The effect of concurrent pain on the management of patients with depression: an analysis of NHS healthcare resource utilisation using the GPRD database

INTRODUCTION

Patients with depression frequently report painful physical symptoms. However, there are scant data from the UK concerning differences in primary and secondary care resource use between depressed patients with and without pain treated in general practice.

METHODS

Patients with depression codes were identified from the General Practice Research Database (GPRD) excluding those with psychoses. The observation period was 1st January 2000-31st December 2006. Patients were further categorised into three groups: (i) no painful physical symptom codes ever in the observation period (NO PAIN); (ii) patients with no other diagnostic or test codes 30 days either side of a pain code (PAIN MINUS DIAGNOSIS) and (iii) patients with pain codes and other diagnostic codes (PAIN PLUS DIAGNOSIS). Rates of general practitioner (GP) visits, antidepressant and concomitant prescribing and switching, secondary care referrals and diagnostic tests were reported per group with 95% confidence limits (CI).

RESULTS

A total of 145,784 patients with depression aged 18-50 years were selected. Of these, 48,615 (33.3%) were classed as NO PAIN, the remaining 66.6% having pain. PAIN MINUS DIAGNOSIS patients constituted 5654 (5.8%) of those with pain. PAIN MINUS DIAGNOSIS and PAIN PLUS DIAGNOSIS had a significantly higher rate of GP visits than NO PAIN patients, 10.37 (95% CI 10.23, 10.52); 11.15 (11.11,11.20) and 7.04 (7.00, 7.08) respectively. Inter and intraclass drug switching was high with 13% of PAIN MINUS DIAGNOSIS and 14% of PAIN PLUS DIAGNOSIS patients having three or more switches compared with 7% of NO PAIN patients. Referral rates to secondary care were significantly higher in both pain groups compared with patients with no pain. Diagnostic testing was significantly greater in PAIN MINUS DIAGNOSIS and PAIN PLUS DIAGNOSIS groups than NO PAIN patients for all test types, with X-rays being the most common test; 3.85 (3.69,4.00); 2.77 (2.74,2.80); 0.91 (0.89, 0.94) respectively.

CONCLUSION

Patients in general practice diagnosed with depression and concurrent painful physical symptoms have higher resource use in primary and secondary care.

Burden of asthma in the hospital setting: an Australian analysis

OBJECTIVES

This study was designed to report factors associated with asthma hospital admission, such as patient characteristics, type of admission and subsequent outcome i.e. discharge or death, for the years 2000-2005. These data are used for health economic models regarding asthma burden in the hospital setting in Australia.

METHODS

Data was obtained from the Australian Centre for Asthma Monitoring using their amalgamated dataset from all states and territories. Admissions under ICD-10 codes J45 'Asthma' plus all subcodes, and J46 'acute severe asthma' were included. Codes for associated comorbidity at the time of admission were identified, as well as the month of death, age, gender and length and the type of stay. Confidence intervals for death rate assumed a binomial distribution because of the rarity of event.

RESULTS

The total number of all-cause deaths for the 5-year observation period was 289 from 202,739 asthma separations or 0.14% or 143 deaths/100,000 separations and the highest rate was seen in patients over 45 years. Acute upper respiratory tract infections were reported in up to 25% of all asthma hospital admissions. Length of stay was up to a mean average of 10.2 days in patients who died (SD 15.3). In 5 years observation there was 152,758 emergency asthma admissions which contributed greatly to Australian healthcare burden.

CONCLUSIONS

The study demonstrates that emergency admissions dominate asthma care in the hospital setting in Australia, which suggests poor asthma control in some patients with subsequent economic burden. Asthma-related mortality remains a risk for specific patients in the hospital setting.

An index for rating the total secondary safety of vehicles from real world crash data

This study proposes a total secondary safety index for light passenger vehicles that rates the relative performance of vehicles in protecting both their own occupants and other road users in the full range of real world crash circumstances. The index estimates the risk of death or serious injury to key road users in crashes involving light passenger vehicles across the full range of crash types. The proposed index has been estimated from real world crash data from Australasia and was able to identify vehicles that have superior or inferior total secondary safety characteristics compared with the average vehicle.

Predictors of COPD symptoms: does the sex of the patient matter?

Although chronic obstructive pulmonary disease (COPD) patients frequently report symptoms, it is not known which factors determine the course of symptoms over time and if these differ according to the sex of the patient. The current study investigated predictors for presence, development and remission of COPD symptoms in 816 males and 312 females completing 3-yr-follow-up in the European Respiratory Society Study on Chronic Obstructive Pulmonary Disease (EUROSCOP). The following were included in generalised estimating equations logistic regression analyses: explanatory variables of treatment; pack-yrs smoking; age, forced expiratory volume in one second % predicted (FEV1 % pred); annual increase in FEV1 and number of cigarettes smoked; body mass index; and phadiatop. Interaction terms of sex multiplied by explanatory variables were tested. Over 3 yrs, similar proportions of males and females reported symptoms. In males only, higher FEV1 % pred was associated with reduction in new symptoms of wheeze and dyspnoea, and symptom prevalence was reduced with annual FEV1 improvement and phlegm prevalence reduced with budesonide treatment (odds ratio 0.66; 95% confidence interval 0.52-0.83). Additionally an increase in the number of cigarettes smoked between visits increased the risk of developing phlegm (1.40 (1.14-1.70)) and wheeze (1.24 (1.03-1.51)) in males but not females. The current study shows longitudinally that symptom reporting is similar by sex. The clinical course of chronic obstructive pulmonary disease can differ by sex, as males show greater response to cigarette exposure and treatment.

Poor asthma control in children: evidence from epidemiological surveys and implications for clinical practice

The objectives of this study is to compile current knowledge about asthma control in children in relation to goals proposed in international guidelines, to elucidate the factors associated with insufficient asthma control and to address the implications for clinical practice. Review of recent worldwide large population epidemiological surveys and clinical asthma studies of more than 20,000 children are the methods used in this study. The studies report high frequencies of sleep disturbances, emergency visits, school absence and limitations of physical activity due to asthma. Only a small percentage of children with asthma reach the goals of good asthma control set out by Global Initiative for Asthma (GINA). There is evidence of underuse of inhaled corticosteroids even in children with moderate or severe persistent asthma and over-reliance on short-acting beta(2)-agonist rescue medication. Both parents and physicians generally overestimate asthma control and have low expectations about the level of achievable control. Many children with asthma are not being managed in accordance with guideline recommendations, and asthma management practices vary widely between countries. Asthma control falls short of guideline recommendations in large proportions of children with asthma worldwide. Simple methods for assessing asthma control in clinical practice are needed. Treatment goals based on raised expectations should be established in partnership with the asthmatic child and the parents. Effective anti-inflammatory treatment should be used more frequently, and patients should be reviewed regularly.

International trends in admissions and drug sales for asthma

OBJECTIVE

To test whether national patterns of asthma drug use, particularly inhaled corticosteroids (ICS), are related to the rate of acute severe asthma exacerbations.

DESIGN

The relation of international trends in hospital admissions for asthma with asthma drug sales was examined using country-specific regressions over the period 1990-1999. Pooled estimates of the regression coefficients were calculated using random effects models.

RESULTS

Data on asthma admissions and asthma drug sales (including the sub-category ICS) were obtained from 11 countries. There was a negative relationship between falling admissions and rising sales of respiratory drugs and ICS in 9 of these 11 countries. A pooled estimate of the change in asthma admission rate per 10,000 associated with a unit increase in sales rate was -6.3 (95% CI -10.4 - -2.3) for all asthma drugs and -11.2 (95% CI -19.7 - -2.8) for ICS.

CONCLUSION

At the national level, there is good evidence that over the last decade, increased sales of asthma drugs, and ICS in particular, were associated with a decline in rates of hospital admission for asthma. This is consistent with a beneficial effect of increasing use of asthma drugs, but other explanations such as decreasing prevalence could also be responsible.

Measurement of scapula upward rotation: a reliable clinical procedure

BACKGROUND

It is important to deal with the scapula when developing rehabilitation strategies for the shoulder complex. This requires clinical measurement tools that are readily available and easy to apply and which provide a reliable evaluation of scapula motion.

AIM

To determine the reliability of the Plurimeter-V gravity inclinometer for the measurement of scapular upward rotation positions during humeral elevation in coronal abduction in a group of patients with shoulder pathology.

METHOD

Twenty six patients were assessed in two repeat tests within a single testing session. Patients exhibiting a wide spectrum of shoulder pathology were selected. The angle of scapular upward rotation was measured during total shoulder abduction. The measurement protocol was performed twice during a single testing session by a single tester. Results of the two tests were compared and the reliability assessed by intraclass correlation coefficients (ICCs).

RESULTS

There was no significant difference in the scapula measurements taken during the two tests at each testing position. Overall, there was very good intrarater reliability (ICC = 0.88). The ICC ranged from 0.81 (at 135 degrees) to 0.94 (at both resting and end of total shoulder abduction range).

CONCLUSION

The Plurimeter-V gravity inclinometer can be used effectively and reliably for measuring upward rotation of the scapula in all ranges of shoulder abduction in the coronal plane.

Predictors of lung function and its decline in mild to moderate COPD in association with gender: results from the Euroscop study

BACKGROUND

There is increasing appreciation of gender differences in COPD but scant data whether risk factors for low lung function differ in men and women. We analysed data from 3 years follow-up in 178 women and 464 men with COPD, participants in the Euroscop Study who were smokers unexposed to inhaled corticosteroids.

METHODS

Explanatory variables of gender, age, starting age and pack-years smoking, respiratory symptoms, FEV(1)%FVC and FEV(1)%IVC (clinically important measures of airway obstruction), body mass index (BMI), and change in smoking were included in multiple linear regression models with baseline and change in post-bronchodilator FEV(1) as dependent variables.

RESULTS

Reduced baseline FEV(1) was associated with respiratory symptoms in men only. Annual decline in FEV(1) was not associated with respiratory symptoms in either men or women, and was 55 ml less in obese men (BMI 30 kg/m(2)) than men having normal BMI, an effect not seen in women. It was 32 ml faster in women with FEV(1)%FVC<median than women with less airway obstruction, a larger difference than in men (8 ml per year). It was 17.7 ml/year faster when increasing the daily number of cigarettes by 10 in men only, but not significantly greater than in women.

CONCLUSION

Respiratory symptoms were associated with reduced baseline FEV(1) in men with COPD. In men, obesity was associated with reduced decline and increasing the number of cigarettes smoked with increased decline in lung function. In women more severe airway obstruction was associated with accelerated decline.

Postural Health in Women: The Role of Physiotherapy

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The association between diet and chronic obstructive pulmonary disease in subjects selected from general practice

It is unclear why some smokers develop chronic obstructive pulmonary disease (COPD) whilst the majority do not. Antioxidants found in food may protect against lung tissue injury, but previous epidemiological studies are inconsistent and do not focus on those most at risk of COPD, namely smokers. This case-controlled study measured the difference in dietary intake between smokers and exsmokers with and without COPD. Cases were patients > 45 yrs of age with > 10 pack-yrs of smoking, a forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) of < or = 70% and a FEV1 of < or = 80% of predicted. Controls were patients >45 yrs of age with > 10 pack-yrs of smoking, a FEV1/FVC of > 70% and a FEV1 > 80% pred. Data were collected using validated questionnaires. Logistic regression analysis for an unmatched case-controlled study was performed. After controlling for other independent predictors of COPD, those with vegetable intake of > or = 1 portion x day(-1) (93 g) were less likely to have COPD, as were those consuming > or = 1.5 portions x day(-1) of fruit. This was not due to an overall reduction in food/calorie intake caused by the disease because: 1) adjusting for body mass index did not alter the estimates; 2) the effect was specific to fruit and vegetables, i.e. not other food groups; and 3) the estimates from incident cases were similar. In conclusion, fruit and vegetable consumption is inversely associated with chronic obstructive pulmonary disease and may explain why some smokers do not develop chronic obstructive pulmonary disease.

Ultrastructural changes to the midgut of the black field cricket (Teleogryllus commodus) following ingestion of potato protease inhibitor II

Ultrastructural changes to the midgut epithelium of nymphs of the black field cricket (Teleogryllus commodus) after ingestion of potato protease inhibitor II (PPI-II) (0.6% (w/v) in artificial diet) were determined by light and electron microscopy. Crickets fed diet containing PPI-II grew more slowly than those fed control diet and changes observed to the PPI-II-fed nymphs included reduction of midgut wall depth, vacuolisation of the epithelial cells, swelling of the microvilli, cellular protrusions into the midgut and eventual rupture of individual or small groups of epithelial cells. These changes were first seen 2 days after PPI-II ingestion. Complete disintegration of the midgut to the basement membrane was not seen during the 27-day observation period and repair and regeneration of pockets of epithelial cells was observed. Immunocytochemistry revealed that PPI-II was localised within the ectoperitrophic matrix space of the gut. The location of the peritrophic matrix was determined by labelling with wheat germ agglutinin (WGA), but no rupture of this structure was observed in PPI-II-fed nymphs.

Smoothelin is an indicator of reversible phenotype modulation of smooth muscle cells in balloon-injured rat carotid arteries

Restenosis is the major obstacle interfering with a successful long-term outcome of balloon angioplasty. Neointima formation following endothelial injury is the result of phenotype modulation and proliferation of smooth muscle cells (SMC). To characterize these time-dependent changes, a rat balloon injury model of carotid artery restenosis was assessed. We applied monoclonal antibodies recognizing desmin, sm-alpha-actin and smoothelin, a novel marker specific for the differentiated phenotype of SMC. Neointima formation could be seen from day 7 after injury onwards. During early phases, the number of smoothelin-positive cells in the media was decreased compared with uninjured controls. Smoothelin staining was absent in the neointima during formation. Increased levels of smoothelin in both media and neointima were observed at days 28 and 56, correlating with a decrease in proliferation as assessed by Ki-67 antigen staining. No such changes were observed for desmin and sm-alpha-actin. Following balloon injury, SMC in both the media and the neointima underwent an early, reversible dedifferentiation, followed by proliferation. The novel SMC-specific marker protein smoothelin can be used to monitor this SMC (de)differentiation in neointima and media. These findings support the pivotal role of SMC phenotype modulation in neointima formation and restenosis.

Coincidence of immune-mediated diseases driven by Th1 and Th2 subsets suggests a common aetiology. A population-based study using computerized general practice data

BACKGROUND

The recent rise in the prevalence of immune-mediated diseases has been attributed to environmental factors such as a lack of microbial challenge, or dietary change, that deviate the overall balance between mutually antagonistic subsets of T helper (Th) cells.

OBJECTIVE

An alternative proposal is that recent environmental changes have resulted in an immune system that is more likely to produce both Th1 and Th2 responses against benign antigens. The prediction of this hypothesis, that Th1 and Th2-mediated diseases are not mutually exclusive, and may be positively associated, is tested here in a whole population.

METHODS

Data from General Practices participating in the Scottish Continuous Morbidity Recording (CMR) project were used to determine the coincidence of the major Th2-mediated atopic diseases; asthma, eczema and allergic rhinitis, with the Th1-mediated autoimmune conditions; type I diabetes, rheumatoid arthritis and psoriasis. We also identified the prescription rates of inhaled therapy for asthma in patients with Th1-mediated disease.

RESULTS

There was a significant increase in the risk of presenting with a Th1-mediated autoimmune condition in patients with a history of allergic disease (standardized prevalence ratio (95% confidence interval) 1.28 (1.18-1.37)). Likewise, the standardized prevalence ratios of presenting with either eczema (1.67 (1.48-1.87)) or allergic rhinitis (1.22 (1.02-1.44)) were significantly increased in subjects with a history of Th1-mediated disease. There was a particularly strong association between current psoriasis and current eczema (standardized prevalence ratio ofpsoriasis in subjects with eczema 2.88, 95% confidence interval (CI) 2.38-3.45). There was also a significant increase in prescriptions for inhaled asthma therapy in patients with Th1 disease.

CONCLUSION

It is concluded that Th1- and Th2-mediated diseases are significantly associated in a large General Practice population. This finding supports the proposal that autoimmune and atopic diseases share risk factors that increase the propensity of the immune system to generate both Th1- and Th2-mediated inappropriate responses to non-pathological antigens.

Cardiovascular and neurohormonal responses to i. v. l-arginine in two groups with primary autonomic failure

Nitric oxide (NO) is synthesised from the amino-acid l-arginine by the enzyme nitric oxide synthetase (NOS) and modulates a wide variety of neural, cardiovascular and hormonal processes. Cardiovascular autonomic dysfunction and impaired neurohormonal secretion characterise patients with primary chronic autonomic failure (AF). To investigate the role of NO, we studied the cardiovascular and neurohormonal effects of intravenous (i. v.) l-arginine (0.5 g/kg) in 20 patients with AF: [10 with multiple system atrophy (MSA) and 10 patients with pure autonomic failure (PAF)] and compared them with age-matched healthy normal subjects. Basal mean arterial pressure (MAP) was higher in MSA and PAF than controls (p < 0.02). Following l-arginine, MAP fell in MSA (mean: -39 +/- 8 mmHg, 95 % CI -21 to -57, p < 0.05) and PAF (-37 +/- 5,95 % CI -26 to -58, p < 0.05) but not in controls. There were no significant changes in HR between the groups. Basal plasma noradrenaline (NA) was similar in controls and MSA, but lower in PAF (p < 0.05). Following l-arginine the percentage rise in plasma NA was similar in controls and MSA, but not in PAF (p < 0.05). Plasma insulin rose similarly in controls and MSA, but was higher in PAF (p < 0.05). Plasma glucose rose to a similar level in all groups. In conclusion, l-arginine, lowered BP in both MSA and PAF. In PAF a contributory factor may be increased insulin release, without a compensatory increase in sympatho-neural activity to counter its potential vasodilator effects. These studies suggest that reducing NO levels, as with NOS inhibitors, may be of benefit in the treatment of postural hypotension and possibly post-prandial hypotension in chronic primary AF.

Mortality in a cohort of IVF patients

BACKGROUND

Risks associated with IVF and related assisted reproduction technologies include complications of ovarian stimulation, surgical procedures and pregnancy itself. Serious complications are uncommon but may be potentially life threatening. The aims of this study were to compare the mortality rates of women who received IVF treatment, as well as those who were referred but were not treated, with the mortality rate in the general female population, to determine the maternal mortality rate following IVF conception and to establish whether any deaths had occurred as a result of treatment complications.

METHODS

Deaths were identified in a cohort of 29 700 Australian IVF patients by record-linkage with the National Death Index and a cancer registry.

RESULTS

The all-cause mortality rates in IVF patients (treated and untreated) were significantly lower than in the general female population of the same age. In treated women, 72 deaths were observed and 125 deaths were expected giving an age-standardized mortality ratio of 0.58 (95% confidence interval 0.48-0.69). Two maternal deaths were identified in the 42 days of the puerperium. Complications of ovarian hyperstimulation syndrome could not be directly related to any of the deaths identified in this cohort.

CONCLUSIONS

As well as providing some reassurance about the safety of IVF treatments, the findings point to the existence of a 'healthy patient effect' whereby the unhealthiest women in the population are deterred from pregnancy and infertility treatment.

The increasing knowledge of the role of periconceptional folate in Victorian women of child-bearing age: follow-up of a randomised community intervention trial

OBJECTIVES

To determine the changes since 1996 in knowledge of folate for the prevention of neural tube defects (NTDs) among women of child-bearing age and measure the residual effect of an earlier consumer-directed information campaign.

DESIGN

A community, randomised trial with three matched pairs of geographically distinct local government areas in Victoria.

INTERVENTION

Printed information recommending folate intake to decrease the risk of NTDs was disseminated in 1997 to women of child-bearing age.

MAIN OUTCOME MEASURE

The proportion of women aware of the association between folate and spina bifida was established in 1996, 1997 and 2000 (approximately 200 respondents per local government area in each survey).

RESULTS

12.5% (adjusted for population sampling fraction) of 1,196 women interviewed in 1996, prior to the intervention, were aware of folate and NTDs. Independent surveys after the intervention in 1997 and again in 2000 showed that this had increased to 17.4% (n=1204) and 30.2% (n=1227) respectively. The intervention had a significant impact on folate awareness (a 4% difference in 1997 and a residual 3.3% in 2000, ORadj=1.24, 95% CI 1.19-1.37, p=0.007).

CONCLUSIONS AND IMPLICATIONS

There has been a continuing increased awareness of folate in women of child-bearing age since 1996. Within this setting, the provision of printed educational material in a brief intervention in 1997 has caused enduring increased awareness of the association between folate and NTDs. The need for ongoing health promotion action on folate remains.

Validation study of a diary for use in acute lower respiratory tract infection

BACKGROUND

Despite lower respiratory tract infection (LRTi) being the most common illness treated by doctors, no validated outcome measure to assess symptom duration and severity has been developed for patient self-completion.

METHODS

As part of a randomized control trial researching management of acute LRTi, an easy self-completion diary was formulated and validated against the 'measure yourself medical outcome profile 2' (MYMOP2), an instrument previously validated in general practice.

RESULTS

Spearman rank correlations of the diary profile versus MYMOP2 profile at baseline (r = 0.62), day 11 (r = 0.81) and change in score over time (r = 0.51) indicate that our diary correlates significantly with MYMOP2. The standardized response mean of the diary profile (mean change/SD change) = 1.48, indicating sensitivity to change.

CONCLUSION

This study shows that a simple symptom diary is internally reliable, valid and sensitive to change for acute LRTi. This instrument could be used as a routine measure of LRTi in further research in both primary and secondary care.