With increasing longevity, the number of older schizophrenic patients is growing. Previous criteria used the age of symptom onset to differentiate between the late manifestations of early-onset schizophrenia and late-onset schizophreniform disorders. Current DSM-IV or ICD 10 nomenclatures do not differentiate between early- and late-onset schizophrenia. Many decades of repeated failures to provide for distinguishing neuropathological findings have prompted narrower definition criteria. Since psychotic or schizophreniform symptoms in old age may be a manifestation of Alzheimer's disease, we attempted to base a distinction between both early- and late-onset schizophrenia on the presence of degenerative changes. This study examined the brains of 64 schizophrenic patients and 18 controls immunocytochemically for tau and amyloid staining. We divided patients according to their ages at the onset of symptoms: <40, >40. Using Braak's classification, we assessed the presence of neurofibrillary pathology. Stages III and IV were observed in 11.1% (2/18) of controls, 36.7% (11/30) of early-onset schizophrenics (<40) and 58.8% (20/34) of late-onset (>40) schizophrenics (chi2=11.39, P =0.003). Stages V and VI (definite Alzheimer's disease) did not significantly differ among groups (chi2=3.6, P =0.165). Astrocytes, subependymal and fibroblastic, also exhibited tau-positive tangles. Chi-square analysis of the data revealed a significant association between tau-positive glial tangles and Braak staging ( P =0.002). Amyloid deposits were sparse in comparison to tau-related changes. The restricted limbic tauopathy not only affected a majority of patients with late-onset schizophrenia (19 female: 1 male among positive cases) ( P =0.048) but also appeared in one-third of those elderly schizophrenic patients whose symptom onset occurred before 40 years of age (8 female: 3 male among positive cases) ( P =0.048). The resultant changes define a type of neuronal cytoskeletal disruption that alters the flow of information through the hippocampus and provides a useful clinico-pathological correlate to a group of patients until recently diagnosed as schizophrenic.
Thirty five claimants with accident neurosis, in which there were gross perplexing somatic symptoms without demonstrable organic pathology were traced and followed-up in their homes, from one to seven years after compensation was received. Few claimants recovered and such recovery as did take place was unrelated to the time of compensation. Family processes leading to over-protection by relatives were examined and appeared to be vitally important in the prolongation of symptoms. The legal process and the delays involved caused great distress.
Background Hospital antimicrobial stewardship (AMS) programmes are multidisciplinary initiatives to optimize antimicrobial use. Most hospitals depend on time-consuming manual audits to monitor clinicians’ prescribing. But much of the information needed could be sourced from electronic health records (EHRs). Objectives To develop an informatics methodology to analyse characteristics of hospital AMS practice using routine electronic prescribing and laboratory records. Methods Feasibility study using electronic prescribing, laboratory and clinical coding records from adult patients admitted to six specialities at Queen Elizabeth Hospital, Birmingham, UK (September 2017–August 2018). The study involved: (i) a review of AMS standards of care; (ii) their translation into concepts measurable from commonly available EHRs; and (iii) a pilot application in an EHR cohort study (n = 61679 admissions). Results We developed data modelling methods to characterize antimicrobial use (antimicrobial therapy episode linkage methods, therapy table, therapy changes). Prescriptions were linked into antimicrobial therapy episodes (mean 2.4 prescriptions/episode; mean length of therapy 5.8 days), enabling several actionable findings. For example, 22% of therapy episodes for low-severity community-acquired pneumonia were congruent with prescribing guidelines, with a tendency to use broader-spectrum antibiotics. Analysis of therapy changes revealed IV to oral therapy switching was delayed by an average 3.6 days (95% CI: 3.4–3.7). Microbial cultures were performed prior to treatment initiation in just 22% of antibacterial prescriptions. The proposed methods enabled fine-grained monitoring of AMS practice down to specialities, wards and individual clinical teams by case mix, enabling more meaningful peer comparison. Conclusions It is feasible to use hospital EHRs to construct rapid, meaningful measures of prescribing quality with potential to support quality improvement interventions (audit/feedback to prescribers), engagement with front-line clinicians on optimizing prescribing, and AMS impact evaluation studies.
There are an increasing number of people living with dementia in care home settings. Recent reports suggest that people who deliver care to residents living with dementia in care homes require specialist support to provide optimum care. To address this need Four Seasons Health Care, the largest provider of care homes within the UK today, sought to design a dementia care framework that enhanced the quality of life for people living with dementia in their care homes. The framework was designed using a robust evidence base, engagement with people living with dementia, their care partners, policy-writers, multi-disciplinary professionals and people within the organization. This paper describes the methodology behind the dementia care framework and outcomes data from the first phase (of 20 care homes that included the care of 451 people living with dementia). The main outcome of was a significant improvement in the quality of the lives of residents across biological, psychological, social and spiritual needs.
more important to service users than their psychiatrists, this does not tell us what happens in practice. The real question which we should be asking is to service users themselves and how they feel religion has been accounted for in treatment. I worry that the answers might be even more demoralising. Taking a spiritual history is both an easy and important task to be undertaken by any professional. It can substantially help a service user feel understood and hence engaged in treatment. The Spirituality Special Interest Group provides several tools which should surely become routine practice for all mental health professionals, at the very least in screening (www.rcpsych.ac.uk/PDF/ DrSEaggeGuide.pdf). The suggestion of prayer with service users is a troubling one with the potential to lead to transgression of boundaries through sharing such an intimate act. It leads to duplicity of the psychiatrist's role, erosion of the purpose of treatment and in my mind is best avoided.
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