Psychiatric hospital reform in low-income and middle-income countries Structured Individualised inTervention And Recovery (SITAR) : a two-arm pragmatic randomised controlled trial study protocol

Introduction Low-income and middle-income settings like India have large treatment gaps in mental healthcare. People with severe mental disorders face impediments to their clinical and functional recovery, and have large unmet needs. The infrastructure and standards of care are poor in colonial period psychiatric hospitals, with no clear pathways to discharge and successfully integrate recovered individuals into the community. Our aim is to study the impact of psychiatric hospital reform on individual patient outcomes in a psychiatric hospital in India. Methods and analysis Structured Individualised inTervention And Recovery (SITAR) is a two-arm pragmatic randomised controlled trial, focusing on patients aged 18–60 years with a hospital stay of 12–120 months and a primary diagnosis of psychosis. It tests the effectiveness of structural and process reform with and without an individually tailored recovery plan on patient outcomes of disability (primary outcome WHO Disability Assessment Scale), symptom severity, social and occupational functioning and quality of life. A computer-generated permuted block randomisation schedule will allocate recruited subjects to the two study arms. We aim to recruit 100 people into each trial arm. Baseline and outcome measures will be undertaken by trained researchers independent to the case managers providing the individual intervention. A health economic analysis will determine the costing of implementing the individually tailored recovery plan

Road-based multi-metric forwarder evaluation for multipath video streaming in urban vehicular communication

In video streaming over vehicular communication, optimal selection of a video packet forwarder is a daunting issue due to the dynamic nature of Vehicular Ad-hoc NETworks (VANETs)and the high data rates of video. In most of the existing studies, extensive considerations of the essential metrics have not been considered. In order to achieve quality video streaming in vehicular network, important metrics for link connectivity and bandwidth efficiency need to be employed to minimize video packet error and losses. In order to address the aforementioned issues, a Road-based Multi-metric Forwarder Evaluation scheme for Multipath Video Streaming (RMF-MVS) has been proposed. The RMF-MVS scheme is adapted to be a Dynamic Self-Weighting score (DSW) (RMF-MVS+DSW) for forwarder vehicle selection. The scheme is based on multipath transmission. The performance of the scheme is evaluated using Peak Signal to Noise Ratio (PSNR), Structural SIMilarity index (SSIM), Packet Loss Ratio (PLR) and End-to-End Delay (E2ED) metrics. The proposed scheme is compared against two baseline schemes including Multipath Solution with Link and Node Disjoint (MSLND) and Multimedia Multi-metric Map-aware Routing Protocol (3MRP) with DSW (3MRP+DSW). The comparative performance assessment results justify the benefit of the proposed scheme based on various video streaming related metrics

DOMINE: a comprehensive collection of known and predicted domain-domain interactions

DOMINE is a comprehensive collection of known and predicted domain–domain interactions (DDIs) compiled from 15 different sources. The updated DOMINE includes 2285 new domain–domain interactions (DDIs) inferred from experimentally characterized high-resolution three-dimensional structures, and about 3500 novel predictions by five computational approaches published over the last 3 years. These additions bring the total number of unique DDIs in the updated version to 26 219 among 5140 unique Pfam domains, a 23% increase compared to 20 513 unique DDIs among 4346 unique domains in the previous version. The updated version now contains 6634 known DDIs, and features a new classification scheme to assign confidence levels to predicted DDIs. DOMINE will serve as a valuable resource to those studying protein and domain interactions. Most importantly, DOMINE will not only serve as an excellent reference to bench scientists testing for new interactions but also to bioinformaticans seeking to predict novel protein–protein interactions based on the DDIs. The contents of the DOMINE are available at http://domine.utdallas.edu

DOMINE: a database of protein domain interactions

DOMINE is a database of known and predicted protein domain interactions compiled from a variety of sources. The database contains domain–domain interactions observed in PDB entries, and those that were predicted by eight different computational approaches. DOMINE contains a total of 20 513 unique domain–domain interactions among 4036 Pfam domains, out of which 4349 are inferred from PDB entries and 17 781 were predicted by at least one computational approach. This database will serve as a valuable resource to those working in the field of protein and domain interactions. DOMINE may not only serve as a reference to experimentalists who test for new protein and domain interactions, but also offers a consolidated dataset for analysis by bioinformaticians who seek to test ideas regarding the underlying factors that control the topological structure of interaction networks. DOMINE is freely available at http://domine.utdallas.edu

Transforming access to care for serious mental disorders in slums (the TRANSFORM Project) : rationale, design and protocol

This paper introduces the TRANSFORM project, which aims to improve access to mental health services for people with serious and enduring mental disorders (SMDs – psychotic disorders and severe mood disorders, often with co-occurring substance misuse) living in urban slums in Dhaka (Bangladesh) and Ibadan (Nigeria). People living in slum communities have high rates of SMDs, limited access to mental health services and conditions of chronic hardship. Help is commonly sought from faith-based and traditional healers, but people with SMDs require medical treatment, support and follow-up. This multicentre, international mental health mixed-methods research project will (a) conduct community-based ethnographic assessment using participatory methods to explore community understandings of SMDs and help-seeking; (b) explore the role of traditional and faith-based healing for SMDs, from the perspectives of people with SMDs, caregivers, community members, healers, community health workers (CHWs) and health professionals; (c) co-design, with CHWs and healers, training packages for screening, early detection and referral to mental health services; and (d) implement and evaluate the training packages for clinical and cost-effectiveness in improving access to treatment for those with SMDs. TRANSFORM will develop and test a sustainable intervention that can be integrated into existing clinical care and inform priorities for healthcare providers and policy makers

Partnerships in a Global Mental Health Research Programme-the Example of PRIME.

Collaborative research partnerships are necessary to answer key questions in global mental health, to share expertise, access funding and influence policy. However, partnerships between low- and middle-income countries (LMIC) and high-income countries have often been inequitable with the provision of technical knowledge flowing unilaterally from high to lower income countries. We present the experience of the Programme for Improving Mental Health Care (PRIME), a LMIC-led partnership which provides research evidence for the development, implementation and scaling up of integrated district mental healthcare plans in Ethiopia, India, Nepal, South Africa and Uganda. We use Tuckman's first four stages of forming, storming, norming and performing to reflect on the history, formation and challenges of the PRIME Consortium. We show how this resulted in successful partnerships in relation to management, research, research uptake and capacity building and reflect on the key lessons for future partnerships

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Psychiatric hospital reform in low-income and middle-income countries; structured individualised intervention and recovery (SITAR)

Background: Low- and Middle-Income countries (LMICs) like India have large treatment gaps in mental health care. People with Severe Mental Disorders (SMD) face impediments to their clinical and functional recovery and have many unmet needs. The infrastructure and standards of care are poor in colonial-period mental hospitals, with no clear pathways to discharge and reintegration into the community. Despite concerns over quality of care and human rights violations these hospitals continue to provide the majority of mental health care for SMD in most LMICs. LMICs need a pragmatic approach to implementing mental health, with evidence-based reforms of psychiatric institutions to meet the needs of service users today. Objective: The aim of the research was to examine the impact of hospital reform on outcomes for long-stay patients. We compared whether larger structural and process reform of a mental hospital brings about change in patient outcomes or a case management based individual service package is needed to effectively translate larger hospital reform into discernible difference in outcomes for long-stay patients often living in closed hospital wards. Methods: This research study comprised three interlinked phases in a mixed methods design. In phase one, a systematic literature review was undertaken to examine evidence on psychiatric hospital reform in LMICs. Phase two comprised a pragmatic randomised clinical trial, called Structured Individualised inTervention And Recovery (SITAR), to study the impact of psychiatric hospital reform. The trial also aimed to study the modality in which reform would reach the service user. SITAR used Need-Based Intensive Case Management (NB-ICM) within the context of the hospital. ’Patients’ experiences of reform were also studied using qualitative methodology. In the third phase, an economic evaluation was undertaken to study the affordability of psychiatric hospital reform as a viable care pathway for very vulnerable people who are long-stay in psychiatric hospitals. Results: Systematic psychiatric hospital reform has a positive impact on outcomes of disability, symptom, social and occupational functioning, and quality of life. NB-ICM has an important role to play in terms of patient’s lived experience of reformed care, it however, did not show a significant impact on measured outcomes in the time period of the study. Conclusion: Systematic reform of psychiatric hospitals appears feasible and affordable and might be an important alternative to the limited care pathways for people with Severe Mental Disorders who have high care needs in LMICs

From schizophrenia to sainthood : Tajuddin Fakir

This paper discusses the case of Tajuddin, a patient in the mental asylum of Nagpur towards the end of the 19th century. Discussions are based on hospital records and annual reports and relevant literature review of the life and times of Tajuddin. Hospital and associated records indicate that Tajuddin was thought to be suffering from cannabis psychosis. He was released from the British army for inappropriate behaviour and was admitted to the Nagpur Mental Asylum, currently a Regional Mental Hospital. During his inpatient stay Tajuddin was believed to have special powers and was considered a saint. The hospital, its staff and patients continue to pay homage to Tajuddin to this day. Religious Trusts established in his name extend all the way up to Mecca. His followers include high ranking officers and Bollywood celebrities. Tajuddin was a charismatic leader, despite suffering from what currently may be considered schizophrenia. His case reflects a curious contradiction of the cultural understandings of psychosis and the shifting sands on which psychiatry’s diagnostic foundations are built