South Bedfordshire Research Articles

Further development of early intervention in psychosis

Dear Editor, Much can be learnt from Singh et al.'s article1 on a 1-year naturalistic study of an early intervention service and by comparing it with other such studies. We have recently published our 3 year study of an early intervention service compared with treatment as usual. 2-4. In our study, patients managed by Early Intervention Team (EIT) based in Luton, South Bedfordshire were compared with those managed by standard Community Mental Heath Teams in the rest of Bedfordshire. We too have found important statistically significant differences between the two groups of patients, with the EIT having the better results. For example, in a comparison of 62 patients in either group, evenly matched by age and sex, the Early Team had better results in terms of employment and education (P = 0.09), patients continuing to live with their families (P = 0.007), having fewer readmissions to hospital (P < 0.0001) and less necessity to use the mental health act (P = 0.004). We feel that contributing factors to these results were the fact that by 3 years, the patients in the early intervention group were more likely to have been prescribed atypical antipsychotics, rather than typicals, including depot injections (P < 0.001), more likely to comply with taking medication (P = 0.015) and were more likely than the treatment as usual group to have received systematic psycho-education or other psychosocial interventions, including knowing how to identify early warning signs of relapse, acting upon these signs and occasional family interventions. Unlike Singh et al., we were able to demonstrate success in persuading patients in the Early Intervention Service (EIS) to stop using illicit drugs, particularly cannabis (P = 0.003), and we attribute this success to our systematic use of psycho-education. Unlike Singh et al., we did not have an employment specialist within the EI team, and therefore, we attribute our success in returning patients to work or education, sometimes despite some ongoing positive symptoms, to the quality of the assertive case management provided by the team. We wholeheartedly support one important observation of Singh et al. that of the need for a ward specifically designed for patients with a first or early episode of psychosis. The provision of such a ward is the most likely way to enable patients with a first episode of psychosis to receive inpatient treatment which is appropriate to their age group and their condition in the most appropriate way possible, so that these patients are more likely to engage with mental health services, and it is clear that such a ward is a presupposition of the IRIS guidelines,5 which were the starting point of the early intervention movement in the UK. Unfortunately, the policy implementation guide for EITs in England does not mention inpatient units, so that new commissioning money for Early Intervention is usually focused on Community Teams, but many first episodes of psychosis are initially treated in hospital. Despite the lack of specific funding, it should be possible in most cases to reconfigure inpatient services so that one ward is made available for the use of first episode patients, who could then receive age and illness specific interventions. Equally, we agree with Singh et al. that it is also our experience that an EIS which is based on a team which assertively follows up patients who have had a first psychotic episode for 3 years will not be able to reduce the duration of untreated psychosis, but that in order to achieve this result, a specific early detection team needs to be set up running parallel to the main EI team. Therefore, in agreement with Singh et al., we suggest that a complete EIS, as is the case with the archetypal service EPPIC,6 needs to be ‘multimodular’, containing at least the following interrelated modules; an Assertive Community Treatment Team, an Early Detection and Home treatment team and an Early Intervention inpatient ward. Not all of this need be funded by new money, but rather by an imaginative re-deployment of resources. A final point needs to be raised; Singh et al. report that substantial numbers of first episode patients were not referred to their service. It is essential that EISs must be funded adequately so that all patients in their catchment area who are experiencing a first psychotic episode can be accommodated in this service. Unfortunately in the case of ETHOS and our own service, this is often not the case. It is essential that adequate funding is made available to ensure that all patients receive the benefits of this treatment model. If this is not the case, our success will be overshadowed with intolerable issues of equity and fair and adequate treatment, which will make further development of Early Intervention in Psychosis in the UK fraught with insoluble difficulties.

Randomised Comparative Trial of the Levonorgestrel Intrauterine System and Mefenamic Acid for the Treatment of Idiopathic Menorrhagia: A Multiple Analysis Using Total Menstrual Fluid Loss, Menstrual Blood Loss, and Pictorial Blood Loss Assessment Charts

This paper presents a comparison of 2 management strategies for idiopathic menorrhagiathe levonorgestrel intrauterine system (LNG IUS) and the more commonly used oral mefenamic acid. The LNG IUS is a progesterone-impregnated intrauterine device that has been shown to reduce menstrual blood loss (MBL). Study subjects were chosen from 391 women who presented to The Luton and Dunstable Hospital NHS Trust in South Bedfordshire, U.K., between May 1996 and December 1998 with the complaint of heavy menstrual bleeding. Enrollment was offered to healthy women age 18 to 47 with menorrhagia, defined as menstrual blood loss of 80 mL or more in one cycle confirmed by the modified alkaline-hematin technique. Each subject maintained a menstrual diary and completed a pictorial blood loss assessment chart (PBAC) within 4 months of starting the trial. In addition, study subjects participated in an objective assessment of total menstrual fluid loss (TMFL), which involved measuring the increase in weight of all tampons and sanitary napkins used in one menstrual cycle. Fifty-one women met all inclusion criteria and were randomized to receive 500 mg oral mefenamic acid 3 times daily on days 1 to 4 of the menstrual cycle (n = 26) or to have insertion of an LNG IUS containing 52 mg levonorgestrel released at 20 μg per 24 hours (n = 25). The study period for each treatment method was 6 cycles. Overall, MBL, TMFL, and PBAC scores improved significantly for both treatment groups. However, compared with those in the mefenamic acid group, women in the LNG IUS group had significantly lower blood loss on all 3 measurements at each evaluation point of the study period (P >.001 for all). Improvements in scores for MBL, TMFL, and PBAC were significantly correlated over the study period (P <.001 for the correlation between MBL and TMFL, P =.0007 for correlation of MBL and PBAC, and P = 0002 for correlation of TMFL and PBAC). Overall, women with the LNG IUS experienced more adverse events, 2 of which were serious, over the course of the study than did women in the mefenamic acid group (158 vs 84). In one patient who developed severe hypertension, the LNG IUS was discovered in the endocervical canal and removed after 55 days. In a second woman, the LNG IUS was expelled after successful treatment for chlamydial endometritis.

Case in focus: Congenital cataracts – inappropriate surgery – sympathetic ophthalmia – blindness. NB v South Bedfordshire Health Authority

Case in focus: Congenital cataracts – inappropriate surgery – sympathetic ophthalmia – blindness. <i> NB v South Bedfordshire Health Authority</i>

Neonatal group B streptococcal infection in South Bedfordshire, 1993–1998

BACKGROUNDGroup B streptococcus (GBS) is now the leading cause of neonatal bacterial sepsis in the western world. The incidence of GBS infection in the United States has been determined, and...

Changing to ‘new style’ antenatal care

This study describes the effects of introducing ‘new style’ antenatal care into South Bedfordshire; a reduced schedule of routine visits and an increased emphasis on community care. During the planning stage, professionals and new mothers were consulted. Guidelines for antenatal care were jointly developed by midwives, GPs and obstetricians. A significant reduction was achieved in the mean number of antenatal visits from 11.7 to 10 after the new system had been in operation for 21 months. Mothers' acceptance of the reduced visits schedule was low, but increased after it had been introduced. Initially, 80% of women were against the change; later this propotion had fallen to 46%. The care of women who developed hypertension in pregnancy was also audited; the proportion of women who managed according to the guidelines increased from 58% to 93% in those with borderline raised blood pressure, and from 57% to 95% in those with diastolic pressures above 100mmHg.

Clinical audit and effective change in leg ulcer services.

An audit of clinical leg ulcer services was undertaken in South Bedfordshire and was followed by a process of implementation using research-based methods; a re-audit was conducted 18 months later. Using an adaptation of the Riverside model, patients were referred to community leg ulcer clinics. They were assessed using Doppler ultrasound; those with ABPI >0.8 were treated using a high-compression four-layer bandage system. Those with ABPI 0.6-0.8 were treated using reduced compression, and those with ABPI <0.6 were sent to their GP for referral for specialist opinion. In October 1993, the average cost of consumables for each patient was £8.53, and this rose to £10.14 in May 1995. However, patients treated in community clinics had a reduced cost of consumables of £7.91 compared with £10.78 for patients treated at home. There was also a corresponding reduction in weekly treatments and an overall reduction in nursing time to treat patients. In 111 patients (134 limbs) treated by high compression in the community clinics, cumulative percentage healing was 54% after 12 weeks and 68% after 24 weeks. Although these results were lower than those achieved in the Riverside project, much of the difference can be explained by the different patient populations and ulcer duration. The results support a system of care which offers rationalisation of service, staff training and research-based effective assessment and treatment.

Correlation of the Lower Greensand Group (Woburn Sands and Carstone) of the Bedfordshire Province, England

The late Aptian-early Albian Lower Greensand Group of the Bedfordshire Province is a series of sands with minor sandstone, silt, clay and ironstone. The sequence includes shallow, nearshore, strongly tidally-influenced sands, sandwaves and localized estuarine sands (channel and sandbar). A detailed correlation of the deposit across southern England from Buckinghamshire to Norfolk has shown two distinct depositional areas, the Bedford and Norfolk Basins. Detailed study has also made the recognition of a more refined subdivision possible, which comprises four units. Correlation techniques were varied and include assessing the gamma-ray signature of the subdivisions of the Lower Greensand. New palynological evidence, together with the sedimentological study, further refines the environment of deposition of the sands in the south Bedfordshire area to be that of an estuary mouth. The estuarine and the marine environment alternate in dominance in different parts of the succession. This interpretation goes some way in explaining the different character of the Lower Greensand in Bedfordshire compared to the rest of southern England. A new interpretation of the controls on sedimentation in this area during the late Aptian-early Albian is possible using the new refined stratigraphic subdivision. This shows that in addition to environmental factors there is a relationship between basement structure and the sedimentary character of the Lower Greensand.

Tissue Viability Society. Auditing a leg ulcer service.

A new service for leg ulcer patients has been established in South Bedfordshire. Christine Moffatt describes how the service is being audited and is an example of quality nursing care changing health outcomes for patients

Childless women revisited. South Bedfordshire Practitioners' Group.

Childless women revisited. South Bedfordshire Practitioners' Group.

A prospective study of otitis externa.

A prospective study of otitis externa in the district of South Bedfordshire was undertaken between October 1990 and January 1991. Patients were referred untreated by general practitioners; self-referred patients with external otitis were also included. A detailed history was taken, the severity of the condition assessed, aural toilet performed, bacteriology swabs taken and the patient treated according to department protocol. 48 patients were included in the study; a similar number of age and sex-matched controls without otitis externa were randomly selected from the ENT outpatient clinics for comparison. Regular swimming emerged as a significant factor in the aetiology of otitis externa. The commonest organism cultured was Pseudomonas aeruginosa and this accounted for the most severe cases seen.

Development of renal scars in children: missed opportunities in management. South Bedfordshire Practitioners' Group.

To assess the antecedent medical care of children with renal scars. Retrospective study of both general practice and hospital records. 12 Group practices in south Bedfordshire and the radiology and paediatric outpatient departments of a district general hospital. 23 Children with renal scars (six boys, 17 girls) from the 12 group practices, identified from outpatient, radiology, and general practice records. Number of children in whom a diagnosis of urinary tract infection had been made without prior examination of a mid-stream specimen of urine; number of children who had had a confirmed urinary tract infection that had not been investigated further; number who had experienced delays in investigation or referral; and number who had received inadequate follow up. In all, 11 of the children had received suboptimal medical care, but the management of the other 12 could not have been better. The most common error was failure to investigate possible urinary tract infections, but follow up of confirmed infections was also inadequate. These problems occurred in hospital as well as in general practice. Opportunities for intervention had been missed in nearly half of this sample of children with renal scars.

The law on doctors speaking out.

Gillian Cardy, a senior clinical medical officer with Bath District Health Authority who was suspended from her duties on 16 December for speaking to the press about planned cuts in family planning services, was reinstated on 8 January after a health authority hearing. At the subsequent meeting of the health authority on 13 January a motion was passed expressing regret at the recent distressing events concerning Dr Cardy and appre? ciation for her work. She had spoken out about plans to cut back the work of family planning clinics and close well women clinics, which, she said, would lead to more unwanted pregnancies. In January last year David Josephs, director of community medicine for South Bedfordshire Health Authority, was suspended for 10 weeks pending a disciplinary hearing after he spoke to the press, and on radio and television, despite instructions from his district general manager to stay silent. Dr Josephs said that stories in the press misquoted him on proposals for schoolchildren to be given condoms to protect them from AIDS and that his subsequent talking with the press was simply an attempt to put the record straight. Dr Josephs was reinstated with a formal written warning for managerial misconduct after a disciplinary hearing that also included a charge that he had leaked a confidential paper about measures to prevent AIDS to the director of social services of the local authority and chief environmental health officers, which he said was sent to professional colleagues for comment under a covering letter marked confidential. He sought leave to appeal against the written warning to the regional health authority on the grounds that there had been a gross miscarriage of justice, but this was refused.

Limited resource.

Barbara Kettley, a nurse working with South Bedfordshire's Macmillan Service, believes that Macmillan Nurses should be a resource for other health professionals and should not be used simply as an emergency service. As an ex-District Nurse herself, she also understands how rewarding it can be for district nurses to care for dying patients at home. 'You have to realise that district nurses are fully trained and competent and that caring for the dying patient at home is one of the most rewarding parts of their job'.

Quality in life — a safety campaign

A SAFETY campaign linking an environmental health department and a crime prevention panel had a discernible effect on the elderly population of South Bedfordshire. Widespread co-operation is felt to be essential to the success of similar ventures, and effort should be devoted to taking the messages to the target audience.

Property in Land in South Bedfordshire, 1750-1832.

Property in Land in South Bedfordshire, 1750-1832.

III.—Notes on the Geology of South Bedfordshire

The District included under the term “South Bedfordshire” is that which lies between the escarpment of the Lower Greensand and the extreme southern limit of the county. Within this area the portion that has been most closely examined is that through which the Midland Railway passes, every excavation of which has been visited, in many cases frequently, both during the construction of the line, and also subsequently.

Palæolithic Implements from the Hills near Dunstable

DURING the past twelve months I have found a small number of Palæolithic implements at great elevations in North Hertfordshire and South Bedfordshire, unconnected with existing river valleys. Four of the implements—1386, 1387, 1393, and 1398 in my collection—are from Caddington: height above Ordnance datum, 595 feet 9 inches. The dry valley close by, to the west, is 470 feet, and the ground gradually falls southwards to 409 feet at the source of the Ver, near Markyate Street, at a distance of 1 3/4 mile. The sections at Caddington exhibit red “clay with flints,” brick earth (or clay), and tenacious brown clay or loam, surmounted by blackish earth, containing broken white-coated flints, a few ochreous flints, and numerous blackish Tertiary pebbles. The whole deposit rests on chalk, and varies in depth from 2 feet to 50 feet. Aware of the importance of finding the worked flints in the undisturbed material, I have, after long searching, found a single implement and one or two flakes in situ at the stony bottom of the upper deposit of tenacious brown clay at a depth of 3 and 4 feet from the surface. A single small Palæolithic implement I have found on the surface at Kensworth: height above Ordnance datum, 759 feet 8 inches. The bottom of the valley, 1¼ mile to the west, at the source of the Ouzel, is 414 feet. Half an ovate Palæolithic implement, obviously derived from the hill-tops, I have found in a field at the bottom of a chalky valley near Houghton Regis. The Caddington implements are pointed (or tongue-shaped), slightly abraded, small in size, and cinnamon-brown in colour. The interest attached to these finds rests not only on the great heights mentioned and the positions away from existing river valleys, but in the nature, age, and mode of deposit of the upper tenacious brown clay in which the implements are embedded. The implements themselves agree in make and appearance with the well-known brown or ochreous implements often found in non-ochreous sand, &c., in existing river valleys. I have at present seen no traces of fossil bones or fresh-water shells in the deposits mentioned.

V.—Notes on the Geology of South Bedfordshire

The Geology of South Bedfordshire is now being exhibited more fully than hitherto, as the extension of the Midland Railway from Bedford to London is opening up a series of sections in the newer Seconday rocks which characterise this part of the county. The following notes were chiefly taken during a walk made last summer along the line, between the towns of Bedford and St. Alban's (Herts). For the first few miles the excavations are slight, and exhibit only the Drift sands and gravels of the rich valley of the Ouse, though these are well worthy of careful examination for flint implements and mammalian remains, which have been discovered on the north side of the river, at Biddenham, by J. Wyatt, Esq. About three miles from Bedford is an excavation in the Oxford clay; the upper portion is dark brown merging into dark blue beneath, and it abounds in fossil wood in various stages of carbonization, the colour of which ranges from brown to jet black; it is so abundant in places that some of the excavators fancied they were coming upon a coal-mine.