Use and misuse of aspirin in rural Ethiopia

Objectives: To investigate ability to distinguish simple analgesics, to document misconceptions about aspirin use, and to identify strategies to diminish potentially harmful aspirin use in Ethiopia. Design: Qualitative study (eight focus group discussions) used to inform cross-sectional survey. Setting: Butajira, a small town in southern Ethiopia, and surrounding rural areas. Participants: Purposively selected informants for focus groups; random sample of urban and rural residents for cross-sectional survey. Main outcome measures: Ability to distinguish aspirin from paracetamol; proportion using aspirin; proportion aware of common risks of aspirin. Results: Questionnaires were completed by 204 of the 250 residents sampled (82% response). Three-quarters of survey participants knew the difference between aspirin and paracetamol. Aspirin was used by 7.3% of respondents, and was mainly taken for headache and fever. In focus group discussions there was a suggestion that aspirin was considered particularly useful for children. There was very low awareness of the risks of using aspirin in children (2.5% unprompted, 18.6% prompted) or in people with asthma (1% unprompted, 5.9% prompted). Aspirin is cheap and widely available in urban and rural areas.Conclusion: Awareness of the risks of aspirin use by children and in asthma is extremely low in this rural Ethiopian setting. Medications are purchased with minimal packaging by a population with low literacy. Drug dispensers and vendors must be trained to convey simple verbal warnings about aspirin use. East African Medical Journal Vol. 83(1) 2006: 31-3

Tomorrow’s world: Current developments in the therapeutic use of technology for psychosis

There is now an established evidence base for the use of information and communication technology (ICT) to support mental healthcare (‘e-mental health’) for common mental health problems. Recently, there have been significant develop-ments in the therapeutic use of computers, mobile phones, gaming and virtual reality technologies for the assessment and treatment of psychosis. We provide an overview of the therapeutic use of ICT for psychosis, drawing on searches of the scientific literature and the internet and using interviews with experts in the field. We outline interventions that are already relevant to clinical practice, some that may become available in the foreseeable future and emerging challenges for their implementation

Containing COVID: the establishment and management of a COVID-19 ward in an adult psychiatric hospital

BACKGROUND: As the coronavirus disease 2019 (COVID-19) epidemic in the UK emerged and escalated, clinicians working in mental health in-patient facilities faced unique medical, psychiatric and staffing challenges in managing and containing the impact of the virus and, in the context of legislation, enforcing social distancing. AIMS: To describe (a) the steps taken by one mental health hospital to establish a COVID-19 isolation ward for adult psychiatric in-patients and (b) how staff addressed the challenges that emerged over the period March to June 2020. METHOD: A descriptive study detailing the processes involved in changing the role of the ward and the measures taken to address the various challenges that arose. Brief clinical cases of two patients are included for illustrative purposes. RESULTS: We describe the achievements, lessons learned and outcomes of the process of repurposing a mental health triage ward into a COVID-19 isolation facility, including the impact on staff. Flexibility, rapid problem-solving and close teamwork were essential. Some of the changes made will be sustained on the ward in our primary role as a triage ward. CONCLUSIONS: Although the challenges faced were difficult, the legacy they have left is that of a range of improvements in patient care and the working environment

Exploring the digital technology preferences of teenagers and young adults (TYA) with cancer and survivors: a cross-sectional service evaluation questionnaire

PURPOSE: Digital technology has the potential to support teenagers and young adults (TYAs) with cancer from the onset of their disease into survivorship. We aimed to establish (1) the current pattern of use of TYA digital technologies within our service-user population, and (2) their preferences regarding digital information and support within the service. METHODS: A cross-sectional survey was administered as a paper and online self-completed questionnaire to TYAs aged 13–24 accessing outpatient, inpatient, and day care cancer services at a regional specialist centre over a 4-week period. RESULTS: One hundred two TYAs completed the survey (55.7% male; 39.8% female; 83.3% paper; 16.7% online; mean age 18.5 years [SD = 3.51]). Of the TYAs, 41.6% rated the importance of digital communication as “essential” to their lives. Half (51.0%) kept in contact with other patients they had met during treatment, and 12.0% contacted patients they had not met in person. Respondents wanted to receive clinical information online (66.3%) and use online chat rooms (54.3%). Future online services desired included virtual online groups (54.3%), online counselling or psychological support (43.5%), and receiving (66.3%) and sharing (48.9%) clinical information online. CONCLUSIONS: Young people with cancer are digital natives. A significant subgroup expressed a desire for digital resources from oncology services, though existing resources are also highly valued. Digital resources have potential to improve patient experience and engagement. IMPLICATIONS FOR CANCER SURVIVORS: There is considerable scope to develop digital resources with which TYAs can receive information and connect with both professionals and fellow patients, following diagnosis, through treatment and survivorship

Acute mental health presentations before and during the COVID-19 pandemic

Background: A number of community based surveys have identified an increase in psychological symptoms and distress but there has been no examination of symptoms at the more severe end of the mental health spectrum. // Aims: We aimed to analyse numbers and types of psychiatric presentations to inform planning for future demand on mental health services in light of the COVID-19 pandemic. // Method: We analysed electronic data between January and April 2020 for 2534 patients referred to acute psychiatric services, and tested for differences in patient demographics, symptom severity and use of the Mental Health Act 1983 (MHA), before and after lockdown. We used interrupted time-series analyses to compare trends in emergency department and psychiatric presentations until December 2020. // Results: There were 22% fewer psychiatric presentations the first week and 48% fewer emergency department presentations in the first month after lockdown initiated. A higher proportion of patients were detained under the MHA (22.2 v. 16.1%) and Mental Capacity Act 2005 (2.2 v. 1.1%) (χ2(2) = 16.3, P < 0.0001), and they experienced a longer duration of symptoms before seeking help from mental health services (χ2(3) = 18.6, P < 0.0001). A higher proportion of patients presented with psychotic symptoms (23.3 v. 17.0%) or delirium (7.0 v. 3.6%), and fewer had self-harm behaviour (43.8 v. 52.0%, χ2(7) = 28.7, P < 0.0001). A higher proportion were admitted to psychiatric in-patient units (22.2 v. 18.3%) (χ2(6) = 42.8, P < 0.0001) after lockdown. // Conclusions: UK lockdown resulted in fewer psychiatric presentations, but those who presented were more likely to have severe symptoms, be detained under the MHA and be admitted to hospital. Psychiatric services should ensure provision of care for these patients as well as planning for those affected by future COVID-19 waves

An online supported self-management toolkit for relatives of people with psychosis or bipolar experiences: the IMPART multiple case study

Background Digital health interventions have the potential to improve the delivery of psychoeducation to people with mental health problems and their relatives. Despite substantial investment in the development of digital health interventions, successful implementation into routine clinical practice is rare. Objectives Use the implementation of the Relatives’ Education And Coping Toolkit (REACT) for psychosis/bipolar disorder to identify critical factors affecting uptake and use, and develop an implementation plan to support the delivery of REACT. Design This was an implementation study using a mixed-methods, theory-driven, multiple case study approach. A study-specific implementation theory for REACT based on normalisation process theory was developed and tested, and iterations of an implementation plan to address the key factors affecting implementation were developed. Setting Early-intervention teams in six NHS mental health trusts in England (three in the north and three in the south). Participants In total, 281 staff accounts and 159 relatives’ accounts were created, 129 staff and 23 relatives took part in qualitative interviews about their experiences, and 132 relatives provided demographic data, 56 provided baseline data, 21 provided data at 12 weeks’ follow-up and 20 provided data at 24 weeks’ follow-up. Interventions REACT is an online supported self-management toolkit, offering 12 evidence-based psychoeducation modules and support via a forum, and a confidential direct messaging service for relatives of people with psychosis or bipolar disorder. The implementation intervention was developed with staff and iteratively adapted to address identified barriers. Adaptations included modifications to the toolkit and how it was delivered by teams. Main outcome measures The main outcome was factors affecting implementation of REACT, assessed primarily through in-depth interviews with staff and relatives. We also assessed quantitative measures of delivery (staff accounts and relatives’ invitations), use of REACT (relatives’ logins and time spent on the website) and the impact of REACT [relatives’ distress (General Health Questionnaire-28), and carer well-being and support (Carer Well-being and Support Scale questionnaire)]. Results Staff and relatives were generally positive about the content of REACT, seeing it as a valuable resource that could help services improve support and meet clinical targets, but only within a comprehensive service that included face-to-face support, and with some additional content. Barriers to implementation included high staff caseloads and difficulties with prioritising supporting relatives; technical difficulties of using REACT; poor interoperability with trust information technology systems and care pathways; lack of access to mobile technology and information technology training; restricted forum populations leading to low levels of use; staff fears of managing risk, online trolling, or replacement by technology; and uncertainty around REACT’s long-term availability. There was no evidence that REACT would reduce staff time supporting relatives (which was already very low), and might increase it by facilitating communication. In all, 281 staff accounts were created, but only 57 staff sent relatives invitations. In total, 355 relatives’ invitations were sent to 310 unique relatives, leading to the creation of 159 relatives’ accounts. The mean number of logins for relatives was 3.78 (standard deviation 4.43), but with wide variation from 0 to 31 (median 2, interquartile range 1–8). The mean total time spent on the website was 40.6 minutes (standard deviation 54.54 minutes), with a range of 0–298 minutes (median 20.1 minutes, interquartile range 4.9–57.5 minutes). There was a pattern of declining mean scores for distress, social dysfunction, depression, anxiety and insomnia, and increases in relatives’ well-being and eHealth literacy, but no changes were statistically significant. Conclusions Digital health interventions, such as REACT, should be iteratively developed, evaluated, adapted and implemented, with staff and service user input, as part of a long-term strategy to develop integrated technology-enabled services. Implementation strategies must instil a sense of ownership for staff and ensure that they have adequate training, risk protocols and resources to deliver the technology. Cost-effectiveness and impact on workload and inequalities in accessing health care need further testing, along with the generalisability of our findings to other digital health interventions. Limitations REACT was offered by the same team running the IMPlementation of A Relatives’ Toolkit (IMPART) study, and was perceived by staff and relatives as a time-limited research study rather than ongoing clinical service, which affected engagement. Access to observational data was limited. Trial registration Current Controlled Trials ISRCTN16267685. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 37. See the NIHR Journals Library website for further project information

Physiological responses during ascent to high altitude and the incidence of acute mountain sickness.

Acute mountain sickness (AMS) occurs when there is failure of acclimatisation to high altitude. The aim of this study was to describe the relationship between physiological variables and the incidence of AMS during ascent to 5300 m. A total of 332 lowland-dwelling volunteers followed an identical ascent profile on staggered treks. Self-reported symptoms of AMS were recorded daily using the Lake Louise score (mild 3-4; moderate-severe ≥5), alongside measurements of physiological variables (heart rate, respiratory rate (RR), peripheral oxygen saturation (SpO2 ) and blood pressure) before and after a standardised Xtreme Everest Step-Test (XEST). The overall occurrence of AMS among participants was 73.5% (23.2% mild, 50.3% moderate-severe). There was no difference in gender, age, previous AMS, weight or body mass index between participants who developed AMS and those who did not. Participants who had not previously ascended >5000 m were more likely to get moderate-to-severe AMS. Participants who suffered moderate-to-severe AMS had a lower resting SpO2 at 3500 m (88.5 vs. 89.6%, p = 0.02), while participants who suffered mild or moderate-to-severe AMS had a lower end-exercise SpO2 at 3500 m (82.2 vs. 83.8%, p = 0.027; 81.5 vs. 83.8%, p 5000 m (OR 2.740, p-value 0.003) predicted the development of moderate-to-severe AMS. The Xtreme Everest Step-Test offers a simple, reproducible field test to help predict AMS, albeit with relatively limited predictive precision

Caudwell Xtreme Everest: A prospective study of the effects of environmental hypoxia on cognitive functioning.

BACKGROUND: The neuropsychological consequences of exposure to environmental hypobaric hypoxia (EHH) remain unclear. We thus investigated them in a large group of healthy volunteers who trekked to Mount Everest base camp (5,300 m). METHODS: A neuropsychological (NP) test battery assessing memory, language, attention, and executive function was administered to 198 participants (age 44.5±13.7 years; 60% male). These were studied at baseline (sea level), 3,500 m (Namche Bazaar), 5,300 m (Everest Base Camp) and on return to 1,300 m (Kathmandu) (attrition rate 23.7%). A comparable control group (n = 25; age 44.5±14.1 years; 60% male) for comparison with trekkers was tested at/or near sea level over an equivalent timeframe so as to account for learning effects associated with repeat testing. The Reliable Change Index (RCI) was used to calculate changes in cognition and neuropsychological function during and after exposure to EHH relative to controls. RESULTS: Overall, attention, verbal ability and executive function declined in those exposed to EHH when the performance of the control group was taken into account (RCI .05 to -.95) with decline persisting at descent. Memory and psychomotor function showed decline at highest ascent only (RCI -.08 to -.56). However, there was inter-individual variability in response: whilst NP performance declined in most, this improved in some trekkers. Cognitive decline was greater amongst older people (r = .42; p < .0001), but was otherwise not consistently associated with socio-demographic, mood, or physiological variables. CONCLUSIONS: After correcting for learning effects, attention, verbal abilities and executive functioning declined with exposure to EHH. There was considerable individual variability in the response of brain function to sustained hypoxia with some participants not showing any effects of hypoxia. This might have implications for those facing sustained hypoxia as a result of any disease

USE AND MISUSE OF ASPIRIN IN RURAL ETHIOPIA

Objectives: To investigate ability to distinguish simple analgesics, to documentmisconceptions about aspirin use, and to identify strategies to diminish potentially harmful aspirin use in Ethiopia.Design: Qualitative study (eight focus group discussions) used to inform cross-sectional survey.Setting: Butajira, a small town in southern Ethiopia, and surrounding rural areas.Participants: Purposively selected informants for focus groups; random sample of urban and rural residents for cross-sectional survey.Main outcome measures: Ability to distinguish aspirin from paracetamol; proportion using aspirin; proportion aware of common risks of aspirin.Results: Questionnaires were completed by 204 of the 250 residents sampled (82% response). Three-quarters of survey participants knew the difference between aspirin and paracetamol. Aspirin was used by 7.3% of respondents, and was mainly taken for headache and fever. In focus group discussions there was a suggestion that aspirin was considered particularly useful for children. There was very low awareness of the risks of using aspirin in children (2.5% unprompted, 18.6% prompted) or in people with asthma (1% unprompted, 5.9% prompted). Aspirin is cheap and widely available in urban and rural areas.Conclusion: Awareness of the risks of aspirin use by children and in asthma is extremely low in this rural Ethiopian setting. Medications are purchased with minimal packaging by a population with low literacy. Drug dispensers and vendors must be trained to convey simple verbal warnings about aspirin use