An examination of the profile and journey of patients with mental illness in the emergency department

© 2018 Objective: To examine the profile and journey of patients with mental illness in the emergency departments (ED) of a Local Health District in Australia. There is limited evidence around the patient profile and journey of people in who present to EDs with mental illness, and the aim of this study was to inform the development of a psychiatric emergency service model. Methods: The study design was a retrospective descriptive analysis of routinely collected data of two hospital EDs. Retrospective health care data of patients who presented to the EDs between July 2016 and June 2017 was analysed using descriptive and inferential statistics. Results: Mental health presentations (N = 4506) consisted of 3.44% of all presentations to the Emergency Department, mostly for anxiety and stress, comorbid alcohol and drug issues, and suicidality. Females were more likely to present, and significantly more likely to present multiple times (specifically for age groups 12–17 and over 65). Presenting issues were associated with age and gender for most diagnostic groups, but not with number of presentations, except for personality disorder. 24.83% were admitted to a mental health inpatient unit, 54.34% were referred to a mental health community team, 4.63% medically, and the remaining referred to alcohol and drug services, GPs, or NGOs. Length of stay was associated with gender (female), age (>65) and diagnosis (drug related and eating disorder). Conclusion: There is limited evidence around the patient profile and journey of people who present to EDs for mental health reasons, and this study contributes to this literature

Ring-fencing a budget for cancer drugs: is it fair?

Ring-fencing is defined as protecting funds for use in a specific area. In the NationalHealth Service in the UK, various methods to ring-fence cancer have beenemployed over the years; more recently the Cancer Drugs Fund in England hasenabled cancer drugs that would not normally be considered cost-effective to beprovided to patients. This has created variation in provision between England andthe devolved countries. While some would argue that ring-fencing allows majoradvances to be made in the treatment of a particular condition, others wouldargue that it is intrinsically unfair. In this debate, Graham and Cassidy have writtenan article arguing the affirmative position and Hughes and Duerden were invitedto respond directly to their arguments. As with all the RCPE's 'Currentcontroversies', the authors have been asked to take a deliberately polarisedposition and so the views they express may be somewhat overstated

Point-of-Care Testing for Pharyngitis in the Pharmacy.

Pharyngitis (also known as sore throat) is a common, predominately viral, self-limiting condition which can be symptomatically managed without antibiotic treatment. Inappropriate antibiotic use for pharyngitis contributes to the development and spread of antibiotic resistance. However, a small proportion of sore throats caused by group A streptococcal (GAS) infection may benefit from the provision of antibiotics. Establishing the cause of infection is therefore an important step in effective antibiotic stewardship. Point-of-care (POC) tests, where results are available within minutes, can distinguish between viral and GAS pharyngitis and can therefore guide treatment in primary healthcare settings such as community pharmacies, which are often the first point of contact with the healthcare system. In this opinion article, the evidence for the use of POC testing in the community pharmacy has been discussed. Evidence suggests that pharmacy POC testing can promote appropriate antibiotic use and reduce the need for general practitioner consultations. Challenges to implementation include cost, training and 'who prescribes', with country and regional differences presenting a particular issue. Despite these challenges, POC testing for pharyngitis has become widely available in pharmacies in some countries and may represent a strategy to contain antibiotic resistance and contribute to antimicrobial stewardship

Inhaled corticosteroids for chronic obstructive pulmonary disease-the shifting treatment paradigm

Chronic obstructive pulmonary disease (COPD) guidelines suggest using inhaled corticosteroids (ICS) in patients with severe airflow limitation or those at high risk of exacerbations. This recommendation is based on evidence demonstrating that ICS, especially when prescribed in fixed-dose combinations (FDC) with long-acting β2 agonists (LABA), improve quality of life (QoL), decrease exacerbations and hospitalisations, and have been associated with a trend towards a reduction in all-cause mortality. Audit shows that routine prescribing practice frequently uses inhaler therapies outside current guidelines recommendations; severe to very severe disease constitutes about 20% of all COPD patients, but up to 75% of COPD patients are prescribed an ICS, with significant numbers given ICS/LABA as first-line maintenance therapy. The role of ICS in the treatment paradigm for COPD is changing, driven by the growing evidence of increased risk of pneumonia, and the introduction of a new class of FDC; LABA and long-acting muscarinic antagonists (LAMA), which simplify dual bronchodilation and present a plausible alternative therapy. As the evidence base for dual therapy bronchodilation expands, it is likely that maximal bronchodilation will move up the treatment algorithm and ICS reserved for those with more severe disease who are not controlled on dual therapy. This change has already manifested in local COPD algorithms, such as those at Tayside, and represents a significant change in recommended prescribing practice. This review reassesses the role of ICS in the shifting treatment paradigm, in the context of alternative treatment options that provide maximal bronchodilation

The four or more medicines (FOMM) support service:results from an evaluation of a new community pharmacy service aimed at over-65s

Background: 57% of all prescriptions dispensed in the UK in 2003 were for people aged ≥60, where ≥20% of them were prescribed ≥ five medicines. Inappropriate prescribing and non-adherence have a significant impact on hospital admissions and patient quality of life. The English government has identified that community pharmacy could make a significant contribution to reducing non-adherence and improving the quality of prescribing, reducing both hospital admissions and medicines wastage. Objective: To evaluate a community pharmacy service aimed at patients over the age of 65 years prescribed four or more medicines. Method: Patients were invited to participate in the service by the community pharmacy team. The pharmacist held regular consultations with the patient and discussed risk of falls, pain management, adherence and general health. They also reviewed the patient’s medication using STOPP/START criteria. Data wereas analysed for the first six months of participation in the service. Key findings: 620 patients were recruited with 441 (71.1%) completing the six month study period. Pharmacists made 142 recommendations to prescribers in 110 patients largely centred on potentially inappropriate prescribing of NSAIDs, PPIs or duplication of therapy. At follow-up there was a significant decrease in the total number of falls (mean -0.116 (-0.217 - -0.014)) experienced and a significant increase in medicines adherence (mean difference in MMAS-8: 0.513 (0.337 – 0.689)) and quality of life. Cost per QALY estimates ranged from £11,885 to £32,466 depending on the assumptions made. Conclusion: By focussing on patients over the age of 65 years with four or more medicines, community pharmacists can improve medicines adherence and patient quality of life

Self-injurious behaviours are associated with alterations in the somatosensory system in children with autism spectrum disorder.

Children with autism spectrum disorder (ASD) frequently engage in self-injurious behaviours, often in the absence of reporting pain. Previous research suggests that altered pain sensitivity and repeated exposure to noxious stimuli are associated with morphological changes in somatosensory and limbic cortices. Further evidence from postmortem studies with self-injurious adults has indicated alterations in the structure and organization of the temporal lobes; however, the effect of self-injurious behaviour on cortical development in children with ASD has not yet been determined. Thirty children and adolescents (mean age = 10.6 ± 2.5 years; range 7-15 years; 29 males) with a clinical diagnosis of ASD and 30 typically developing children (N = 30, mean age = 10.7 ± 2.5 years; range 7-15 years, 26 males) underwent T1-weighted magnetic resonance and diffusion tensor imaging. No between-group differences were seen in cerebral volume, surface area or cortical thickness. Within the ASD group, self-injury scores negatively correlated with thickness in the right superior parietal lobule t = 6.3, p \u3c 0.0001, bilateral primary somatosensory cortices (SI) (right: t = 4.4, p = 0.02; left: t = 4.48, p = 0.004) and the volume of the left ventroposterior (VP) nucleus of the thalamus (r = -0.52, p = 0.008). Based on these findings, we performed an atlas-based region-of-interest diffusion tensor imaging analysis between SI and the VP nucleus and found that children who engaged in self-injury had significantly lower fractional anisotropy (r = -0.4, p = 0.04) and higher mean diffusivity (r = 0.5, p = 0.03) values in the territory of the left posterior limb of the internal capsule. Additionally, greater incidence of self-injury was associated with increased radial diffusivity values in bilateral posterior limbs of the internal capsule (left: r = 0.5, p = 0.02; right: r = 0.5, p = 0.009) and corona radiata (left: r = 0.6, p = 0.005; right: r = 0.5, p = 0.009). Results indicate that self-injury is related to alterations in somatosensory cortical and subcortical regions and their supporting white-matter pathways. Findings could reflect use-dependent plasticity in the somatosensory system or disrupted brain development that could serve as a risk marker for self-injury

Quantitative assessment of white matter injury in preterm neonates: Association with outcomes.

OBJECTIVE: To quantitatively assess white matter injury (WMI) volume and location in very preterm neonates, and to examine the association of lesion volume and location with 18-month neurodevelopmental outcomes. METHODS: Volume and location of WMI was quantified on MRI in 216 neonates (median gestational age 27.9 weeks) who had motor, cognitive, and language assessments at 18 months corrected age (CA). Neonates were scanned at 32.1 postmenstrual weeks (median) and 68 (31.5%) had WMI; of 66 survivors, 58 (87.9%) had MRI and 18-month outcomes. WMI was manually segmented and transformed into a common image space, accounting for intersubject anatomical variability. Probability maps describing the likelihood of a lesion predicting adverse 18-month outcomes were developed. RESULTS: WMI occurs in a characteristic topology, with most lesions occurring in the periventricular central region, followed by posterior and frontal regions. Irrespective of lesion location, greater WMI volumes predicted poor motor outcomes ( CONCLUSIONS: The predictive value of frontal lobe WMI volume highlights the importance of lesion location when considering the neurodevelopmental significance of WMI. Frontal lobe lesions are of particular concern