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OBJECTIVE: To investigate the relationship between social exclusion and outcomes of mentally ill patients with substance abuse problems receiving assertive outreach treatment in London. METHOD: Analysis was conducted on data on 580 patients from the 'Pan-London Assertive Outreach Study (PLAO)'. Data were collected using clinician-rated scales of alcohol and drug abuse in the last 6 months before baseline. Outcomes - hospitalization and compulsory hospitalization- were assessed over a 9-month follow-up period. RESULTS: The analysis identified a group of patients with substance abuse who suffer from social exclusion and forensic problems (n = 77, 15.8%), and had poorer outcomes than the rest of the patients in terms of hospitalization (52% vs. 36% respectively) and compulsory (39% vs. 22% respectively) hospitalization. CONCLUSION: There is a distinct group of patients whose treatment requires social inclusion and forensic expertise. Future research into which model of service is suitable for these patients and in what setting is recommended.

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The authors describe normal imaging of the meninges and meningeal spaces and MR (magnetic resonance) imaging findings in tumoral and nontumoral diseases. Dural or/and pial enhancement may be related to tumoral, infectious or granulomatous diseases.

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A case of primary meningeal intermediate grade melanocytic neoplasm involving the right C2 nerve root is presented. MRI findings may suggest this rare entity, especially when an extra-axial lesion is located in the posterior fossa or cervical spinal canal and demonstrates shortening of both T1 and T2. Eventually, definitive diagnosis relies on histology which demonstrates spindle-shaped melanocytic cells that are Fontana stained and positive for HMB:45 antigen. Cellularity, pleomorphism, mitotic rate, proliferation index and invasiveness are useful criteria to distinguish among the spectrum of primary melanocytic tumors of the central nervous system ranging from melanocytoma to malignant melanoma.

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The aim of this study was to (1) assess Subjective Quality of Life (SQOL) of patients with Chronic Fatigue Syndrome (CFS) using a generic concept and to compare the findings with those in groups with mental disorders and healthy subjects, and (2) investigate whether and, if so, to what extent socio-demographic and clinical variables predict SQOL in CFS patients. Seventy-three patients diagnosed with CFS were randomly selected and interviewed from two specialised clinics. CFS was diagnosed using the Oxford Criteria. SQOL was assessed on the Manchester Short Assessment of Quality of Life (MANSA) and Health-Related Quality of Life (HRQOL) on the Medical Outcome Study Short-Form 36 (MOS) SF-36. A battery of mood and symptom questionnaires, including the Symptom Checklist Questionnaire (SCL-90-R), was administered to assess various aspects of symptomatology as potential predictor variables. Multiple regression analyses were conducted to identify predictors of SQOL. Overall, SQOL was low in CFS patients and less favourable than in groups with mental disorders and healthy subjects. Satisfaction was particularly low with life as a whole, leisure activities and financial situation. Whilst SQOL was only moderately correlated with HRQOL, the SCL-90-R score, especially SCL-90-R Depression scale score, was the best predictor of SQOL explaining 35% of the variance. HRQOL and generic SQOL appear distinct despite some overlap. The findings underline that SQOL is significantly disrupted in CFS patients. Depressive symptoms are statistically the strongest 'predictor' of SQOL, although the direction of the relationship is not established. These data suggest that treatment of depression associated with CFS, regardless of causation, could help to improve SQOL in CFS patients.

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OBJECTIVE: This national cross-sectional survey investigated the communication and information needs of mental health counselors in the United Kingdom as well as the difficulty these professionals experienced in obtaining help from other mental health care providers. METHODS: Mailed questionnaires were sent to a random sample of 400 registered counselors. A total of 230 counselors returned the questionnaire, for a response rate of 58 percent. Descriptive statistics, correlations, and multiple logistic regression analysis were used to analyze the results. RESULTS: The respondents reported being in contact mostly with other counselors, general practitioners, and psychiatrists. Most of the respondents (80 percent) reported other counselors to be quite or extremely helpful when consulted; the proportions were much lower for other types of practitioners, especially general practitioners and psychiatrists. Reported barriers to coordination of counseling services included lack of time and communication problems with other professionals. A total of 160 respondents (70 percent) reported not having the necessary training or skills for managing severe cases of mental illness, and 168 (73 percent) indicated that they had a need for information about mental illness. Predictors of information needs were a lack of the necessary skills for managing severe cases, contact with mostly other counselors, and a desire for information about illness, the services of voluntary agencies (agencies with charity status and other nonstatutory organizations), and mental health law. CONCLUSIONS: This survey highlighted the importance of meeting the information, communication, and training needs of mental health counselors in the United Kingdom in order for counselors to provide high-quality counseling services.

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The aims of this cross-sectional survey were to assess psychotic sufferers' perception of the effectiveness of their medication, the distress caused by adverse effects and the impact these might have on overall patient satisfaction with treatment. Three hundred and forty-one people diagnosed with psychosis who called a national mental health helpline (SANELINE) in the UK, between July 1998 and February 1999, were asked to take part in the survey. They were given a choice of either a postal questionnaire or a telephone interview in which the same questionnaire was used. One hundred and nineteen were interviewed on the telephone and 83 (out of 222) returned completed questionnaires. In total, information was available from 202 callers. Almost one-half of the respondents were dissatisfied with their medication, and almost all of them reported experiencing at least one adverse effect. Depression (or low mood), sedation and difficulty thinking and concentrating were the most prevalent adverse effects. Weight gain was the most distressing, particularly to women. Those taking atypical antipsychotics were significantly more likely than those on typical antipsychotics to experience insomnia and dry mouth, but were less likely to perceive depression and difficulty thinking/concentrating as quite or extremely distressing. Low satisfaction, as opposed to high satisfaction, was significantly associated with reporting weight gain, difficulty thinking/concentrating, insomnia and sexual dysfunction. It was also significantly associated with reporting weight gain, difficulty thinking/concentrating, muscle/joint stiffness and depression as quite or extremely distressing. Attention should be given to the management of cognitive impairment and weight gain as adverse effects of antipsychotics. Doctors should be more open to discussing the risks and nature of adverse effects with patients who should also be encouraged to do so.

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This paper reports on a cross-sectional survey investigating communication and information needs of community psychiatric nurses attached to community mental health teams in the United Kingdom. Community psychiatric nurses' access to and communication with other professionals was also assessed. In total, 200 teams were randomly sampled UK-wide, and postal questionnaires were sent to community psychiatric nurses attached to these teams; 110 questionnaires were completed and returned (55% response rate). Spearman's rho, Pearson's correlation and the chi-square test were used in bivariate analyses and multiple logistic regression in multivariate analysis. Participants reported to be mainly in contact with psychiatrists (71%) and other community psychiatric nurses (52%). Eighty-four per cent and 91% reported psychiatrists and community psychiatric nurses, respectively, to be quite/extremely helpful when consulted; the proportions were lower for general practitioners and counsellors/therapists (32% and 31%, respectively). All reported lack of time and 84% reported communication problems with other professionals as barriers to their work. Although 70% reported having the necessary training/skills for managing severe cases, 76% indicated they had information needs. Being a long-serving community psychiatric nurse (OR = 4.51, 95% CI = 1.06-19.20), perceiving the discussion of cases with other professionals as less helpful (OR = 4.82, 95% CI = 1.16-20.01), being mainly in contact with other CPNs (OR= 6.72, 95% CI= 1.21-37.15), reporting not having the necessary training/skills (OR = 7.78, 95% CI = 1.37-44.25), and wanting information on mental health law (OR= 12.27, 95% CI = 1.75-86.36) were significant predictors of having information needs. This survey provided valuable information on problems facing these nurses and highlighted the need for training and for easier access to and increased communication with other professionals.

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This paper investigates whether informal carers' experience of caring for their dying cancer patients at home affects their retrospective evaluation of the services received by these patients from community nurses, GPs, and the health and social services in general. Analysis was conducted on a sub-sample of the Regional Study of Care for the Dying (RSCD), a retrospective survey of family members and others who knew most about the last year of life of a random sample of people who died in 20 health districts in the UK in 1990. The sub-sample consisted of 1,858 carers of people who died from cancer (ICD, 140-208). The results showed statistically significant associations between carers' satisfaction with community nurses, GPs, and the health and social services in general and their perceptions that caring at home was a rewarding activity, and that their social activities were severely or fairly restricted. Carers' satisfaction with all providers was also more likely to have been reported by those who reported having had no need for more home help. All this suggests the importance of supporting carers to enable them to fulfil their caretaking role and to cope with caring at home. This in turn could lead to an increase in their level of acceptability of the services provided.

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This review addresses some of the methodological, theoretical and technical issues related to using satisfaction as an outcome measure of the quality of palliative care. The components of palliative care are presented, and the different approaches for evaluation discussed. The limitations of using prospective or retrospective designs are stated with emphasis on the bias resulting from using either patients or carers (proxies) as informants. The role of expectations, aspirations, and perceived health status as antecedents of patient satisfaction is discussed, as are the problems associated with using these to explain satisfaction with palliative care. The limitations of adapting the dimensions of patient satisfaction with medical care to satisfaction with palliative care when designing instruments are discussed. All this highlights the need to develop separate models of satisfaction with palliative care for patients and carers, and to design instruments which are specific to patients or carers.

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The objective of this study was to investigate how many patients who die from causes other than cancer might benefit from specialist palliative care. This was achieved by secondary analysis of data from the Regional Study of Care for the Dying, a retrospective national population-based interview survey. The investigation involved 20 self-selected English health districts, nationally representative in terms of social deprivation and most aspects of health services provision. A total of 3696 patients were randomly selected from death registrations in the last quarter of 1990; an interview concerning the patient was completed 10 months after the death by bereaved family, friends or officials. The results show that a third (243/720) of cancer patients who were admitted to hospices or had domiciliary palliative care scored at or above the median on three measures of reported symptom experience in the last year of life. That is the number of symptoms (eight or more), the number of distressing symptoms (three or more) and the number of symptoms lasting more than six months (three or more). A total of 269 out of 1605 noncancer patients (16.8%) fulfilled these criteria. On this basis, it is estimated that 71,744 people who die from nonmalignant disease in England and Wales each year may require specialist palliative care. An increase of at least 79% in caseload would, therefore, be expected if specialist palliative care services were made fully available to noncancer patients. This is a conservative estimate, as non-cancer patients were matched to only one-third of cancer patients who had specialist palliative care. It is concluded that clinicians and patient groups caring for patients with advanced nonmalignant disease must work together with specialist palliative care services and with health commissioners to develop, fund and evaluate appropriate, cost-effective services which meet patient and family needs for symptom control and psychosocial support.

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To assess associations between informal caregivers' satisfaction with services delivered to their dying cancer patients and their perceptions of the duration of functional limitation and the duration of various symptoms experienced by these patients, a secondary analysis was conducted on a subsample of the Regional Study of Care for the Dying (RSCD). The RSCD is a retrospective interview survey of family members or others who knew about the last year of life of a random sample of people who died in 20 health districts in the UK in 1990. The subsample consisted of 1858 informal caregivers of people who died from cancer (ICD codes 140-208). More than half (52%) of informal caregivers were highly satisfied with community nurses, compared to 39% and 35% of those who reported high satisfaction with services provided by general practitioners and hospital doctors respectively. Informal caregivers of patients who died from a lymphatic or haematopoietic tissue cancer were more likely than others to report high satisfaction with hospital doctors (47%), while least satisfaction was reported by those who cared for patients who had a neoplasm of the genito-urinary or respiratory/intrathoracic organs (30%). The duration of pain was not significantly related to any of the satisfaction measures. The results suggest the need to take patient clinical characteristics into account in population-based evaluations of palliative care. They also indicate the need for more research to be carried out to assess the reasons behind the dissatisfaction of informal caregivers of patients with respiratory or genito-urinary cancers with services provided by hospital doctors and to detect whether these patients have unmet needs that should be addressed. More research is also needed into the management of symptoms by the general practitioners, especially symptoms pertaining to respiration and incontinence.

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The associations between measures assessing bereaved carers' health status and their perceptions of the quality of palliative care delivered by community nurses, general practitioners and hospital doctors to cancer patients in their last year of life are investigated in this paper. Analysis was conducted on a sub-sample from the Regional Study of Care for the Dying (RSCD), a survey in which relatives or friends of a random sample of deaths in 1990 in 20 health districts in England were interviewed some 10 months after the death. The sub-sample consisted of 1858 carers of people who died from cancer. The results showed statistically significant associations between bereaved carers' self-rating of health status, their psychological functioning, their experience of bereavement-related health problems, and their satisfaction with services delivered by the different providers. Further research is needed, however, to explore in-depth the nature of these associations.

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This paper examines access to and use of the physician resources for ambulatory care by residents of Winnipeg and rural areas in Manitoba. Analyses were conducted on physician claims submitted to Manitoba Health in the fiscal years 1986-87 and 1991-92. The percentage of people who made contact with physicians, the number of visits per 100 residents, and the number of visits per user were used to asses changes between 1986 and 1991. There were important variations between residents of Winnipeg and the rural regions in access to and use of physicians' services across the years, and by physician specially. These variations accompanied a decrease in physician supply in the province.

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The association between bereaved informal caregivers' satisfaction with services delivered by district nurses, general practitioners and hospital doctors, and various service and non-service variables was examined to assess whether satisfaction is a reflection of service characteristics, non-service related factors, or attributable to both. Secondary analysis was undertaken on a sub-sample from the "Regional Study of Care for the Dying" (RSCD) in which bereaved relatives or friends of a random sample of deaths in 1990 in 20 health districts across England were interviewed some ten months after the death. 1858 relatives or close friends/neighbours of people who died from cancer were included in this analysis. Using multiple logistic regression, larger odds ratio were found in association with service than non-service variables. For example, high satisfaction with district nurses was strongly associated with visiting the patient very frequently (OR = 10.8, 95% CI = 4.5 - 25.9), while the GP visiting 20 times or more (OR = 5.5, 95% CI = 3.6 - 8.5), and informing the informal caregiver of the diagnosis (OR = 3.3, 95% CI = 2.3 - 4.7) were associated with high satisfaction with GPs. However, some non-service variables were significantly associated with satisfaction. For instance, having no bereavement-related psychological problems was positively associated with high satisfaction with district nurses (OR = 2.3, 95% CI = 1.6 - 3.4) and GPs (OR = 2.0, 95% CI = 1.4 - 2.8), while the informal caregiver perceiving caring as rewarding as opposed to a burden was positively associated with high satisfaction with district nurses (OR = 3.7, 95% CI = 1.8 - 7.5) and negatively associated with high satisfaction with hospital doctors (OR = 0.46, 95% CI = 0.24 - 0.86). The findings indicate that, in post-bereavement surveys evaluating services delivered to dying cancer patients, informal caregivers' satisfaction is mainly determined by service characteristics. However, attributes of both patients and informal caregivers also play an important role.

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