The effect of intensive case management on the relatives of patients with severe mental illness

Objective: Relatives play a vital role in caring for patients with severe mental illness but receive inadequate support from psychiatric services. Evidence suggests that although intensive case management is directed primarily at patients, relatives may benefit a's well. This study examined whether relatives of patients who were receiving intensive case management had more contact with mental health professionals than relatives of patients who were receiving standard case management. It also examined whether relatives of patients receiving intensive case management appraised caregiving less negatively and experienced less psychological distress than relatives of patients receiving standard case management. Methods: The sample was drawn from the pool of patients participating in the UK700 randomized controlled trial of intensive case management. Prospective data on contact between case managers and the relatives of 146 patients were collected over a two-year period. At a two-year follow-up assessment, relatives of 116 patients were. interviewed with the Experience of Caregiving Inventory and the 12-item General Health Questionnaire. Results: Considerably more relatives of patients receiving intensive case management had contact with a case manager during the study period than relatives of patients receiving standard case management (70 percent compared with 45 percent). However, relatives of patients receiving intensive case management did not-appraise caregiving less negatively or experience less psychological distress than relatives of patients who were receiving. standard case management. Conclusions: Reducing case managers' caseloads alone. will not guarantee adequate support for relatives.. Instead, providing more support will need to be an explicit aim, and staff will require specific additional training to achieve it.

Uptake of a free coronary heart disease risk screening programme in community pharmacy: the Healthy Heart Assessment service

Introduction Health promotion (HP) aims to enhance good health while preventing ill-health at three levels of activity; primary (preventative), secondary (diagnostic) and tertiary (management).1 It can range from simple provision of health education to ongoing support, but the effectiveness of HP is ultimately dependent on its ability to influence change. HP as part of the Community Pharmacy Contract (CPC) aims to increase public knowledge and target ‘hard-to-reach’ individuals by focusing mainly on primary and tertiary HP. The CPC does not include screening programmes (secondary HP) as a service. Coronary heart disease (CHD) is a significant cause of morbidity and mortality in the UK. While there is evidence to support the effectiveness of some community pharmacy HP strategies in CHD, there is paucity of research in relation to screening services.2 Against this background, Alliance Pharmacy introduced a free CHD risk screening programme to provide tailored HP advice as part of a participant–pharmacist consultation. The aim of this study is to report on the CHD risk levels of participants and to provide a qualitative indication of consultation outcomes. Methods Case records for 12 733 people who accessed a free CHD risk screening service between August 2004 and April 2006 offered at 217 community pharmacies were obtained. The service involved initial self-completion of the Healthy Heart Assessment (HHA) form and measurement of height, weight, body mass index, blood pressure, total cholesterol and highdensity lipoprotein levels by pharmacists to calculate CHD risk.3 Action taken by pharmacists (lifestyle advice, statin recommendation or general practitioner (GP) referral) and qualitative statements of advice were recorded, and a copy provided to the participants. The service did not include follow-up of participants. All participants consented to taking part in evaluations of the service. Ethical committee scrutiny was not required for this service development evaluation. Results Case records for 10 035 participants (3658 male) were evaluable; 5730 (57%) were at low CHD risk (<15%); 3636 (36%) at moderate-to-high CHD risk (≥15%); and 669 (7%) had existing heart disease. A significantly higher proportion of male (48% versus 30% female) participants were at moderate- to-high risk of CHD (chi-square test; P < 0.005). A range of outcomes resulted from consultations. Lifestyle advice was provided irrespective of participants’ CHD risk or existing disease. In the moderate-to-high-risk group, of which 52% received prescribed medication, lifestyle advice was recorded for 62%, 16% were referred and 34% were advised to have a re-assessment. Statin recommendations were made in 1% of all cases. There was evidence of supportive and motivational statements in the advice recorded. Discussion Pharmacists were able to identify individuals’ level of CHD risk and provide them with bespoke advice. Identification of at-risk participants did not automatically result in referrals or statin recommendation. One-third of those accessing the screening service had moderate-to-high risk of CHD, a significantly higher proportion of whom were men. It is not known whether these individuals had been previously exposed to HP but presumably by accessing this service they may have contemplated change. As effectiveness of HP advice will depend among other factors on ability to influence change, future consultations may need to explore patients’ attitude towards change in relation to the Trans Theoretical Model4 to better tailor HP advice. The high uptake of the service by those at moderate-to-high CHD risk indicates a need for this type of screening programme in community pharmacy, perhaps specifically to reach men who access medical services less.

Experiences with sustainability indicators and stakeholder participation: A case study relating to a 'Blue Plan' project in Malta

The practical application of systemic sustainability analysis (SSA; Bell and Morse, 1999) as applied in-a project instigated and managed by 'Blue Plan', one of the regional activity centres of the Mediterranean Action Plan, is set out and explained in this paper. The context in which SSA was applied and adapted to SPSA (systemic and prospective sustainability analysis). is described in the Mediterranean, primarily in Malta. The SSA process is summarized, its extension and linkage to the prospective approach is described and the comments of stakeholders in the context are added. Some preliminary outcomes are suggested. The pauticular focus of the paper is on the lessons learned from doing SSA/SPSA within a classic blueprint project framework. It is-not assumed that SSA/SPSA is 'finished' or 'definitive'. Rather, we suggest that it is a developing and changing approach that practitioners can adapt and change to meet the specific needs of the circumstances that confront them. Copyright (C) 2004 John Wiley & Sons, Ltd and ERP Environment.

The sequential analysis of repeated binary responses: a score test for the case of three time points

In this paper a robust method is developed for the analysis of data consisting of repeated binary observations taken at up to three fixed time points on each subject. The primary objective is to compare outcomes at the last time point, using earlier observations to predict this for subjects with incomplete records. A score test is derived. The method is developed for application to sequential clinical trials, as at interim analyses there will be many incomplete records occurring in non-informative patterns. Motivation for the methodology comes from experience with clinical trials in stroke and head injury, and data from one such trial is used to illustrate the approach. Extensions to more than three time points and to allow for stratification are discussed. Copyright © 2005 John Wiley & Sons, Ltd.

Introducing assistive technology into the existing homes of older people: Feasibility, acceptability, costs and outcomes

We examined how far, and at what cost, the housing stock could be modified to accommodate the assistive technology (AT) necessary to enable older people to remain in their own homes. A multidisciplinary team devised seven hypothetical user profiles for 10 case study areas, with five local authorities and five housing associations in England and Wales. Each profile was considered at two times, five years apart, with the users' functional abilities deteriorating in between. In addition, in-depth interviews were carried out with a sample of 67 older people in the case study areas about their use and experience of a wide range of AT. The interviews showed the need to listen to older people and that they welcomed AT when it addressed a perceived need. The results showed that the extent of adaptation required of buildings to accommodate a user's needs varied greatly. It was also found that there was confusion about the terminology of AT, including the idea of the 'smart house'. The study shows that the adaptability of the housing depends on a range of factors and costs.

Case Study: Interacting with Volumetric Medical Datasets in Networked CAVE Environments

Virtual Reality (VR) is widely used in visualizing medical datasets. This interest has emerged due to the usefulness of its techniques and features. Such features include immersion, collaboration, and interactivity. In a medical visualization context, immersion is important, because it allows users to interact directly and closelywith detailed structures in medical datasets. Collaboration on the other hand is beneficial, because it gives medical practitioners the chance to share their expertise and offer feedback and advice in a more effective and intuitive approach. Interactivity is crucial in medical visualization and simulation systems, because responsiveand instantaneous actions are key attributes in applications, such as surgical simulations. In this paper we present a case study that investigates the use of VR in a collaborative networked CAVE environment from a medical volumetric visualization perspective. The study will present a networked CAVE application, which has been built to visualize and interact with volumetric datasets. We will summarize the advantages of such an application and the potential benefits of our system. We also will describe the aspects related to this application area and the relevant issues of such implementations.

Dynamic virtual environments using really simple syndication

This paper investigates the use of really simple syndication (RSS) to dynamically change virtual environments. The case study presented here uses meteorological data downloaded from the Internet in the form of an RSS feed, this data is used to simulate current weather patterns in a virtual environment. The downloaded data is aggregated and interpreted in conjunction with a configuration file, used to associate relevant weather information to the rendering engine. The engine is able to animate a wide range of basic weather patterns. Virtual reality is a way of immersing a user into a different environment, the amount of immersion the user experiences is important. Collaborative virtual reality will benefit from this work by gaining a simple way to incorporate up-to-date RSS feed data into any environment scenario. Instead of simulating weather conditions in training scenarios, actual weather conditions can be incorporated, improving the scenario and immersion.

VERA: virtual environment for research in archaeology

The VERA (Virtual Environment for Research in Archaeology) project is based on a research excavation of part of the large Roman town at Silchester, which aims to trace the site's development from its origins before the Roman conquest to its abandonment in the fifth century A.D. [1]. The VERA project aims to investigate how archaeologists use Information Technology (IT) in the context of a field excavation, and also for post-excavation analysis. VERA is a two-year project funded by the JISC VRE 2 programme that involves researchers from the University of Reading, University College London, and York Archaeological Trust. The overall aim of the project is to assess and introduce new tools and technologies that can aid the archaeological processes of gathering, recording and later analysis of data on the finds and artefacts discovered. The researchers involved in the project have a mix of skills, ranging from those related to archaeology, and computer science, though to ones involving usability and user assessment. This paper reports on the status of the research and development work undertaken in the project so far; this includes addressing various programming hurdles, on-site experiments and experiences, and the outcomes of usability and assessment studies.

Virtual reality Post Traumatic Stress Disorder (PTSD) exposure therapy results with active duty Iraq war combatants

Post Traumatic Stress Disorder (PTSD) is reported to be caused by traumatic events that are outside the range of usual human experience including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Initial data suggests that at least 1 out of 6 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality (VR) delivered exposure therapy for PTSD has been used with reports of positive outcomes. The aim of the current paper is to present the rationale and brief description of a Virtual Iraq PTSD VR therapy application and present initial findings from its use with PTSD patients. Thus far, Virtual Iraq consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern VR contexts for exposure therapy, including a city and desert road convoy environment. User-centered design feedback needed to iteratively evolve the system was gathered from returning Iraq War veterans in the USA and from a system deployed in Iraq and tested by an Army Combat Stress Control Team. Results from an open clinical trial at San Diego Naval Medical Center of the first 18 treatment completers indicate that 14 no longer meet PTSD diagnostic criteria at post-treatment, with only one not maintaining treatment gains at 3 month follow-up. Clinical tests are also currently underway at Ft. Lewis, Emory University, Weill Cornell Medical College, Walter Reed Army Medical Center and 10 other sites. Other sites are preparing to use the application for a variety of PTSD and VR research purposes.

Virtual reshaping and invisibility in obstacle scattering

We consider reshaping an obstacle virtually by using transformation optics in acoustic and electromagnetic scattering. Among the general virtual reshaping results, the virtual minification and virtual magnification in particular are studied. Stability estimates are derived for scattering amplitude in terms of the diameter of a small obstacle, which implies that the limiting case for minification corresponds to a perfect cloaking, i.e., the obstacle is invisible to detection.

Uncertainty and feasibility studies: an Italian case study

Uncertainty affects all aspects of the property market but one area where the impact of uncertainty is particularly significant is within feasibility analyses. Any development is impacted by differences between market conditions at the conception of the project and the market realities at the time of completion. The feasibility study needs to address the possible outcomes based on an understanding of the current market. This requires the appraiser to forecast the most likely outcome relating to the sale price of the completed development, the construction costs and the timing of both. It also requires the appraiser to understand the impact of finance on the project. All these issues are time sensitive and analysis needs to be undertaken to show the impact of time to the viability of the project. The future is uncertain and a full feasibility analysis should be able to model the upside and downside risk pertaining to a range of possible outcomes. Feasibility studies are extensively used in Italy to determine land value but they tend to be single point analysis based upon a single set of “likely” inputs. In this paper we look at the practical impact of uncertainty in variables using a simulation model (Crystal Ball ©) with an actual case study of an urban redevelopment plan for an Italian Municipality. This allows the appraiser to address the issues of uncertainty involved and thus provide the decision maker with a better understanding of the risk of development. This technique is then refined using a “two-dimensional technique” to distinguish between “uncertainty” and “variability” and thus create a more robust model.

Virtual reality Post Traumatic Stress Disorder (PTSD) exposure therapy results with active duty OIF/OEF service members

Posttraumatic stress disorder (PTSD) is reported to be caused by exposure to traumatic events including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Initial data suggest that at least 1 out of 6 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual reality (VR) delivered exposure therapy for PTSD has been used with reports of positive outcomes. The aim of the current paper, is to present the rationale and brief description of a Virtual Iraq/Afghanistan PTSD VR therapy application and present initial findings from its use with PTSD patients. Thus far, Virtual Iraq/Afghanistan consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern VR contexts for exposure therapy, including a city and desert road convoy environment. User-centered design feedback, needed to iteratively evolve the system, was gathered from returning Iraq War veterans in the USA and from a system deployed in Iraq and tested by an Army Combat Stress Control Team. Results from an open clinical trial at San Diego Naval Medical Center of the first 20 treatment completers indicate that 16 no longer met PTSD screening criteria at post-treatment, with only one not maintaining treatment gains at 3 month follow-up.

The treatment of mental contamination: a case series

The recommended treatment for obsessive-compulsive disorder (OCD) is cognitive behavior therapy (CBT) incorporating exposure and response prevention (ERP), which is effective for approximately 50% of patients. However, there has been little advance in treatment outcomes since the introduction of ERP in 1979. It has been suggested that some progress can be made in treating contamination obsessions and washing compulsions by addressing feelings of dirtiness and contamination that arise without physical contact with a tangible contaminant. To date, the treatment of these “mental contamination” fears in OCD has not been systematically explored. This paper reports on a case series of 12 participants with OCD who received 10 to 20 sessions of a CBT-based treatment for mental contamination. At the end of treatment, 7 participants no longer met the diagnostic criteria for OCD and mental contamination and these gains were maintained at 6-month follow-up. The clinical implications of these findings are discussed.

The effect of the national setting on employment practice: the case of downsizing

Although there is now a sizeable body of academic literature that tries to explain cross-country differences in terms of corporate control, capital market development, investor protection and politics, there is as yet very little literature on the degrees of protection accorded to other corporate stakeholders such as employees, based on a systematic comparison of firm level evidence. We find that both theories of legal origin and the varieties of capitalism approach are poor predictors of the relative propensity of firms to make redundancies in different settings. However, the political orientation of the government in place and even more so the nature of the electoral system are relatively good explanators of this propensity. In other words, political structures and outcomes matter more than more rigid institutional features such as legal origin. We explore the reasons for this, drawing out the implications for both theory and practice.