EDITORIAL COMMENT

The support for the Standard which has been forthcoming in recent weeks is most encouraging and this weeks issue indicates not only the value of enlisting a goodly number of "eyes and ears" but as well the widening interest being evoked.

Mr. Hughes has asked us to acknowledge the support, encouragement and guidance he has received from Dr. Wallace, in assembling and setting in order the material for his excellent contribution on the use of Modecate Therapy in chronic schizophrenia. The technical aspects with which the article deals may have limitations both in interest and understanding for many of us, but the knowledge that in our midst research of this kind is a continuing progress, lends us all encouragement and in the fact that in this instance it has been attended by such a measure of success, we rejoice.

Elsewhere in this issue attention is drawn to the need for contributions to be in by Monday morning - the need is a very real one - the mechanics of publishing weekly make serious incursions into time allocated for other purposes including free time given voluntarily, and the more this can be spread over, the easier the task.

CLUB NEWS:

On November 21st, 1971 Winwick played the Bay Horse in the 3rd. Round of the J. Write Cup. Winwick were the victors, the score being Winwick 3 Bay Horse 2.

Next week the team play an away game against Stockham Capseal.

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SOCIAL THERAPY REVIEW:

This week's sports events concern only the men's football team. It is unfortunate that the ladies have not had any match but this is because other hospitals seem to find difficulty in raising a team. The girls, however, contented themselves with an afternoons practise on Thursday.

The men had two matches, One on Tuesday which was played away at Rainhill and won by 6 goals to 2 and the other, a league match, played at home, and won 4 2 to Prestwich hospital. They remain in good form, and. incidentally, unbeaten.

The Christmas Bazzar, this year, is to be held in the gym on Friday 3rd December, 1971. As you all know we have been appealing for any bric-a-brac, clothes, empty jewellery boxes and paper carrier bags etc. that you may no longer have any use for. The appeal still stands. We will be more than grateful for anything that you can find to bring in for us. If necessary, we will call again at all the wards in order to collect items. We've only a week left and lots of stalls to fill.

The department have attempted to adapt the old programme of social events in order that we might carry integration one step further and have mixed sessions in the gym more often than we have previously. We hope to start some new venues and ask for help from all the staff in making them a success. The new list of events will be circulated, in due course, and should you have any comments please make them!

K. Appleton.

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CADET NEWS

It has been suggested that there should be periodic meetings for Cadet Nurses, at which personal observations, views and would be problems can be openly discussed.

Previously Cadets have attended Technical College only one day per week. This year we are split into two groups attending on two different three day block release periods.

This means that communications are rather limited and there is a danger of us becoming 'out of touch' with each other. A suggested time is Wednesday evenings 4.45p.m. until 5.45 p.m. in the Social Therapy Department. A final decision will be circulated as soon as possible and it is hoped all will be able to attend.

A. G. Clare,
     Cadet Nurse.

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WINWICK STAFF SOCIAL CLUB

A

D I S C 0

THURSDAY, 2nd DECEMBER, 1971

AT

8 P.M.

 

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THERE'LL BE A HOT TIME IN THE OLD TOWN

ON

F R I D A Y , D E C E M B E R   1 0th

When The

HOSPITAL FIRE BRIGADE

Holds A

D A N C E

AT WINWICK HOSPITAL CLUB

COMMENCING 5.00 p.m.

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Admission by Ticket Only

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Tickets available from the Members of the

HOSPITAL FIRE BRIGADE.

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A touch of Research with Progress in Mind

A Ward Project with Modecate:

This article has been submitted to the Standard for many reasons, not the least of which is to attempt to show that team work on a ward can result in what we feel to be a degree of progress bringing satisfaction with achievement and bringing to bear training in observation, and calculation of outcome, in a clinical project in which everyone on the ward can be involved.

It is hoped that this article will provide interest and stimulation for all readers, that they may perhaps contribute some project and observations on findings of their own, on their wards or departments.

Our project in collaboration with the medical staff started on Ward Male 1 Down, (when that ward was the acute admission ward), in October, 1969. The objective was primarily an attempt to provide some better answer to the successful continuous treatment of the sufferer from chronic schizophrenia; to reduce the need for admission; and to utilize methodology to achieve sufficient organisation for satisfactory rehabilitative procedures. The project amongst other approaches in fact, enabled us to reduce our bed numbers considerably.

A particular patient with frequent admissions due to neglecting to take medication after discharges, (which is a common finding in the schizophrenic patient), was selected in the first instance for a trial with Modecate. We will identify him as L.S.

The dose considered usual is mgs. 25 the effect of which is considered to last for, from 14 to 35 days according to the literature. In the case of L.S. we used this dose, and reviewed his response closely, and it was decided to make the intervals between doses, 21 days; we found that his psychotic symptoms were relieved after 14 days. Continued observation did not show any evidence of relapse, and following the second injection of mgs 25 he was transferred to a medium term ward (Male 1 Up), with consequentially less supervision, to assess his further progress. In addition he was reviewed weekly in Male 1 Down. His progress continued to be satisfactory and discharge was recommended in January, 1970.

What may, now be regarded as the most important part of his management, had to be organised; that is, the provision of "follow-up" supervision and support, and the continuation of Modecate injections at regular intervals. In this case, the patient lived with his aged mother, which meant that there would be no supervision available in his household.

Bearing in mind that this case will be the first that Mental Welfare would experience in the use of Modecate outside the hospital, I contacted the Mental Welfare Officer for the patient's area, and informed him of the need for adequate follow up visits and of the need to arrange administration of Modecate in correct dosage and correct intervals (21 days) by the Health Visitor or District Nurse. Arrangements were also made for Out-Patient attendance at his local clinic.

This case illustrates the value of Modecate, together with close observation and frequent assessment in hospital and adequate follow-up arrangements after discharge.

One only has to compare his pre-modecate history (several admissions with short remissions in between) with post-modecate history (no further admissions to date since January 1970).

With this encouragement, we decided after further review of the literature and reports on the use of Modecate, to employ its use on a wider scale; especially at first, with frequently admitted chronic schizophrenic patients who were unreliable with oral medication.

The routine we adopted, was to administer tablets Moditen in the initial phase of the treatment, to assess tolerance and the degree of any side-effects. After 10 to 14 days, and if the tablets were well tolerated and showed signs of effective control of symptoms, a first injection was administered, usually of mgs 12.5 as a test dose, but depending, to some extent on the size of the individual, and the degree of severity of symptoms: on occasion the normal maintenance dose of mgs 25, was administered initially. Routine administration orally of Disipal or Kemadrin, accompanied Modecate, and the initial use of tabs Moditen; it was found that the incidence of Parkinsonian side effects were limited. Continuous assessment followed and the dose of Modecate was adjusted where necessary, that is, increase or reduction of doses given. or lengthening or reduction of period between doses. To the end of August,1971 50 patients have been treated and the maximum dose has been mgs 37.5 every 21 days. We adopted a policy that no patient be discharged until (at the earliest) after the administration of the second dose.

The criteria tending to be adopted for a selectivity of patients suitable for Modecate therapy, early in the project was as follows:

1.	Chronic Schizophrenia
2.	Patient neglecting to take oral medication as prescribed, after discharge.
3.	Frequent re-admissions, and shortening periods of remission.
4.	As an alternative in most cases, to longer term care .

Later in the project, we decided to administer Modecate therapy to patients, who were admitted to hospital for the first time.

The placement of the 50 patients treated to the end of August, 1971 is as follows on review:

a)	Attending Ward for continuation	20
b)	Attending clinic or visited in own area	10
c)	Discontinued of own volition	3
d)	Discontinued by M.O.	3
e)	Transferred within hospital	8
f)	In-patients	3
g)	Move to other Catchment area, no current record	3
	The number of patients who had previous admissions before Modecate therapy	31
	The number of patients placed on Modecate therapy after first admission	19

Of patients transferred to other wards (8), 4 have been subsequently discharged and 2 more awaiting suitable accommodation in the community the ward most involved in transfers being formerly Male 2Up, now Female side 7Up.

Comparing modecate treated patients who had a history of relapse and re-admissions, prior to treatment; (i.e. a comparison, using the patients on their own standards) the expected percentage of re-admissions formerly, would be virtually 100%, (of the 31 chosen patients) with a fair frequency of admission within a year or less of previous discharge.

In fact re-admissions have been 10 in number, of the total 31. It can be said too, that of the re-admissions, 7 of them presented an appreciably lesser degree of severity of symptoms, than on previous admissions.

As indicated earlier, the importance of adequate follow-up arrangements both for injection and review is paramount, and we considered possible arrangements as follows:

a)	To attend ward on day injection due (local patients)
b)	Arrange for visits at home from health visitor or attendance at health centre in the vicinity of their own home.
c)	Attend works medical centre.
d)	Attendance at Out-patients clinics (consultants) and adequate cover by Mental Welfare Officers.

Item (d) is in conjunction with either (a) (b) Or (c).

We adopted whichever of these procedures seemed most satisfactory from the patients point of view.

It would seem therefore that we have achieved some degree of success with these procedures, and are continuing to use Modecate in wider circumstances, in the case of schizophrenic patients including first admissions and patients or longer term wards.

The adverse effects of this preparation, so far, have been few: in the main control of extra pyramidal effects is achieved by modifying dosage of Modecate, and the use of anti Parkonsonian drugs. Two or three cases, have shown signs of depression, which were resolved by the use of antidepressant tablets in addition.

The long term use has yet to be finally assessed, but we hope that smaller doses in the long term will maintain stability and enable the individual to remain a constructive member of the community. To finalise, we awaited with some trepidation in the early days, as to whether or not, patients would return to the ward or visit the Health Centre on the prescribed day.

Our trepidation was quite unjustified; as (with three exceptions) all patients to our great satisfaction attended either on the day prescribed or the day before or after: ( mainly to fit in with work hours), it was also evident that patients were taking their anti-parkinsonian drugs as prescribed.

NOTE:- During the period of the project the ward function was transferred from ward Male 1 Down, 40 beds to male Upper Delph 18 beds.

Case No.	Number of Previous Admissions	Average Admissions Per Year	Date Commenced Modecate Injections	Last Discharged On	Subsequent Admissions	Remarks
1	5 1967-70	1.66	Oct. 1969	Jan. 1970	NIL	----
2	17 1957-70	1.3	Feb. 1970	Mar. 1970	NIL	In full time work since discharge
3	6 1967-70	2	Oct. 1970	Nov. 1970	NIL	Occasional attendance as day patient
4	4 1969-70	2	Sep. 1970	Oct. 1970	NIL	----
5	6 1965-70	1	Jul. 1970	Aug. 1970	NIL	In full time work since discharge

The above illustrates the advantages of the use of Modecate therapy in chronic schizophrenics who, were frequently admitted to hospital prior to treatment by Modecate.

I wish to express my appreciation of staff efforts on the ward and their co-operation, during the project.

T. N. Hughes.

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IN SINCERITY OF GRACE

Now to the hunger of the waiting crowd, the trapeze artist enters the circus ring.

As the lights glow in colour and the music for the act begins, she climbs with grace far above the level.of the security of a ground base.

Gone is the ladder. Now as if in a mystic spell she goes through her act high above and to the serenade of the music she sets out swinging on the trapeze with a poise which holds the crowd beneath in a fantasy unknown before, quelling the hungry passion.

With an uncanny grace swinging, twisting and performing with perfection and poise, her very being in harmony with the music she continues her actions, and then in the hush she falls. The safety net is sound, but still as in a trance she misses the net and hits the ground.

Still her face smiles and she lies in the grace of death, betraying her end only by a trickle of blood flowing from her lips and then panics are too late by others.

Joan Lock

Every Wednesday evening staff from the Social Therapy take a group of patients from this hospital to the Warrington Swimming Baths. More often than not they use the Gala pool and spend a very pleasant hour from 6.30 to 7.30 p.m.

Other staff have started to join the class. Surely there must be other staff beginners and swimmers who would benefit greatly. The water is warm and this hour could develop into a very pleasant healthy activity. So how about it staff? everybody, I mean, not just nurses - keep your summer aquatic activities and your unwanted bulges down.

B. Naylor

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The charge of censorship has been laid at the door of the Editors of The Standard on several occasions. In the absence of any reply I would like to indicate some of the lines on which such a charge might reasonably be upheld.

Some form of selection will always be evident in the final product - otherwise the size and content of any two issues might vary wildly. Selection, and choice, are not good grounds for a censorship charge, since they may imply no more than a passing whim. Further, the choice may be no more important than which of two issues a particular contribution should appear in.

If it is the case that an adequate volume of material is available to the Editors; then a censorship charge would have to be founded on evidence of repeated non-selection. Should such evidence be adduced, then the question,'Is censorship necessarily bad?', would have to be considered.

It is my personal opinion, in a catchphrase, that censorship is guilty until proved innocent. And there's the rub. For censorship, whatever the pros and cons of the reasoned argument which the Editors' actions level against an article when considering whether or not to publish, is self-evident - something is not there - and invariably lays the Editors' actions open to differing interpretations. Only a full and clear discussion of the issues involved can resolve the question, and this, of course, is the very state of affairs which the blue pencil ruled out in the first place.

There is, however, a way out of the impasse - could not the Editors, when faced with the probably unpleasant task of refusing publication, briefly communicate to both the contributor and their own Publications Committee the reasons for their action?

R. Bruton

WELCOME TO:

Nursing Assistants:
Mrs. A. Jenks
Mrs. H. Ashley
Mrs. E. Chaplin
Miss G. Bennett
Mrs C. Savage

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The Editors wish to remind contributors that items for inclusion should be in the hands of the Editors by Monday of the week of publication.

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