Frequent attendance and the concordance between PHQ screening and GP assessment in the detection of common mental disorders

OBJECTIVE

Frequent Attenders (FAs) have high rates of both common mental disorders (CMD) and physical disorders, partly justifying this service use behaviour. This study examines both case and non-case concordance between CMDs as estimated by a self-report screening questionnaire and as rated by the general practitioner (GP), in FAs compared to Other Attenders (OAs).

METHODS

2275 patients of an overlapping sample of 55 GPs from 2 surveys performed 10 years apart, completed in the waiting room the Patient Health Questionnaire (PHQ) and Client Service Receipt Inventory on 6-month service use. For each patient, the GP rated mental health on a 0-4 scale, with a clear indication that scores of 2 and above referred to caseness. PHQ-CMDs included major and other depressive, anxiety, panic, and somatoform disorders, identified using the original PHQ DSM-IV criteria-based algorithms. FA was defined as the top 10% of attenders in age, sex and survey-year stratified subgroups.

RESULTS

FAs had higher rates of PHQ-CMDs (42% versus 23% for OAs, p < .0001). They reported more personal and social problems, disability and had higher GP-rated physical illness. Survey-day antidepressant/anxiolytic medication prescription was higher for FAs (p < .0001), with (p = .02) but also without a CMD (p < .0001). Both GP/PHQ case and non-case concordance differed between FAs and OAs, with a non-case concordance odds ratio of 0.5 (95% CI: 0.3-0.7, p = .001) for FAs compared to OAs.

CONCLUSION

Despite a greater likelihood of GPs detecting CMDs in FAs, our findings suggest a potential risk of 'over-detection' of patients not reaching CMD threshold criteria among FAs.

Von Willebrand Factor and Mitral Valve Prolapse

The levels of von Willebrand factor (vWF: Ag) were measured in 27 patients with mitral valve prolapse (MVP) and compared to 27 age matched controls. Decreased levels of vWF:Ag (<80%) were found in 59% (16/27) of those with MVP compared to only 7% (2/27) of the controls (p <0.001). Mean vWF: Ag levels were also significantly lower in those with MVP (68 ± 30% versus 100 ± 23%, p <0.001). In those with MVP and congestive heart failure secondary to ruptured chordae tendineae, however, the mean level of vWF:Ag was not significantly different from control values (95 ± 32). There was an increased incidence of recurrent nose bleeds in those with MVP and low levels of vWF: Ag. We conclude that there is a relationship between MVP and low levels of vWF:Ag which may explain the increased incidence of epistaxis in such patients. Increased release of vWF: Ag in those with MVP and concomitant congestive heart failure may account for the normal levels found in this subgroup.

Relative Sensitivity of Different Tests in the Detection of Low Titer Lupus Anticoagulants

Lupus anticoagulants (LA) and anticardiolipin antibodies have been strongly associated with recurrent abortion and fetal death. Because steroids have been reported to improve the fetal outcome of LA associated pregnancies, presumably by decreasing the levels of LA, it becomes desirable to have a simple and reliable test to monitor the levels of the putative antibody. To this effect, we assessed the capacity of the following coagulation tests to detect the presence of LA in serial dilutions of patient plasma with pooled normal plasma: kaolin clotting time (KCT), tissue thromboplastin inhibition test (TTIT), dilute Russell Viper venom time (DRVVT) and activated partial thromboplastin time with standard and high concentrations of phospholipids (SC and HCAPTT). All samples were also evaluated for the presence of anticardiolipin antibodies with an ELISA. The KCT was able to detect LA at a much greater dilution in normal plasma than any of the other clotting assays. The ELISA was comparable to KCT in its ability to detect high dilutions of LA.

Systematic review of the cost-effectiveness of preoperative antibiotic prophylaxis in reducing surgical-site infection

BACKGROUND

Surgical-site infections (SSIs) increase the length of hospital admission and costs. SSI prevention guidelines include preoperative antibiotic prophylaxis. This review assessed the reporting quality and cost-effectiveness of preoperative antibiotics used to prevent SSI.

METHODS

PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Index of Economic Articles (EconLit), Database of Abstracts of Reviews of Effect (including the National Health Service Economic Evaluation Database) and Cochrane Central databases were searched systematically from 1970 to 2017 for articles that included costs, preoperative antibiotic prophylaxis and SSI. Included were RCTs and quasi-experimental studies conducted in Organisation for Economic Co-operation and Development countries with participants aged at least 18 years and published in English. Two reviewers assessed eligibility, with inter-rater reliability determined by Cohen's κ statistic. The Consolidated Health Economic Evaluation and Reporting Standards (CHEERS) and modified Drummond checklists were used to assess reporting and economic quality. Study outcomes and characteristics were extracted, and incremental cost-effectiveness ratios were calculated, with costs adjusted to euros (2016) (€1 = US $1·25; £1 sterling = €1·28).

RESULTS

Twelve studies published between 1988 and 2014 were included from 646 records identified; nine were RCTs, two were nested within RCTs and one was a retrospective chart review. Study quality was highest in the nested studies. Cephalosporins (first, second and third generation) were the most frequent prophylactic interventions. Eleven studies demonstrated clinically effective interventions; ten were cost-effective (the intervention was dominant); in one the intervention was dominated by the control; and in one the intervention was more effective and more expensive than the control.

CONCLUSION

Preoperative antibiotic prophylaxis does reduce SSI, costs to hospitals and health providers, but the reporting of economic methods in RCTs is not standardized. Routinely nesting economic methods in RCTs would improve economic evaluations and ensure appropriate selection of prophylactic antibiotics.

Impact of baseline clinical and laboratory features on the risk of thrombosis in children with acute lymphoblastic leukemia: A prospective evaluation

BACKGROUND

Children with acute lymphoblastic leukemia (ALL) have increased risk of thromboembolism (TE). However, the predictors of ALL-associated TE are as yet uncertain.

OBJECTIVE

This exploratory, prospective cohort study evaluated the effects of clinical (age, gender, ALL risk group) and laboratory variables (hematological parameters, ABO blood group, inherited and acquired prothrombotic defects [PDs]) at diagnosis on the development of symptomatic TE (sTE) in children (aged 1 to ≤18) treated on the Dana-Farber Cancer Institute ALL 05-001 study.

PROCEDURES

Samples collected prior to the start of ALL therapy were evaluated for genetic and acquired PDs (proteins C and S, antithrombin, procoagulant factors VIII (FVIII:C), IX, XI and von Willebrand factor antigen levels, gene polymorphisms of factor V G1691A, prothrombin gene G20210A and methylene tetrahydrofolate reductase C677T, anticardiolipin antibodies, fasting lipoprotein(a), and homocysteine).

RESULTS

Of 131 enrolled patients (mean age [range] 6.4 [1-17] years) 70 were male patients and 20 patients (15%) developed sTE. Acquired or inherited PD had no impact on the risk of sTE. Multivariable analyses identified older age (odds ratio [OR] 1.13; 95% confidence interval [CI]: 1.01, 1.26) and non-O blood group (OR 3.64, 95% CI: 1.06, 12.51) as independent predictors for development of sTE. Patients with circulating blasts had higher odds of developing sTE (OR 6.66; 95% CI: 0.82, 53.85).

CONCLUSION

Older age, non-O blood group, and presence of circulating blasts, but not PDs, predicted the risk of sTE during ALL therapy. We recommend evaluation of these novel risk factors in the development of ALL-associated TE. If confirmed, these easily accessible variables at diagnosis can help develop a risk-prediction model for ALL-associated TE.