Mental health in general practice: GP perspectives and exploration of a clinical psychology pilot initiative

Abstract Background: GPs provide a high proportion of consultations for patients presenting with mental health difficulties; however, they have little formal training in this area. Aims: To explore the existing literature concerning GPs’ experience of working with patients presenting with mental health difficulties, particularly focussing on GPs’ emotional responses. Method: PsycINFO, Medline, EMBASE, CINAHL, Scopus and EThOS were searched. Key inclusion criteria included: conducted in a UK setting; no earlier than 2004. After screening by title, abstract and full paper, common themes across studies were generated through narrative analysis. Quality was appraised using the Critical Appraisal Skills Programme for qualitative research checklist. Results: Fifteen articles were included in the analysis. Common themes included feelings of uncertainty and anxiety, perceived professional incompetence and disempowerment, scepticism and dread, hopelessness, frustration, and burden and responsibility. Methodological limitations in both the reviewed literature and current review are highlighted for context. Conclusions: GPs appear to experience working with patients presenting with mental health difficulties as testing. In light of the current proportion of GP workload that relates to mental health, this is concerning. Support may be provided through improved communication and collaboration with specialist services, as well as enhanced training

Exploring the third delay: an audit evaluating obstetric triage at Mulago National Referral Hospital

BACKGROUND: Mulago National Referral Hospital has the largest maternity unit in sub-Saharan Africa. It is situated in Uganda, where the maternal mortality ratio is 310 per 100,000 live births. In 2010 a ‘Traffic Light System’ was set up to rapidly triage the vast number of patients who present to the hospital every day. The aim of this study was to evaluate the effectiveness of the obstetric department’s triage system at Mulago Hospital with regard to time spent in admissions and to identify urgent cases and factors adversely affecting the system. METHODS: A prospective audit of the obstetric admissions department was carried out at the Mulago Hospital. Data were obtained from tagged patient journeys using two data collection tools and compiled using Microsoft Excel. StatsDirect was used to compose graphs to illustrate the results. RESULTS: Informal triage was occurring 46 % of the time at the first checkpoint in a woman’s journey, but the ‘Traffic Light System’ was not being used and many of the patient’s vital signs were not being recorded. CONCLUSIONS: It is hypothesised that the ‘Traffic Light System’ is not being used due to its focus on examination finding and diagnosis, implying that it is not suitable for an early stage in the patient’s journey. Replacing it with a simple algorithm to categorise women into the urgency with which they need to be seen could rectify this

Structured professional judgment to assist the evaluation and safety planning of suicide risk: The Risk of Suicide Protocol (RoSP)

Background: The Risk of Suicide Protocol (RoSP) is a structured professional judgment (SPJ) scheme designed in line with NICE guidelines to improve clinicians' ability to evaluate and manage suicide risk. Aims: This study aimed to evaluate the efficacy of RoSP in two settings: (1) unexpected deaths of people in the community who were known to mental health services; and (2) an inpatient hospital specializing in the assessment and treatment of patients with personality disorder. Method: In Study 1, information from a database of unexpected deaths (N = 68) within an NHS health board was used to complete a RoSP assessment (blind to cause of death) and information from the Coroner's Court was used to assign people to suicide vs. natural causes/accidental death. In Study 2, patients (N = 62) were assessed on the RoSP upon admission to hospital and their self-injurious behaviors were recorded over the first 3 months of admission. Results: (1) Evaluations using RoSP were highly reliable in both samples (ICCs 0.93–0.98); (2) professional judgment based on the RoSP was predictive of completed suicide in the community sample (AUC = 0.83) and; (3) was predictive of both suicide attempts (AUC = 0.81) and all self-injurious behaviors (AUC = 0.80) for the inpatient sample. Conclusion: RoSP is a reliable and valid instrument for the structured clinical evaluation of suicide risk for use in inpatient psychiatric services and in community mental health services. RoSP's efficacy is comparable to well-established structured professional judgment instruments designed to predict other risk behavior (e.g., HCR-20 and the prediction of violence). The use of RoSP for the clinical evaluation of suicide risk and safety-planning provides a structure for meeting NICE guidelines for suicide prevention and is now evidence-based

Results from the workshop “problem formulation for the use of gene drive in mosquitoes”.

CAPRISA, 2017.Abstract available in pdf

Exome sequencing identifies rare damaging variants in ATP8B4 and ABCA1 as novel risk factors for Alzheimers Disease

The genetic component of Alzheimer’s disease (AD) has been mainly assessed using Genome Wide Association Studies (GWAS), which do not capture the risk contributed by rare variants. Here, we compared the gene-based burden of rare damaging variants in exome sequencing data from 32,558 individuals —16,036 AD cases and 16,522 controls— in a two-stage analysis. Next to known genes TREM2, SORL1 and ABCA7, we observed a significant association of rare, predicted damaging variants in ATP8B4 and ABCA1 with AD risk, and a suggestive signal in ADAM10. Next to these genes, the rare variant burden in RIN3, CLU, ZCWPW1 and ACE highlighted these genes as potential driver genes in AD-GWAS loci. Rare damaging variants in these genes, and in particular loss-of-function variants, have a large effect on AD-risk, and they are enriched in early onset AD cases. The newly identified AD-associated genes provide additional evidence for a major role for APP-processing, Aβ-aggregation, lipid metabolism and microglial function in AD

The Calcium Oscillator of GnRH-1 Neurons Is Developmentally Regulated

Oscillations in intracellular calcium levels have been described in GnRH-1 neurons in both prenatal and adult cells. However, differences have been reported in the mechanisms underlying these [Ca2+]i oscillations, dependent on the model used. The goal of this study was to address whether these changes depend on the maturation status of GnRH-1 neurons by assaying prenatal GnRH-1 cells maintained in explants, at two different developmental stages. This report documents an increase in the frequency of [Ca2+]i oscillations between 1 and 3 wk of in vitro maturation. During the early stage, [Ca2+]i oscillations are blocked by tetrodotoxin and are mainly triggered by excitatory neurotransmitters, γ-aminobutyric acid (GABA), and glutamate. In contrast, in the later stage, some cells exhibit residual tetrodotoxin-insensitive [Ca2+]i oscillations, which are sustained by action potential-independent GABA and glutamate release. The strength of these two excitatory inputs remained relatively constant during the maturation process, and the increase in frequency of [Ca2+]i oscillations observed at the later stage is due to a novel excitatory input carried by cholecystokinin. Together, these data indicate developmentally regulated release and interactions of neurotransmitters (known regulators of GnRH-1 cells in adults) and point to extrinsic factors regulating GnRH-1 cellular physiology

Exome sequencing identifies rare damaging variants in ATP8B4 and ABCA1 as risk factors for Alzheimer's disease

Alzheimer's disease (AD), the leading cause of dementia, has an estimated heritability of approximately 70%(1). The genetic component of AD has been mainly assessed using genome-wide association studies, which do not capture the risk contributed by rare variants(2). Here, we compared the gene-based burden of rare damaging variants in exome sequencing data from 32,558 individuals-16,036 AD cases and 16,522 controls. Next to variants in TREM2, SORL1 and ABCA7, we observed a significant association of rare, predicted damaging variants in ATP8B4 and ABCA1 with AD risk, and a suggestive signal in ADAM10. Additionally, the rare-variant burden in RIN3,CLU,ZCWPW1 and ACE highlighted these genes as potential drivers of respective AD-genome-wide association study loci. Variants associated with the strongest effect on AD risk, in particular loss-of-function variants, are enriched in early-onset AD cases. Our results provide additional evidence for a major role for amyloid-beta precursor protein processing, amyloid-beta aggregation, lipid metabolism and microglial function in AD