Variation in compulsory psychiatric inpatient admission in England:a cross-sectional, multilevel analysis

Background: Rates of compulsory admission have increased in England in recent decades, and this trend is accelerating. Studying variation in rates between people and places can help identify modifiable causes. Objectives: To quantify and model variances in the rate of compulsory admission in England at different spatial levels and to assess the extent to which this was explained by characteristics of people and places. Design: Cross-sectional analysis using multilevel statistical modelling. Setting: England, including 98% of Census lower layer super output areas (LSOAs), 95% of primary care trusts (PCTs), 93% of general practices and all 69 NHS providers of specialist mental health services. Participants: 1,287,730 patients. Main outcome measure: The study outcome was compulsory admission, defined as time spent in an inpatient mental illness bed subject to the Mental Health Act (2007) in 2010/11. We excluded patients detained under sections applying to emergency assessment only (including those in places of safety), guardianship or supervision of community treatment. The control group comprised all other users of specialist mental health services during the same period. Data sources: The Mental Health Minimum Data Set (MHMDS). Data on explanatory variables, characterising each of the spatial levels in the data set, were obtained from a wide range of sources, and were linked using MHMDS identifiers. Results: A total of 3.5% of patients had at least one compulsory admission in 2010/11. Of (unexplained) variance in the null model, 84.5% occurred between individuals. Statistically significant variance occurred between LSOAs [6.7%, 95% confidence interval (CI) 6.2% to 7.2%] and provider trusts (6.9%, 95% CI 4.3% to 9.5%). Variances at these higher levels remained statistically significant even after adjusting for a large number of explanatory variables, which together explained only 10.2% of variance in the study outcome. The number of provider trusts whose observed rate of compulsory admission differed from the model average to a statistically significant extent fell from 45 in the null model to 20 in the fully adjusted model. We found statistically significant associations between compulsory admission and age, gender, ethnicity, local area deprivation and ethnic density. There was a small but statistically significant association between (higher) bed occupancy and compulsory admission, but this was subsequently confounded by other covariates. Adjusting for PCT investment in mental health services did not improve model fit in the fully adjusted models. Conclusions: This was the largest study of compulsory admissions in England. While 85% of the variance in this outcome occurred between individuals, statistically significant variance (around 7% each) occurred between places (LSOAs) and provider trusts. This higher-level variance in compulsory admission remained largely unchanged even after adjusting for a large number of explanatory variables. We were constrained by data available to us, and therefore our results must be interpreted with caution. We were also unable to consider many hypotheses suggested by the service users, carers and professionals who we consulted. There is an imperative to develop and evaluate interventions to reduce compulsory admission rates. This requires further research to extend our understanding of the reasons why these rates remain so high. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Size and clustering of ethnic groups and rates of psychiatric admission in England

Aims and method To compare rates of admission for different types of severe mental illness between ethnic groups, and to test the hypothesis that larger and more clustered ethnic groups will have lower admission rates. This was a descriptive study of routinely collected data from the National Health Service in England. Results There was an eightfold difference in admission rates between ethnic groups for schizophreniform and mania admissions, and a fivefold variation in depression admissions. On average, Black and minority ethnic (BME) groups had higher rates of admission for schizophreniform and mania admissions but not for depression. This increased rate was greatest in the teenage years and early adulthood. Larger ethnic group size was associated with lower admission rates. However, greater clustering was associated with higher admission rates. Clinical implications Our findings support the hypothesis that larger ethnic groups have lower rates of admission. This was a between-group comparison rather than within each group. Our findings do not support the hypothesis that more clustered groups have lower rates of admission. In fact, they suggest the opposite: groups with low clustering had lower admission rates. The BME population in the UK is increasing in size and becoming less clustered. Our results suggest that both of these factors should ameliorate the overrepresentation of BME groups among psychiatric in-patients. However, this overrepresentation continues, and our results suggest a possible explanation, namely, changes in the delivery of mental health services, particularly the marked reduction in admissions for depression

The Green Bank Ammonia Survey: Unveiling the Dynamics of the Barnard 59 star-forming Clump

Understanding the early stages of star formation is a research field of ongoing development, both theoretically and observationally. In this context, molecular data have been continuously providing observational constraints on the gas dynamics at different excitation conditions and depths in the sources. We have investigated the Barnard 59 core, the only active site of star formation in the Pipe Nebula, to achieve a comprehensive view of the kinematic properties of the source. These information were derived by simultaneously fitting ammonia inversion transition lines (1,1) and (2,2). Our analysis unveils the imprint of protostellar feedback, such as increasing line widths, temperature and turbulent motions in our molecular data. Combined with complementary observations of dust thermal emission, we estimate that the core is gravitationally bound following a virial analysis. If the core is not contracting, another source of internal pressure, most likely the magnetic field, is supporting it against gravitational collapse and limits its star formation efficiency.Comment: 18 pages, 18 figure

Pharmacological profiling of the hemodynamic effects of cannabinoid ligands: a combined in vitro and in vivo approach.

The receptors mediating the hemodynamic responses to cannabinoids are not clearly defined due to the multifarious pharmacology of many commonly used cannabinoid ligands. While both CB1 and TRPV1 receptors are implicated, G protein-coupled receptor 55 (GPR55) may also mediate some of the hemodynamic effects of several atypical cannabinoid ligands. The present studies attempted to unravel the pharmacology underlying the in vivo hemodynamic responses to ACEA (CB1 agonist), O-1602 (GPR55 agonist), AM251 (CB1 antagonist), and cannabidiol (CBD; GPR55 antagonist). Agonist and antagonist profiles of each ligand were determined by ligand-induced GTPcS binding in membrane preparations expressing rat and mouse CB1 and GPR55 receptors. Blood pressure responses to ACEA and O-1602 were recorded in anesthetized and conscious mice (wild type, CB1 / and GPR55 / ) and rats in the absence and presence of AM251 and CBD. ACEA demonstrated GTPcS activation at both receptors, while O-1602 only activated GPR55. AM251 exhibited antagonist activity at CB1 and agonist activity at GPR55, while CBD demonstrated selective antagonist activity at GPR55. The depressor response to ACEA was blocked by AM251 and attenuated by CBD, while O-1602 did not induce a depressor response. AM251 caused a depressor response that was absent in GPR55 / mice but enhanced by CBD, while CBD caused a small vasodepressor response that persisted in GPR55 / mice. Our findings show that assessment of the pharmacological profile of receptor activation by cannabinoid ligands in in vitro studies alongside in vivo functional studies is essential to understand the role of cannabinoids in hemodynamic control

Population Frequencies Determined by Next-generation Sequencing Provide Strategies for Prospective HLA Epitope Matching for Transplantation

Compatibility for human leukocyte antigen (HLA) genes between transplant donors and recipients improves graft survival but prospective matching is rarely performed due to the vast heterogeneity of this gene complex. To reduce complexity, we have combined next-generation sequencing and in silico mapping to determine population frequencies and matching probabilities of 150 antibody-binding eplets across all 11 classical HLA genes in 2000 ethnically heterogeneous renal patients and donors. We show that eplets are more common and more uniformly distributed between donors and recipients than the respective HLA isoforms. Simulation of targeted eplet matching shows that a high degree of overall compatibility, and perfect identity at the clinically important HLA class II loci, can be obtained within a patient waiting list of approximately 250 subjects. Internal epitope-based allocation is thus feasible for most major renal transplant programs, while regional or national sharing may be required for other solid organs

Use of community treatment orders and their outcomes: an observational study

Background Community treatment orders are widely used in England. It is unclear whether their use varies between patients, places and services, or if they are associated with better patient outcomes. Objectives To examine variation in the use of community treatment orders and their associations with patient outcomes and health-care costs. Design Secondary analysis using multilevel statistical modelling. Setting England, including 61 NHS mental health provider trusts. Participants A total of 69,832 patients eligible to be subject to a community treatment order. Main outcome measures Use of community treatment orders and time subject to community treatment order; re-admission and total time in hospital after the start of a community treatment order; and mortality. Data sources The primary data source was the Mental Health Services Data Set. Mental Health Services Data Set data were linked to mortality records and local area deprivation statistics for England. Results There was significant variation in community treatment order use between patients, provider trusts and local areas. Most variation arose from substantially different practice in a small number of providers. Community treatment order patients were more likely to be in the ‘severe psychotic’ care cluster grouping, male or black. There was also significant variation between service providers and local areas in the time patients remained on community treatment orders. Although slightly more community treatment order patients were re-admitted than non-community treatment order patients during the study period (36.9% vs. 35.6%), there was no significant difference in time to first re-admission (around 32 months on average for both). There was some evidence that the rate of re-admission differed between community treatment order and non-community treatment order patients according to care cluster grouping. Community treatment order patients spent 7.5 days longer, on average, in admission than non-community treatment order patients over the study period. This difference remained when other patient and local area characteristics were taken into account. There was no evidence of significant variation between service providers in the effect of community treatment order on total time in admission. Community treatment order patients were less likely to die than non-community treatment order patients, after taking account of other patient and local area characteristics (odds ratio 0.69, 95% credible interval 0.60 to 0.81). Limitations Confounding by indication and potential bias arising from missing data within the Mental Health Services Data Set. Data quality issues precluded inclusion of patients who were subject to community treatment orders more than once. Conclusions Community treatment order use varied between patients, provider trusts and local areas. Community treatment order use was not associated with shorter time to re-admission or reduced time in hospital to a statistically significant degree. We found no evidence that the effectiveness of community treatment orders varied to a significant degree between provider trusts, nor that community treatment orders were associated with reduced mental health treatment costs. Our findings support the view that community treatment orders in England are not effective in reducing future admissions or time spent in hospital. We provide preliminary evidence of an association between community treatment order use and reduced rate of death. Future work These findings need to be replicated among patients who are subject to community treatment order more than once. The association between community treatment order use and reduced mortality requires further investigation. Study registration The study was approved by the University of Warwick’s Biomedical and Scientific Research Ethics Committee (REGO-2015-1623). 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. 9. See the NIHR Journals Library website for further project information

The Green Bank Ammonia Survey (GAS): First Results of NH3 mapping the Gould Belt

We present an overview of the first data release (DR1) and first-look science from the Green Bank Ammonia Survey (GAS). GAS is a Large Program at the Green Bank Telescope to map all Gould Belt star-forming regions with $A_V \gtrsim 7$ mag visible from the northern hemisphere in emission from NH$_3$ and other key molecular tracers. This first release includes the data for four regions in Gould Belt clouds: B18 in Taurus, NGC 1333 in Perseus, L1688 in Ophiuchus, and Orion A North in Orion. We compare the NH$_3$ emission to dust continuum emission from Herschel, and find that the two tracers correspond closely. NH$_3$ is present in over 60\% of lines-of-sight with $A_V \gtrsim 7$ mag in three of the four DR1 regions, in agreement with expectations from previous observations. The sole exception is B18, where NH$_3$ is detected toward ~ 40\% of lines-of-sight with $A_V \gtrsim 7$ mag. Moreover, we find that the NH$_3$ emission is generally extended beyond the typical 0.1 pc length scales of dense cores. We produce maps of the gas kinematics, temperature, and NH$_3$ column densities through forward modeling of the hyperfine structure of the NH$_3$ (1,1) and (2,2) lines. We show that the NH$_3$ velocity dispersion, ${\sigma}_v$, and gas kinetic temperature, $T_K$, vary systematically between the regions included in this release, with an increase in both the mean value and spread of ${\sigma}_v$ and $T_K$ with increasing star formation activity. The data presented in this paper are publicly available.Comment: 33 pages, 27 figures, accepted to ApJS. Datasets are publicly available: https://dataverse.harvard.edu/dataverse/GAS_DR

Droplets I: Pressure-Dominated Sub-0.1 pc Coherent Structures in L1688 and B18

We present the observation and analysis of newly discovered coherent structures in the L1688 region of Ophiuchus and the B18 region of Taurus. Using data from the Green Bank Ammonia Survey (GAS), we identify regions of high density and near-constant, almost-thermal, velocity dispersion. Eighteen coherent structures are revealed, twelve in L1688 and six in B18, each of which shows a sharp "transition to coherence" in velocity dispersion around its periphery. The identification of these structures provides a chance to study the coherent structures in molecular clouds statistically. The identified coherent structures have a typical radius of 0.04 pc and a typical mass of 0.4 Msun, generally smaller than previously known coherent cores identified by Goodman et al. (1998), Caselli et al. (2002), and Pineda et al. (2010). We call these structures "droplets." We find that unlike previously known coherent cores, these structures are not virially bound by self-gravity and are instead predominantly confined by ambient pressure. The droplets have density profiles shallower than a critical Bonnor-Ebert sphere, and they have a velocity (VLSR) distribution consistent with the dense gas motions traced by NH3 emission. These results point to a potential formation mechanism through pressure compression and turbulent processes in the dense gas. We present a comparison with a magnetohydrodynamic simulation of a star-forming region, and we speculate on the relationship of droplets with larger, gravitationally bound coherent cores, as well as on the role that droplets and other coherent structures play in the star formation process.Comment: Accepted by ApJ in April, 201