Elizabeth Scott

Involving Clients in Programme Evaluation and Research: A New Methodology for Occupational Therapy

Eliciting client satisfaction with services has become common in mental health settings and in the planning of service delivery systems. It is also compatible with the client-centred practice of occupational therapy. The traditional approach to collecting satisfaction information involves staff interviewing clients using questionnaires developed by staff. However, there is often a lack of variability in responses and the vast majority of clients report being satisfied. A review of the literature reveals that these favourable reports may be a result of social desirability and of clients being interviewed by treatment providers who have the power to give or withhold care. This paper reviews the relationship between occupational therapy and client involvement, examines the rationale for involving clients in programme evaluation and research, reviews the limitations with traditional methods of collecting information about client satisfaction, and discusses how clients are involved in evaluation and research in todays mental health care setting.

ANAESTHETIC-INDUCED INCREASE IN IONISED CALCIUM IN BLOOD MONONUCLEAR CELLS FROM MALIGNANT HYPERTHERMIA PATIENTS

The cytoplasmic concentration of ionised calcium, [Ca2+]i, is believed to be altered by agents that induce a malignant hyperthermia (MH) crisis in susceptible individuals. MH patients were identified by the halothane and halothane/caffeine contracture tests done in isolated muscle biopsy specimens. [Ca2+]i was measured in isolated peripheral blood mononuclear cells from MH patients and controls by means of the fluorescent calcium ion indicator quin2. In the absence of halothane there was no significant difference in [Ca2+]i in cells from normal and MH patients. Addition of halothane (4 microliter/ml) significantly increased [Ca2+]i in cells from MH patients but not in controls. The halothane-induced increase in [Ca2+]i required extracellular calcium ions. This is the first evidence of the mechanism of action of halothane in cells of MH patients; the differential effect of halothane on [Ca2+]i might constitute the basis for a non-invasive screening test for MH.

COMPARISON OF EFFECTS OF SEVERAL INHALATION ANAESTHETICS ON CAFFEINE-INDUCED CONTRACTURES OF NORMAL AND MALIGNANT HYPERTHERMIC SKELETAL MUSCLE

We have compared the combined effects of halothane, enflurane, isoflurane and methoxyflurane on caffeine-induced contractures of normal and malignant hyperthermia susceptible (MHS) skeletal muscle fascicles. We have found that caffeine contractures without and with the addition of any of these four anaesthetics are higher in MHS than in normal muscle. The differences between the normal and MHS muscle are about the same for all drug combinations. For all four anaesthetics the degree of increase of the contracture is about the same in the normal as in the MHS muscle. For both the MHS and the normal muscle the caffeine contractures are from greatest to least: halothane > isoflurane > enflurane > methoxyflurane. Examination of the relationships among the caffeine specific concentrations in the presence of the various anaesthetics shows significant differences for the comparisons of halothane with the other three anaesthetics but, for the most part, the comparisons among methoxyflurane, enflurane and isoflurane are not meaningful statistically.RéesuméOn a comparé les effets potentialisateurs de ľhalothane, de ľenflurane, de ľisofiurane et du méthoxyflurane sur la réponse à la stimulation par caféine du muscle normal et du muscle de sujets susceptibles à ľhyperthermie maligne. La réponse à la caféine s’est avérée plus importante chez les sujets susceptibles à ľhyperthermie que chez ceux présentant un muscle normal, et ceci indépendamment de la présence ou de ľabsence de ľun des anesthésiques comparés. La différence entre la réponse du muscle normal et celle du muscle de sujets anormaux était à peu près la màme avec les quatre agents étudiés. Lapotentialisation de ľeffet de la caféine était à peu près la mçme avec les quatre anesthésiques pour le muscle normal et ľanormal, ľhalothane étant le plus actif, suivi de ľisofiurane, de ľenflurane et du méthoxyflurlane. Ľexamen des rapports entre les concentrations spécifiques de caféine en présence des quatre anesthésiques montre des différences significatives entre ľhalothane et les trois autres, mais non entre les trois autres.

Effect of temperature, time and fascicle size on the caffeine contracture test

The caffeine contracture test is the most commonly used method of diagnosing malignant hyperthermia. We have examined some factors which may influence the results of this test. These have included the temperature of the bathing solution, the size of the muscle fascicles, and the combined effect of the passage of time and prior equilibration with caffeine or with caffeine plus halothane. For both malignant hyperthermic susceptible (MHS) and normal fascicles, caffeine contractures were greater at 37° C than at 22° C, while halothane and caffeine plus halothane contractures were similar at 37° C and at 22° C. Good differentiation between the normal and the MHS fascicles were observed at both temperatures although the discrimination was slightly, although not always significantly, better at 22° C. The weight, length or diameter of the fascicles had little or no effect on the height of the caffeine or the caffeine plus halothane contractures. We compared caffeine plus halothane contractures exhibited by newly prepared muscle fascicles with caffeine plus halothane contractures manifested by fascicles which had already been equilibrated with either caffeine alone or with caffeine and halothane for at least one hour. Differences in contracture heights among the techniques were small and often not significant, particularly at 37° C. The greatest discrimination between the MHS and the normal muscle fascicles was provided by determining the caffeine plus halothane contracture curves at 22° C, using muscle fascicles which had previously been equilibrated with incremental doses of caffeine in the absence of halothane. Slightly less accurate but still reasonably satisfactory results were also obtained at 37° C using muscle strips which were either freshly prepared or which had prior exposure to caffeine or to caffeine in combination with halothane and, at 22° C, using either newly prepared muscle or muscle which had already been equilibrated with caffeine plus halothane. The widest differentiation between the MHS and the normal muscle was given by the caffeine plus halothane contractures and the least by the halothane contractures. MHS patients whose muscle fascicles exhibited greater than normal caffeine plus halothane contractures but normal caffeine contractures and normal halothane contractures had had the most mild clinical reactions. On the other hand MHS patients whose muscle fascicles demonstrated halothane contractures, caffeine contractures and caffeine plus halothane contractures which were all greater than normal had had the most severe reactions. It is concluded, therefore, that if the amount of muscle available is very small, a satisfactory caffeine contracture test can still be performed by doing the various parts of the test sequentially on the same fascicle. If the time available for performing the test is limited, then the several parts of the test should rather be performed simultaneously on separate muscle fascicles.RésuméLe test à la caféine est la méthode la plus courante pour établir le diagnostic ďhyperthermic maligne. Nous avons étudié certains facteurs susceptibles de modifier les résultats, à savoir la température de la solution où baigne le spécimen musculaire, le calibre des fibres musculaires, et les effets combinés de la durée ďexposition et atteinte ďéquilibre avec la caféine ou la caféine associée à ľhalothane. Pour la fibre normale comme pour celle de sujets susceptibles de présenter de ľhyperthermie maligne, les contractures étaient plus importantes à 37° qu’à 22° C. Les réponses étaient semblables aux deux températures si ľhalothane était utilisé. On pouvait bien différencier le muscle normal de ľanormal aux deux températures bien que la différence était légèrement plus visible (pas toujours de façon significative) è 22° qu’à 37° C. Le poids, la longueur et le diamàtre des fibres n’avaient pas ou peu ďeffet sur le résultat du test. Nous avons comparé les résultats du test à la caféine-halothane sur des fibres qui venaient ďêtre préparées avec ceux observés lorsque les fibres avaient été équilibrées par une heure ďexposition à la solution de caféine ou de caféine-halothane. Les différences étaient petites et souvent non significatives, en particulier à 37° C. Les meilleurs conditions pour différencier la fibre normale de ľanormale se retrouvaient en établissant la réponse à la cafàine-halothane à 22° C avec des fibres équilibrées au préalable à des doses progressives de caféine sans halothane. On obtenait des résultats légèrement moins précis mais encore acceptables à 37° C avec des fibres fraîchement préparées ou équilibrées à la caféeine-halothane. La meilleure différenciation entre la normalité et ľanormalité était obvservée avec ľassociation caféine-halothane et la moins bonne avec la contracture à ľhalothane. Les patients susceptibles à ľhyperthermic présentant une réponse à la caféine-halothane plus grande que la normale, mais une réponse normale à la caféine ou à ľhalothane isolés, présentment les phénomènes cliniques les plus discrets. Ceux dont les résultats étaient supérieurs é la normale avec la caféine, ľhalothane et ľassociation caféine-halothane, présentaient les manifestations cliniques les plus graves. II est conclu que si la quantité de muscle disponible est petite, on peut tout de même obtenir un test valable en procédant aux différentes étapes de façon séquentielle. Si ľurgence exige des résultats rapides, il vaut mieux procéder simultanément aux différentes étapes en utilisant des fibres séparées.

Dantrolene - in vitro studies in malignant hyperthermia susceptible (MHS) and normal skeletal muscle

Dantrolene sodium, a hydantoin analogue, is efficacious in the therapy of malignant hyperthermia (MH). In order to improve our knowledge of the mode of action of dantrolene, we have examined the influence of dantrolene sodium on; (1) twitch and resting tensions, in the absence and the presence of caffeine, of intact skeletal muscle fascicles; and (2) caffeine induced tension rises of single chemically skinned skeletal muscle fascicles.We have found that dantrolene appears to exert its beneficial action on malignant hyperthermia susceptible (MHS) skeletal muscle by an indirect action on the sarcoplasmic reticulum (SR). Thus dantrolene inhibits twitch tensions of skeletal muscle fascicles, probably by indirectly preventing the release of calcium from the SR. To a lesser extent dantrolene inhibits caffeine induced contractures of skeletal muscle fascicles, probably by indirectly accelerating the uptake of calcium into the SR. Because the former effect is greater than the latter in vivo dantrolene sodium is effective only when given prior to total loss of calcium from the SR. Vigilant temperature and EKG monitoring of all patients during anaesthesia is, therefore, essential.RésuméLe dantrolène sodique, un analogue de l’hydantoin, est efficace dans le traitement de VHyperthermie maligne. Pour améliorer notre connaissance du mode d’action du dantrolène, nous avons étudié l’influence du dantrolène sodique sur: 1) la tension de contraction et de repos avec ou sans caféine sur des faisceaux de muscle squelettique intacts; et 2) l’augmentation de la tension induite par la caféine sur des faisceaux de muscle squelettique enrobés chimiquements. Nous avons trouvé que le dantrolène semble exercer son action bénéfique sur le muscle squelettique susceptible à l’Hyperthermie maligne par une action indirecte sur le réticulum sarcoplasmique (RS). Le dantrolène inhibe les tensions de contraction des faisceaux de muscle squelettique, probablement en prévenant indirectement le largage du calcium du RS. A un moindre degré, le dantrolène inhibe les contractures des faisceaux du muscle squelettique induites par la caféine probablement en accélérant indirectement la captation du calcium dans le RS.Parce que le premier effet est plus important que le deuxième in-vivo, le dantrolène est efficace uniquement lorsqu’il est administré avant le largage total du calcium par le RS, Une surveillance vigilante de la température et de V électrocardiogramme pendant l’anesthésie est essentielle.

Comparison of the caffeine skinned fibre tension (CSFT) test with the caffeine-halothane contracture (CHC) test in the diagnosis of malignant hyperthermia.

We have compared and contrasted two diagnostic tests for Malignant Hyperthermia (MH) -the Caffeine-Halothane Contracture Test and the Caffeine Skinned Fibre Tension Test. Both tests show a strongly positive relationship both with the occurrence of MH reactions and with each other. The former test is more rapid and requires less skill. The latter test can be performed on much less muscle and permits storage of the muscle over prolonged periods of time.RésuméNous avons comparé deux épreuves diagnostiques pour rhyperthermie maligne (MH) - le test de contracture caféïne sur fibres dépouillées. Les deux tests ont montré une relation fortement positive entre eux et avec 1’incidence de réactions causées par rhyperthermie maligne. Le premier test est plus rapide et plus facilement realisable. Cette derniàre épreuve néessite moins de muscle et permet le storage du spécimen pour des périodes de temps prolongées.

Functional Consequences of Bipolar Affective Disorder: An Occupational Therapy Perspective

An investigation into the functional consequences for an outpatient group of euthymic clients with the diagnosis of bipolar disorder(N=62) was conducted at the Bipolar Clinic at the Clarke Institute of Psychiatry. Participants completed a questionnaire that was based on the Role Checklist and that measured their level of involvement, satisfaction, and functioning in various life roles. The questionnaire also included criteria for adaptive level of functioning. Approximately one third of the sample did not meet the criteria for adaptive level of functioning. Furthermore the self-care, productivity and leisure problems identified in the open-ended questions suggest that the functional consequences of bipolar affective disorder are substantial for this euthymic outpatient group of clients. The implications of these results are discussed in the context of the Occupational Therapy Guidelines for Client-Centred Mental Health Practice.

Failure of the tourniquet-twitch test as a diagnostic or screening test for malignant hyperthermia.

We have performed the tourniquet-twitch test of Roberts and Ryan in normal and in malignant hyperthermia (MH) patients and relatives. This test measures the ratio of electrically induced thumb twitches noted after 10 min of ischemia with those noted immediately prior to the ischemia. We found no significant differences in this ratio between normal subjects and those who have had MH reactions, or relatives of such individuals. Furthermore, we have observed no significant differences in tourniquet-twitch ratios between those with normal caffeine-halothane contractures and persons with caffeine-halothane contractures tests positive for MH. These findings do not agree with those of Roberts and Ryan, who reported that tourniquet-twitch ratios were higher in MH patients than in normal patients. We have, however, determined that subjects with tourniquet-twitch ratios ≥1.8 are substantially younger than those with tourniquet-twitch ratios ≤1.0. Therefore we do not believe that the tourniquet-twitch test is useful as a diagnostic, or even as a screening test for MH.

Responding to workload measurement needs.

Workload measurement is a way of capturing and recording the time and/or activities of personnel in the performance of their health care duties. The traditional focus of workload systems in occupational therapy has been on resource allocation, activity tracking and long range planning. The systems are not organized to link with other institutional, financial and management tools to identify and cost client and programme resource use. The position taken in this paper is that occupational therapy workload measurement systems must be expanded to meet these new managerial responsibilities. Occupational therapists must be able to prospectively predict their workload to accommodate the move towards case costing and programme management. The paper also provides information from a national survey which indicates that there is support from the field for this position.

Surviving the Management Game: Workload Measurement Systems in a Cost-Conscious Environment

Using a procedure-based occupational therapy workload measurement system developed at, and applied by, Sunnybrook Health Science Centre, this paper explores the objectives of such a system from the point of view of the occupational therapy manager. It also takes into account the synergistic relationship between the occupational therapist and the administrative/business aspect of health care, paying special attention to past and present trends in health-care accountability. In this paper it is argued that occupational therapy managers must relate their procedures and overhead costs to actual client care, if they are to be included in programme management and client costing. The process used by occupational therapy to describe its own procedures for the system is outlined. The system was then developed in conjunction with other institutional, financial and management tools for the client cost conversion process. By using a procedure based workload measurement system, occupational therapy is able to accurately describe client costing, thereby articulating our role in client care.