England.

METHODS

Patients undergoing index outpatient 2-ww LGI clinic assessment between 1 June 2019 and 31 October 2019 (FtF group) and 1 June 2020 and 31 October 2020 (VC group) were identified. Relevant data were obtained using electronic patient records. Compliance with national cancer waiting time targets was assessed. Environmental and financial impact analyses were performed.

RESULTS

In total, 1,531 patients were analysed (median age=70, male=852, 55.6%). Of these, 757 (49.4%) were assessed virtually via telephone; the remainder were seen FtF (n=774, 50.6%). Ninety-two (6%, VC=44, FtF=48) patients had malignant pathology and 64 (4.2%) had colorectal cancer (CRC); of these, 46 (71.9%, VC=26, FtF=20) underwent treatment with curative intent. The median waiting times to index appointment, investigation and diagnosis were significantly lower following VC assessment (p<0.001). The cancer detection rates (p=0.749), treatments received (p=0.785) and median time to index treatment for CRC patients (p=0.156) were similar. A significantly higher proportion of patients were seen within two weeks of referral in the VC group (p<0.001). VC appointments saved patients a total of 9,288 miles, 0.7 metric tonnes of CO2 emissions and £7,482.97. Taxpayers saved £80,242.00 from VCs. No formal complaints were received from patients or staff in the VC group.

CONCLUSION

Virtual 2-ww LGI clinics were effective, safe and were associated with tangible environmental and financial benefits.

Technology Matters: Digital micro interventions to support parenting: Evaluating time out apps

Digital interventions to support parenting skills are popular but engagement can be low. Digital micro interventions such as apps targeting specific aspects of parenting are a novel development with the potential to overcome this challenge. Time out is an evidence-based component of many parenting skills training programmes and is an appropriate target for digital micro intervention. We describe the eight requirements of high-quality time out according to the literature and how these can be supported by an app. Searches of the App Store, Google Play, and Alexa Skills in the UK identified six apps designed to support time out. Current time out apps all promoted consistency, but they all risked low-quality time out through inappropriate initiation, duration, and termination. Professionals in child and adolescent mental health should explore the details of any digital micro interventions being used by parents for time out and provide appropriate counselling. We recommend that all future digital micro interventions in this area should incorporate evidence-based guidance.

Institutional investors and cost of capital: The moderating effect of ownership structure

Guiding institutional investors to actively participate in corporate governance is a hot issue to improve the internal governance of China’s listed companies. This study seeks to provide a comprehensive understanding of the mechanism that underlies the governance effects of the heterogeneity of institutional investors on the cost of capital, and the influence of ownership structure on the relationship between them. Using an unbalanced panel data on A-share listed companies of Shanghai and Shenzhen in China’s capital market during the 2014–2019 period, this study reveals how institutional investors with longer holding period and higher shareholding ratio are negatively associated with the cost of capital in China’s capital market. Furthermore, this study successfully confirms the moderating effect of ownership structure in the relationship between institutional investors and the cost of capital. China’s state-owned enterprises are more likely to introduce improvements at the corporate governance level, and ownership concentration weakens the negative influence of institutional investors on the cost of capital. The research contributes to a deeper understanding of the impacts of institutional investor’s heterogeneity and ownership structure on the cost of capital in China. In the process, the study yields useful implications for the theory and practice of corporate governance.

High-altitude pulmonary edema

Lay summary: High Altitude Pulmonary Edema (HAPE) is a potentially fatal disease of altitude, in which the lungs can become filled with fluid. In this article we explore the mechanisms causing this condition and how it can be viewed as a condition of a mismatch between current environment and evolutionary experience.

Engaging patients and family members to design and implement patient-centered kidney disease research

We need more research projects that partner and engage with patients and family members as team members. Doing this requires that patients and family members set research priorities and fully participate in research teams. Models for this patient and family member engagement as research partners can help increase patient centered outcomes research. In this article, we describe how we have successfully engaged patients with kidney disease and family members as Co-Investigators on a 5-year research project testing a health system intervention to improve kidney disease care. Background This article describes a method for successful engagement of patients and family members in all stages of a 5-year comparative effectiveness research trial to improve transitions of care for patients from chronic kidney disease to end-stage kidney disease. Methods This project utilized the Patient-Centered Outcomes Research Institute's conceptual model for engagement with patients and family members. We conducted a qualitative analysis of grant planning meetings to determine patient and family member Co-Investigators' priorities for research and to include these engagement efforts in the research design. Patient and family member Co-Investigators partnered in writing this paper. Results Patients and family members were successfully engaged in remote and in-person meetings to contribute actively to research planning and implementation stages. Three patient-centered themes emerged from our data related to engagement that informed our research plan: kidney disease treatment decision-making, care transitions from chronic to end-stage kidney disease, and patient-centered outcomes. Conclusions The model we have employed represents a new paradigm for kidney disease research in the United States, with patients and family members engaged as full research partners. As a result, the study tests an intervention that directly responds to their needs, and it prioritizes the collection of outcomes data most relevant to patient and family member Co-Investigators. Trial registration NCT02722382 .

Exosomes Derived from Bone Marrow Mesenchymal Stem Cells as Treatment for Severe COVID-19

This prospective nonrandomized open-label cohort study addresses the safety and efficacy of exosomes (ExoFlo™) derived from allogeneic bone marrow mesenchymal stem cells as treatment for severe COVID-19. During April 2020, ExoFlo was provided to 24 SARS-CoV-2 polymerase chain reaction-positive patients at a single hospital center, all of whom met criteria for severe COVID-19 as well as moderate-to-severe acute respiratory distress syndrome. Patients received a single 15 mL intravenous dose of ExoFlo and were evaluated for both safety and efficacy from days 1 to 14 post-treatment. All safety endpoints were met with no adverse events observed within 72 h of ExoFlo administration. A survival rate of 83% was observed. In total, 17 of 24 (71%) patients recovered, 3 of 24 (13%) patients remained critically ill though stable, and 4 of 24 (16%) patients expired for reasons unrelated to the treatment. Overall, after one treatment, patients' clinical status and oxygenation improved with an average pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) increase of 192% (P < 0.001). Laboratory values revealed significant improvements in absolute neutrophil count [mean reduction 32% (P value <0.001)] and lymphopenia with average CD3+, CD4+, and CD8+ lymphocyte counts increasing by 46% (P < 0.05), 45% (P < 0.05), and 46% (P < 0.001), respectively. Likewise, acute phase reactants declined, with mean C-reactive protein, ferritin, and D-dimer reduction of 77% (P < 0.001), 43% (P < 0.001), and 42% (P < 0.05), respectively. In conclusion, owing to its safety profile, capacity to restore oxygenation, downregulate cytokine storm, and reconstitute immunity, ExoFlo is a promising therapeutic candidate for severe COVID-19. Future randomized controlled trials (RCTs) are needed to determine ExoFlo therapeutic potential.

Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial

Care for patients transitioning from chronic kidney disease to kidney failure often falls short of meeting patients' needs. The PREPARE NOW study is a cluster randomized controlled trial studying the effectiveness of a pragmatic health system intervention, 'Patient Centered Kidney Transition Care,' a multi-component health system intervention designed to improve patients' preparation for kidney failure treatment. Patient-Centered Kidney Transition Care provides a suite of new electronic health information tools (including a disease registry and risk prediction tools) to help providers recognize patients in need of Kidney Transitions Care and focus their attention on patients' values and treatment preferences. Patient-Centered Kidney Transition Care also adds a 'Kidney Transitions Specialist' to the nephrology health care team to facilitate patients' self-management empowerment, shared-decision making, psychosocial support, care navigation, and health care team communication. The PREPARE NOW study is conducted among eight [8] outpatient nephrology clinics at Geisinger, a large integrated health system in rural Pennsylvania. Four randomly selected nephrology clinics employ the Patient Centered Kidney Transitions Care intervention while four clinics employ usual nephrology care. To assess intervention effectiveness, patient reported, biomedical, and health system outcomes are collected annually over a period of 36 months via telephone questionnaires and electronic health records. The PREPARE NOW Study may provide needed evidence on the effectiveness of patient-centered health system interventions to improve nephrology patients' experiences, capabilities, and clinical outcomes, and it will guide the implementation of similar interventions elsewhere.

TRIAL REGISTRATION

NCT02722382.

Strong Neutron Pairing in core+4n Nuclei

The emission of neutron pairs from the neutron-rich N=12 isotones ^{18}C and ^{20}O has been studied by high-energy nucleon knockout from ^{19}N and ^{21}O secondary beams, populating unbound states of the two isotones up to 15 MeV above their two-neutron emission thresholds. The analysis of triple fragment-n-n correlations shows that the decay ^{19}N(-1p)^{18}C^{*}→^{16}C+n+n is clearly dominated by direct pair emission. The two-neutron correlation strength, the largest ever observed, suggests the predominance of a ^{14}C core surrounded by four valence neutrons arranged in strongly correlated pairs. On the other hand, a significant competition of a sequential branch is found in the decay ^{21}O(-1n)^{20}O^{*}→^{18}O+n+n, attributed to its formation through the knockout of a deeply bound neutron that breaks the ^{16}O core and reduces the number of pairs.

Quasifree (p, 2p) Reactions on Oxygen Isotopes: Observation of Isospin Independence of the Reduced Single-Particle Strength

Quasifree one-proton knockout reactions have been employed in inverse kinematics for a systematic study of the structure of stable and exotic oxygen isotopes at the R^{3}B/LAND setup with incident beam energies in the range of 300-450  MeV/u. The oxygen isotopic chain offers a large variation of separation energies that allows for a quantitative understanding of single-particle strength with changing isospin asymmetry. Quasifree knockout reactions provide a complementary approach to intermediate-energy one-nucleon removal reactions. Inclusive cross sections for quasifree knockout reactions of the type ^{A}O(p,2p)^{A-1}N have been determined and compared to calculations based on the eikonal reaction theory. The reduction factors for the single-particle strength with respect to the independent-particle model were obtained and compared to state-of-the-art ab initio predictions. The results do not show any significant dependence on proton-neutron asymmetry.

Downregulation of estrogen receptor and modulation of growth of breast cancer cell lines mediated by paracrine stromal cell signals

PURPOSE

Breast cancers have a poorer prognosis if estrogen receptor expression was lost during recurrence. It is unclear whether this conversion is cell autonomous or whether it can be promoted by the microenvironment during cancer dormancy. We explored the ability of marrow-derived stromal cell lines to arrest co-cultured breast cancer cells and suppress estrogen receptor alpha (ER) expression during arrest, facilitating the emergence of estrogen-independent breast cancer clones.

METHODS

Cancer cell growth, ER protein, microRNA, and mRNA levels were measured in breast cancer cell lines exposed to conditioned medium from marrow stromal lines in the presence and absence of estrogen and of signaling pathway modulators.

RESULTS

We demonstrate that paracrine signaling from the stromal cell line HS5 downregulated ER in T47D and MCF7 breast cancer cells. This occurred at the mRNA level and also through decreased ER protein stability. Additionally, conditioned medium (CM) from HS5 arrested the breast cancer cells in G0/G1 in part through interleukin-1 (IL1) and inhibited cancer cell growth despite the activation of proliferative pathways (Erk and AKT) by the CM. Similar findings were observed for CM from the hFOB 1.19 osteoblastic cell line but not from two other fibroblastic marrow lines, HS27A and KM101. HS5-CM inhibition of MCF7 proliferation could not be restored by exogenous ER, but was restored by the IL1-antagonist IL1RA. In the presence of IL1RA, HS5-CM activation of AKT and Erk enabled the outgrowth of breast cancer cells with suppressed ER that were fulvestrant-resistant and estrogen-independent.

CONCLUSIONS

We conclude that marrow-derived stromal cells can destabilize estrogen receptor protein to convert the ER status of growth-arrested ER+ breast cancer cell lines. The balance between stromal pro- and anti-proliferative signals controlled the switch from a dormant phenotype to estrogen-independent cancer cell growth.

First Measurement of Several β-Delayed Neutron Emitting Isotopes Beyond N=126

The β-delayed neutron emission probabilities of neutron rich Hg and Tl nuclei have been measured together with β-decay half-lives for 20 isotopes of Au, Hg, Tl, Pb, and Bi in the mass region N≳126. These are the heaviest species where neutron emission has been observed so far. These measurements provide key information to evaluate the performance of nuclear microscopic and phenomenological models in reproducing the high-energy part of the β-decay strength distribution. This provides important constraints on global theoretical models currently used in r-process nucleosynthesis.

Risk assessment and management approaches on mental health units

This exploratory and descriptive study took place in one Canadian province. The study aimed to: (1) to identify and describe the nature and extent of current risk assessment and management approaches used in the adult inpatient mental health and forensic units; and (2) to identify good practice and shortfalls in the nature and extent of the approaches currently utilized. Data were collected from 48 participants through nine focus groups. Participants reported that they used a clinical approach to risk assessment. They had also not considered risk assessment and management as a proactive structured process. Education and training was also limited and skills were developed over time through practice. Five keys issues are discussed as important: reliance on clinical judgement alone is not the best choice to make; the need to consider risk as a whole concept; risk management being more reactive than proactive; education and training; and client involvement in risk assessment.

Non-linear relationship between serum 25-hydroxyvitamin D concentration and subsequent hip fracture

Serum 25-OH vitamin D levels were compared in 254 hip fracture subjects and 2,402 matched control subjects. There was a significant inverse association between 25-OH vitamin D and hip fracture only between 0 and 70 nmol/L.

INTRODUCTION

Vitamin D is integral to bone metabolism, however the utility of serum 25-OH vitamin D as a risk marker for hip fractures is controversial.

METHODS

We conducted a case-control study of patients admitted to the hospitals with hip fractures in Calgary, Alberta, (catchment population 1.4 million) between January 1, 2007 and August 31, 2011. We searched the laboratory information system of Calgary Laboratory Services for serum 25-OH vitamin D levels within 6 months prior to admission on patients admitted to hospital with hip fractures. Cases were identified through the Calgary Laboratory Services laboratory information system and were matched to controls for age, sex, and month of testing. The hip fracture-25-OH vitamin D association was examined using multiple linear and spline regression.

RESULTS

Of 305 subjects initially identified with hip fractures, serum 25-OH vitamin D levels were available for 254 (83 %). These were matched to 2,402 control subjects. We observed a significant (p < 0.01) non-linear relationship such that 25-OH vitamin D was inversely associated with hip fracture only below 70 nmol/L (odds ratio = 0.81 per 10 nmol/L increase; 95 % CI 0.86-0.93).

CONCLUSIONS

The utility of 25-OH vitamin D level as a risk marker for hip fracture depends on the cut-off level used and was of potential use only for lower levels of 25-OH vitamin D.

Success Factors for Implementation of Entrepreneurial Knowledge Management in Malaysian Banks

This research focuses on developing and testing the concept of entrepreneurial knowledge management (EKM) to view knowledge management (KM) activities in domestic banks. The ability of banks to learn from the explicit and implicit knowledge it possess and turn it into knowledge assets that can generate income stream is a major factor for sustainable competitive advantage. We used structural equation modelling (SEM) to analyse the data gathered, given that SEM has become one of the popular statistical tools to test the relationships proposed in a parsimonious model. The research has empirically determined that the majority of the respondents are aware that knowledge is important in the business of banking. However, it appears some have relegated KM to Management Information Technology (IT) and neglected to cast a wider net to appreciate the importance of EKM for the purpose of creating unique entrepreneurial knowledge asset to enable sustainable differentiation and competitive advantage for generating future income streams.

Concentration of lipocalin region of collagen XXVII alpha 1 in the serum of dogs with hemangiosarcoma

BACKGROUND

Hemangiosarcoma (HSA) is a common malignancy of dogs with characteristic early, aggressive metastasis. Diagnosis of HSA is challenging because of lack of sensitive and specific diagnostic tests.

HYPOTHESIS

Specific proteins that are increased in serum of dogs with HSA might represent useful biomarkers of the disease.

ANIMALS

Thirty-four dogs with HSA and 42 healthy dogs from the Ontario Veterinary College Teaching Hospital.

METHODS

This case-control study compared serum proteins in dogs with HSA and healthy dogs. Proteins were separated by 2-dimensional difference gel electrophoresis and identified by liquid chromatography and tandem mass spectrometry.

RESULTS

Western blot analysis showed that serum collagen XXVII peptide concentration in serum of dogs with large metastatic HSA burdens (1,488, 231-3,754 DU; median, minimum-maximum); was, on average, 9.5-fold higher than in healthy dogs (156; 46-2,101 DU). While concentrations for dogs with osteosarcomas (678; 124-3,251 DU), lymphomas (423; 92-2,777 DU), carcinomas (1,022; 177-3,448 DU), and inflammatory disease were also increased, values were consistently lower than those for HSA. Receiver operating characteristic curves revealed an estimated area under the curve of 83% for HSA cases whereas areas for other neoplastic and nonneoplastic diseases were nondiscriminatory. Serum collagen XXVII peptide concentration before splenectomy (1,350; 1,156-1,929 DU) was reduced after tumor removal (529; 452-562 DU) and chemotherapy but increased in 2 dogs with tumor recurrence (511-945 DU; 493-650 DU).

CONCLUSIONS AND CLINICAL IMPORTANCE

Collagen XXVII peptide might be useful for diagnosis and monitoring of advanced HSA.

Violence and aggression: a literature review

This paper reports the results of a literature review that was undertaken to provide background for a small pilot study that introduced violence measurement instruments that was to assist the development of nursing practice on an acute psychiatric unit. Multiple databases were searched, focusing on publications since 1994: CINAHL, Ovid Healthstar, Ovid MEDLINE (R), EMBASE, and PsycINFO. The search used the following four groups of key word alternatives (used in truncated form to allow for ending permutations) in combination with each other: violence, aggression, dangerous; prediction, assessment, factor, risk, issue, cause, reason; mental, psychiatric; inpatient, short-term, acute, admission. Searching was supplemented with footnote chasing of those papers retrieved and existing resources of the first author. Consequently, the synthesis of the results discussed cannot be considered a systematic review of the literature and is a reflection of some of the key issues found in the literature.

Development, deployment and usability of a point-of-care decision support system for chronic disease management using the recently-approved HL7 decision support service standard

Clinical decision support is recognized as one potential remedy for the growing crisis in healthcare quality in the United States and other industrialized nations. While decision support systems have been shown to improve care quality and reduce errors, these systems are not widely available. This lack of availability arises in part because most decision support systems are not portable or scalable. The Health Level 7 international standard development organization recently adopted a draft standard known as the Decision Support Service standard to facilitate the implementation of clinical decision support systems using software services. In this paper, we report the first implementation of a clinical decision support system using this new standard. This system provides point-of-care chronic disease management for diabetes and other conditions and is deployed throughout a large regional health system. We also report process measures and usability data concerning the system. Use of the Decision Support Service standard provides a portable and scalable approach to clinical decision support that could facilitate the more extensive use of decision support systems.

Organizing and delivering training for acute mental health services: a discussion paper

Recent policy statements that address the quality of care provided by acute mental health services have highlighted an urgent need for specialist nurse education and training. However, examples of how to design and implement such training initiatives are sparse. Drawing on recent experience of developing an innovative training programme for acute psychiatric settings, this paper seeks to examine some of the key issues associated with current training provision for acute inpatient mental health workers. The methodological and practical concerns surrounding this type of initiative are discussed with the main aspects of programme content, service user participation, team training and organizational challenges being explored. Resulting from this work, several recommendations regarding the content, organization and delivery of future training initiatives are made.

Is there a relationship between risk assessment and observation level?

The literature is divided into two sections, one on assessment and one on observation, with only one study that tries to make any connection between them. This study, conducted in both acute and forensic areas, attempts to show that there are some direct relationships between assessment criteria and observation levels in both these areas. An instrument was designed and implemented prospectively to collect data about both assessment criteria and the resulting decisions about observation level. Logistic Regression Analysis, descriptive, and inferential statistics, such as Chi-square and cross-tabulations, were used to analyse the data. The results showed that there is a relationship between the risk assessment and the enhanced observation level that patients are placed on at the time of admission. The nature of the relationship was limited to seven variables from the 12 in the risk assessment used. This implies that the variables may be different in risk assessment content and extent in each clinical area and we can speculate that there may be individual profiles of the assessment-observation level relationship in each clinical area.

Exploring core relationships between insight and communication and social skills in mentally disordered offenders

This paper reports collective data analysis for the Behavioural Status Index insight and communication and social skills subscales. This is an instrument designed specifically for health care practitioners to measure behavioural and social functioning among mental health clients, in particular those in forensic care. Data were collected, using a repeated measures method by primary nurses, from a sample of 503 patients in two high security mental health hospitals in the UK. Results are reported for interscalar item correlations and factor analysis. Data trends are indicative of clinically interesting relationships. A six-factor structure emerged suggesting groupings of intra- and interscalar behaviours. The first of these contained all the Behavioural Status Index insight items. Significant differences were found on a number of factors between independent groups. Generally, results indicate that patients on lower dependency wards scored more normatively on the factors, adding to instrument validity. Men were found to score more normatively than women. According to Mental Health Act 1983 classifications, psychopathically disordered patients scored more normatively than mentally ill patients, who in turn scored more normatively than patients with learning disability. Clinical practice implications and ongoing European studies examining the use of the instrument in clinical practice and its association to treatment planning are discussed.

The relationship between risk and insight in a high-security forensic setting

It is often intimated amongst practitioners in mental healthcare that clients who display poor insight either into their mental health or behaviour present a greater risk either to themselves or others. This paper reports relationships found between the risk and insight subscales of the Behavioural Status Index. This is an instrument designed specifically for healthcare practitioners to measure health functioning amongst mental health clients, in particular those in forensic mental healthcare. Data were collected, using a repeated measures method by primary nurses, from a sample of 503 patients in two high-security mental health hospitals. Seven factors emerged through factor analysis. The first of these contained all the insight items. Significant differences were found on a number of factors between independent groups. Generally, results indicate that patients on lower dependency wards scored more normatively on the factors, adding to instrument validity. Men were found to score more normatively than women. Clinical practice implications and ongoing European studies examining the use of the instrument in clinical practice and its association with treatment planning are discussed.

Child homicide

Between 1967 and 1988, 69 cases of single perpetrator/single victim child homicide resulted in remands into custody in the Yorkshire region. Sixty-four of these cases were examined retrospectively to identify the characteristics of the perpetrators and of victims under 16 years, the relationship of the victim to the accused and the circumstances of the offence. Sixty-four men singly accused of killing a single child victim are described in detail. They were characterized by relatively young age and a lack of long-term stable relationships. Previous psychiatric contact and/or a history of self-harm was noted in one-third of cases. Over half of the group had a criminal record and previous violence to children was noted in 28% of cases. Fathers or surrogate fathers accounted for nearly two-thirds of the accused. In terms of the victims, children under six months were at greatest risk. Nearly one-third of victims were the biological offspring of the accused. Sexually motivated homicide accounted for approximately 18.7% of deaths. Victim behaviours and domestic disharmony acted as precipitants in 64% of the cases, with 54.7% of the victims dying as a result of physical beatings. Alcohol consumption at the material time was more common than noted in previous studies of child homicide.

Measuring risk in a high security forensic setting through the behavioural status index

This paper reports data analysis for the Behavioural Status Index risk sub-scale. Data were collected, using a repeated measures method by primary nurses, from a sample of 503 individual patients in two high security mental health hospitals. Results are reported for descriptive statistics, and factor analysis; and differences between the independent groups of Mental Health Act 1983 classification, ward dependency and gender. Data trends are indicative of clinically interesting relationships. A distinct factorial structure emerged suggesting groupings of attentional, violent, destructive, iconic-compensatory and escapist behaviours. Results are reported to be underpinning current European studies.

Measuring communication and social skills in a high security forensic setting using the behavioural status index

Assessing patient functioning in the areas of communication and social skills is a core area of practice within psychiatric nursing. Difficulties within these areas can often represent the root of a number of presenting problems. Objective assessment can be difficult without a validated assessment schema. The Behavioural Status Index (BSI) offers such a system of baseline assessment and longitudinal monitoring as a basis for treatment, further specialised assessment, or measurement of outcome during and after interventions. This paper introduces some basic theory and describes the function and purpose of the BSI. This is followed by data analysis for the BSI communications and social skills sub-scale. Data were collected, using a repeated measures method by primary nurses, from a sample of 503 individual patients in two high security mental health hospitals. Results are reported for descriptive statistics, and factor analysis; and differences between the independent groups of Mental Health Act 1983 classification, ward dependency and gender. Data trends are indicative of clinically interesting relationships. A distinct factorial structure emerged suggesting groupings of assertive-interpersonal, non-verbal, social-perceptive and para-linguistic behaviours. Results are reported to be underpinning current European studies.

A risk assessment and management strategy for community nursing

Many nursing interventions carry risks of harm to the patient, the nurse or the general public, and the potential for subsequent litigation or censure. This article proposes a six-point risk management strategy, which, if implemented, could reduce the chance of potential harm and litigation within a community nursing service. The strategy encompasses organizational, cultural, clinical, employee, environmental, and incident-reporting issues. A policy statement is proposed from which a risk management strategy could be developed. This is underpinned by the acceptance and ownership of risk management by all managers and clinicians, which is best achieved through a culture of honesty and openness, and where the management of risk is considered one of the fundamental duties of every member of staff. The strategy aims to enable the creation of a more coordinated, systematic and focused approach to the management of risks.

ASCA Observation of the Quiescent X-Ray Counterpart to SGR 1627-41

We present a 2-10 keV ASCA observation of the field around the soft gamma repeater SGR 1627-41. A quiescent X-ray source, whose position is consistent both with that of a recently discovered BeppoSAX X-ray source and with the Interplanetary Network localization for this soft gamma repeater, was detected in this observation. In 2-10 keV X-rays, the spectrum of the X-ray source may be fit equally well by a power-law, blackbody, or bremsstrahlung function, with unabsorbed flux approximately 5x10-12 ergs cm-2 s-1. We do not confirm a continuation of a fading trend in the flux, and we find no evidence for periodicity, both of which were noted in the earlier BeppoSAX observations.

Dimensions of decreased psychological well-being in advanced dementia

Evaluation of psychological well-being among persons with an advanced dementia is primarily dependent on verbal and non-verbal cues and behaviors that are observed and interpreted by others. The purpose of the present study was to determine how many components of psychological well-being can be measured. Fifty-seven individuals who were institutionalized for advanced dementia and exhibited agitation or withdrawal were evaluated by direct observations and by interviews with nursing home staff. Engagement was measured by the Lawton Positive Affect scale, visual analog scale, and reported degree of patient's interest in the environment. Mood was measured by a global indicator of mood interpreted from facial expression and two mood items from the Multidimensional Observation Scale for Elderly Subjects. Agitation was measured by a visual analog scale and by the Short Form of the Cohen-Mansfield Agitation Inventory. Correlation analyses and multidimensional scaling provided evidence for three dimensions of psychological well-being: engagement-apathy, happy sad mood, and calm-agitation. Evaluation of these three dimensions is important for measuring quality of care in long-term care settings and for determining effectiveness of therapeutic interventions.

The Behavioural Status Index (BSI) some preliminary reliability studies

This paper reports results of reliability studies for an assessment instrument that has undergone extensive empirical investigation: the Behavioural Status Index. Results indicate acceptable levels of test re-test reliability, item analysis and internal consistency. Inter-rater reliability is reported as equivocal Future empirical studies are discussed.

Evaluation of Simulated Presence: a personalized approach to enhance well-being in persons with Alzheimer's disease

OBJECTIVE

To evaluate the efficacy of Simulated Presence, a personalized approach to enhance well-being among nursing home residents with Alzheimer's disease and related dementia's (ADRD).

DESIGN

Latin-Square, double blinded, 3-factor design with restrictive randomization of three treatments (the study intervention, a placebo audio tape of a person reading the newspaper, and usual care). The three factors were treatment, time, and facility type.

SETTING

Nine nursing homes in Eastern Massachusetts and Southern New Hampshire.

PARTICIPANTS

Fifty-four subjects with documented ADRD who were aged 50 years or older, medically stable, had resided in their current nursing home for at least 3 months, and who had no planned discharge. All subjects had a history of agitated or withdrawn behaviors.

INTERVENTION

The purpose of Simulated Presence is to provide a personalized intervention for persons with moderate to severe cognitive impairment. Through a unique testing process, some of the best loved memories of the ADRD person's lifetime are identified and then those memories are introduced to the patient in the format of a telephone conversation using a continuous play audio tape system. The intervention may be used for extended periods of time because each repetition is viewed as a fresh, live telephone call as a result of the short-term memory deficit of the person with ADRD.

MEASUREMENTS

Direct observations of outcomes included using a newly developed scale, the Scale for the Observation of Agitation in Persons with Dementia, an agitation visual analog scale, the Positive Affect Rating Scale (mood and "interest"), a withdrawal visual analog scale, and facial diagrams of mood. Reported measures included daily staff observation logs of responses to interventions offered, and weekly staff surveys using the short-form Cohen-Mansfield Agitation Inventory and the Multidimensional Observation Scale for Elderly Subjects (mood and "interest"). Severity of dementia was assessed by the Mini-Mental State Exam, the Test for Severe Impairment, the Bedford Alzheimer's Nursing Scale, and the ADL Self-Performance Scale.

RESULTS

Chi-square analysis of direct observations, using facial diagrams, revealed that Simulated Presence was equivalent to usual care (P = .141) and superior to placebo for producing a happy facial expression (P = .001). A positive effect was also documented in nursing staff observation logs using Analysis of Variance techniques (ANOVA) for subjects during Simulated Presence phases compared with the placebo phases (P < .001) and usual care phases (P < .001). According to ANOVA analyses of "interest" from weekly surveys, Simulated Presence was superior to both usual care (P = .001) and placebo (P = .008). We were unable to find evidence of significant differences (P < .05) among interventions for other direct observations and weekly reports of overall agitation or mood aspects of withdrawal. Subjects accepted the intervention most of the time, except for five subjects who refused it more than 50% of the time.

CONCLUSION

This study provided evidence that Simulated Presence can be effective in enhancing well-being and decreasing problem behaviors in the nursing home setting as a substitute for or complement to usual care.

The Behavioural Status Index: therapeutic assessment of risk, insight, communication and social skills

An overview is given of the Behavioural Status Index (BSI), a developing classification instrument offering practical approaches to assessment and therapy surrounding social 'risk'. The approach hypothesizes that social 'risk' presented by a patient tends to correlate inversely with his/her degree of personal insight and capacity to perform well in key communicative and social skills, though no causal claims are made. Evidence exists to suggest that personal insight and communicative and social skills deserve serious consideration in a therapeutic approach to violent and dangerous behaviours. 'Risky' behaviours, as operationalized in the 'risk' subscale of the BSI, insight into the self and its activities, and communicative and social skills, may provide three critical foci for treatment planning in high security psychiatric care. A hypothetical linked factorial structure is proposed.

Predicting inpatient violence using the Broset Violence Checklist (BVC)

This paper reports early analysis of the Broset Violence Checklist. An instrument aiming to assist in the process of the prediction of violence from mentally ill in-patients. Early results appear promising and directions for future research using the instrument are suggested.