Doctors' reporting of mental health stigma and barriers to help-seeking

BACKGROUND

Medical practitioners experience high levels of mental disorders but may be reluctant to seek care.

AIMS

To determine medical practitioner attitudes towards other doctors with anxiety/depression, barriers to seeking mental healthcare, treatments received for depression and the effects of age.

METHODS

Data from the National Mental Health Survey of Doctors and Medical Students, conducted in Australia, were analysed (N = 10 038 medical practitioners). Attitudes to anxiety/depression were assessed with 12 statements (total stigma score, range 12-60). Barriers to seeking professional help, and coping strategies used, for anxiety/depression were measured. Practitioners with a history of depression were asked what personal supports and treatments were received. Practitioners were compared by age-younger (40 years and younger), middle-aged (41-60) and older (61+).

RESULTS

Attitudes and help-seeking behaviours varied with age. Older doctors had a more positive outlook and less total stigma, with the exception that they believed a doctor with anxiety/depression was less reliable. Younger practitioners were most likely to report barriers, such as confidentiality, impact on career progression and registration, to seeking help. For practitioners with depression, counselling and counselling plus medication were most likely to be received by the younger and middle-aged groups, whereas medication alone was most likely to be received by the middle-aged and older groups.

CONCLUSIONS

Stigmatizing attitudes towards mental disorder and barriers to help-seeking remain prevalent within the medical profession. Our results suggest doctors' health programs should address mental health stigma in younger practitioners and facilitate education about psychological treatments in older practitioners.

An 11-year review of hip fracture hospitalisations, health outcomes, and predictors of access to in-hospital rehabilitation for adults ≥ 65 years living with and without dementia: a population-based cohort study

This study examined hip fracture hospitalisation trends and predictors of access to rehabilitation for adults aged ≥ 65 years living with and without dementia. The hospitalisation rate was 2.5 times higher for adults living with dementia and adults who lived in aged care were between 4.8 and 9.3 times less likely to receive rehabilitation.

INTRODUCTION

To examine hip fracture hospitalisation temporal trends, health outcomes, and predictors of access to in-hospital rehabilitation for older adults living with and without dementia.

METHODS

A population-based retrospective cohort study of adults aged ≥ 65 years hospitalised with a hip fracture during 2007-2017 in New South Wales, Australia.

RESULTS

Of the 69,370 hip fracture hospitalisations, 27.1% were adults living with dementia. The hip fracture hospitalisation rate was 2.5 times higher for adults living with dementia compared with adults with no dementia (1186.6 vs 492.9 per 100,000 population). The rate declined by 6.1% per year (95%CI - 6.6 to - 5.5) for adults living with dementia and increased by 1.0% per year (95%CI 0.5-1.5) for adults with no dementia. Multivariable associations identified that adults living with dementia who experienced high frailty and increasing age were between 1.6 and 1.8 times less likely to receive in-hospital rehabilitation. Adults who were living in long-term aged care facilities were between 4.8 and 9.3 times less likely to receive in-hospital rehabilitation which varied by the presence of dementia or delirium.

CONCLUSION

Consistent criteria should be applied to determine rehabilitation access, and rehabilitation services designed for older adults living with dementia or in aged care are needed.

HIGHLIGHTS

• Adults living with dementia were able to make functional gains following hip fracture rehabilitation. • Need to determine consistent criteria to determine access to hip fracture rehabilitation. • Rehabilitation services specifically designed for adults living with dementia or in aged care are needed.

A Hormone That Lost Its Receptor: Anti-Müllerian Hormone (AMH) in Zebrafish Gonad Development and Sex Determination

Fetal mammalian testes secrete Anti-Müllerian hormone (Amh), which inhibits female reproductive tract (Müllerian duct) development. Amh also derives from mature mammalian ovarian follicles, which marks oocyte reserve and characterizes polycystic ovarian syndrome. Zebrafish (Danio rerio) lacks Müllerian ducts and the Amh receptor gene amhr2 but, curiously, retains amh To discover the roles of Amh in the absence of Müllerian ducts and the ancestral receptor gene, we made amh null alleles in zebrafish. Results showed that normal amh prevents female-biased sex ratios. Adult male amh mutants had enormous testes, half of which contained immature oocytes, demonstrating that Amh regulates male germ cell accumulation and inhibits oocyte development or survival. Mutant males formed sperm ducts and some produced a few offspring. Young female mutants laid a few fertile eggs, so they also had functional sex ducts. Older amh mutants accumulated nonvitellogenic follicles in exceedingly large but sterile ovaries, showing that Amh helps control ovarian follicle maturation and proliferation. RNA-sequencing data partitioned juveniles at 21 days postfertilization (dpf) into two groups that each contained mutant and wild-type fish. Group21-1 upregulated ovary genes compared to Group21-2, which were likely developing as males. By 35 dpf, transcriptomes distinguished males from females and, within each sex, mutants from wild types. In adult mutants, ovaries greatly underexpressed granulosa and theca genes, and testes underexpressed Leydig cell genes. These results show that ancestral Amh functions included development of the gonadal soma in ovaries and testes and regulation of gamete proliferation and maturation. A major gap in our understanding is the identity of the gene encoding a zebrafish Amh receptor; we show here that the loss of amhr2 is associated with the breakpoint of a chromosome rearrangement shared among cyprinid fishes.

Future hospital service utilisation in older adults living in long-term residential aged care or the community hospitalised with a fall-related injury

This study identified group-based trajectories of hospitalisation for older adults who were living in residential aged care facilities (RACF) or the community for up to 4 years after an index fall injury hospitalisation. Greater than 3 subsequent fall injury hospitalisations and time until move to a RACF were key predictors of RACF and community-living trajectory group memberships, respectively.

INTRODUCTION

To examine hospital service use trajectories of people aged ≥ 65 years who had a fall injury hospitalisation and were either living in a residential aged care facility (RACF) or the community at the time of the index fall and to identify factors predictive of their trajectory group membership.

METHOD

A group-based trajectory analysis of hospitalisations of people aged ≥ 65 years who had a fall injury hospitalisation during 2008-2009 in New South Wales, Australia, was conducted. Linked hospitalisation and RACF data were examined for a 5-year period. Group-based trajectory models were derived based on number of subsequent hospital admissions following the index fall injury hospitalisation. Multinominal logistic regression examined predictors of trajectory group membership.

RESULTS

There were 24,729 fall injury hospitalisations; 78.8% of fallers were living in the community and 21.2% in a RACF. Five distinct trajectory groups were identified for community-living and four trajectory groups for RACF residents. Key predictors of trajectory group membership for both community-living and RACF residents were age group, number of comorbidities and dementia status. For RACF residents, depression, assistance with activities of daily living and number of subsequent fall injury admissions were also predictors of group membership, with time to move to a RACF a predictor of group membership for community living.

CONCLUSIONS

Identifying trajectories of ongoing hospital use informs targeting of strategies to reduce hospital admissions and design of services to allow community-living individuals to remain as long as possible within their own residence.

Comparison of hospitalised trends, treatment cost and health outcomes of fall-related hip fracture for people aged ≥ 65 years living in residential aged care and the community

This study compared hip fracture rates and health outcomes of older people living in residential aged care facilities (RACFs) to the community. The RACF resident age-standardised hospitalisation rate was five times higher than the community rate and declining. RACF residents experience overall worse health outcomes and survival post-hip fracture.

INTRODUCTION

To compare hospitalisation trends, characteristics and health outcomes following a fall-related hip fracture of older people living in residential aged care facilities (RACFs) to older people living in the community.

METHODS

A retrospective analysis of fall-related hip fracture hospitalisations of people aged ≥ 65 years during 1 July 2008 and 30 June 2013 in New South Wales (NSW), Australia's largest populated state. Linked hospitalisation, RACF and Aged Care Assessment Appraisal data collections were examined. Negative binomial regression examined the significance of hospitalisation temporal trends.

RESULTS

There were 28,897 hip fracture hospitalisations. One-third were of older people living in RACFs. The hospitalisation rate was 2180 per 100,000 (95%CI: 2097.0-2263.7) for RACF residents and 390 per 100,000 (95%CI 384.8-395.8) for older people living in the community. The hospitalisation rate for RACF residents was estimated to decline by 2.9% annually (95%CI: - 4.3 to - 1.5). Hospital treatment cost for hip fractures was AUD$958.5 million. Compared to older people living in the community, a higher proportion of RACF residents were aged ≥ 90 years (36.1% vs 17.2%), were female (75.3% vs 71.8%), had > 1 Charlson comorbidity (37.6% vs 35.6%) and 58.2% had dementia (vs 14.4%). RACF residents had fewer in-hospital rehabilitation episodes (18.7% vs 60.9%) and a higher proportion of unplanned readmissions (10.6% vs 9.1%) and in-hospital mortality (5.9% vs 3.3%) compared to older people living in the community.

CONCLUSIONS

RACF residents are a vulnerable cohort of older people who experience worse health outcomes and survival post-hip fracture than older people living in the community. Whether access to individualised hip fracture rehabilitation for RACF residents could improve their health outcomes should be examined.

Community-based provision of direct-acting antiviral therapy for hepatitis C: study protocol and challenges of a randomized controlled trial

BACKGROUND

To achieve the World Health Organization hepatitis C virus (HCV) elimination targets, it is essential to increase access to treatment. Direct-acting antiviral (DAA) treatment can be provided in primary healthcare services (PHCS), improving accessibility, and, potentially, retention in care. Here, we describe our protocol for assessing the effectiveness of providing DAAs in PHCS, and the impact on the HCV care cascade. In addition, we reflect on the challenges of conducting a model of care study during a period of unprecedented change in HCV care and treatment.

METHODS

Consenting patients with HCV infection attending 13 PHCS in Australia or New Zealand are randomized to receive DAA treatment at the local tertiary institution (standard care arm), or their PHCS (intervention arm). The primary endpoint is the proportion commenced on DAAs and cured. Treatment providers at the PHCS include: hepatology nurses, primary care practitioners, or, in two sites, a specialist physician. All PHCS offer opioid substitution therapy.

DISCUSSION

The Prime Study is the first real-world, randomized, model of care study exploring the impact of community provision of DAA therapy on HCV-treatment uptake and cure. Although the study has faced challenges unique to this period of time characterized by changing treatment and service delivery, the data gained will be of critical importance in shaping health service policy that enables the elimination of HCV.

TRIAL REGISTRATION

ClinicalTrials.gov , ID: NCT02555475 . Registered on 15 September 2015.

Gonadal soma controls ovarian follicle proliferation through Gsdf in zebrafish

BACKGROUND

Aberrant signaling between germ cells and somatic cells can lead to reproductive disease and depends on diffusible signals, including transforming growth factor-beta (TGFB) -family proteins. The TGFB-family protein Gsdf (gonadal soma derived factor) controls sex determination in some fish and is a candidate for mediating germ cell/soma signaling.

RESULTS

Zebrafish expressed gsdf in somatic cells of bipotential gonads and expression continued in ovarian granulosa cells and testicular Sertoli cells. Homozygous gsdf knockout mutants delayed leaving the bipotential gonad state, but then became a male or a female. Mutant females ovulated a few oocytes, then became sterile, accumulating immature follicles. Female mutants stored excess lipid and down-regulated aromatase, gata4, insulin receptor, estrogen receptor, and genes for lipid metabolism, vitellogenin, and steroid biosynthesis. Mutant females contained less estrogen and more androgen than wild-types. Mutant males were fertile. Genomic analysis suggests that Gsdf, Bmp15, and Gdf9, originated as paralogs in vertebrate genome duplication events.

CONCLUSIONS

In zebrafish, gsdf regulates ovarian follicle maturation and expression of genes for steroid biosynthesis, obesity, diabetes, and female fertility, leading to ovarian and extra-ovarian phenotypes that mimic human polycystic ovarian syndrome (PCOS), suggesting a role for a related TGFB signaling molecule in the etiology of PCOS. Developmental Dynamics 246:925-945, 2017. © 2017 Wiley Periodicals, Inc.

Impairment in instrumental activities of daily living with high cognitive demand is an early marker of mild cognitive impairment: the Sydney memory and ageing study

BACKGROUND

Criteria for mild cognitive impairment (MCI) consider impairment in instrumental activities of daily living (IADL) as exclusionary, but cross-sectional studies suggest that some high-level functional deficits are present in MCI. This longitudinal study examines informant-rated IADL in MCI, compared with cognitively normal (CN) older individuals, and explores whether functional abilities, particularly those with high cognitive demand, are predictors of MCI and dementia over a 2-year period in individuals who were CN at baseline.

METHOD

A sample of 602 non-demented community dwelling individuals (375 CN and 227 with MCI) aged 70-90 years underwent baseline and 24-month assessments that included cognitive and medical assessments and an interview with a knowledgeable informant on functional abilities with the Bayer Activities of Daily Living Scale.

RESULTS

Significantly more deficits in informant-reported IADL with high cognitive demand were present in MCI compared with CN individuals at baseline and 2-year follow-up. Functional ability in CN individuals at baseline, particularly in activities with high cognitive demand, predicted MCI and dementia at follow-up. Difficulties with highly cognitively demanding activities specifically predicted amnestic MCI but not non-amnestic MCI whereas those with low cognitive demand did not predict MCI or dementia. Age, depressive symptoms, cardiovascular risk factors and the sex of the informant did not contribute to the prediction.

CONCLUSIONS

IADL are affected in individuals with MCI, and IADL with a high cognitive demand show impairment predating the diagnosis of MCI. Subtle cognitive impairment is therefore likely to be a major hidden burden in society.

Prevalence and characteristics of depression in mild cognitive impairment: the Sydney Memory and Ageing Study

OBJECTIVE

Depression might be a risk factor for dementia. However, little is known about the prevalence of depressive symptoms in mild cognitive impairment (MCI) and whether mood or motivation-related symptoms are predominant.

METHOD

A total of 767 non-demented community-dwelling adults aged 70-90 years completed a comprehensive assessment, including neuropsychological testing, and a past psychiatric/medical history interview. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS) and Kessler Psychological Distress Scale (K10). Exploratory factor analysis was performed on the GDS and K10 to derive 'mood' and 'motivation' subscales.

RESULTS

A total of 290 participants were classified as having MCI and 468 as cognitively normal (CN). Participants with MCI reported more depressive symptoms, and more MCI participants met the cut-off for clinically significant symptoms, relative to CN participants. Those with amnestic MCI (aMCI), but not non-amnestic MCI, had more depressive symptoms and were more likely to meet the cut-off for clinically significant depressive symptoms, relative to CN participants. Participants with MCI reported more mood-related symptoms than CN participants, while there were no differences between groups on motivation-related symptoms.

CONCLUSION

Individuals with MCI, especially aMCI, endorse more depressive symptoms when compared with cognitively intact individuals. These findings highlight the importance of assessing and treating depressive symptoms in MCI.

Making decisions about delirium: a qualitative comparison of decision making between nurses working in palliative care, aged care, aged care psychiatry, and oncology

BACKGROUND

Delirium has a significant impact on nursing practice from diagnosis and management, with under-detection and variable management of delirium being international problems. This study aimed to explore nurses' assessment and management of delirium when caring for people with cancer, the elderly or older people requiring psychiatric care in the inpatient setting.

METHODS

Participants in this qualitative study were nurses working in Australian public hospital inpatient dedicated units in palliative care, aged care (geriatrics), aged care (geriatric) psychiatry and oncology. Semi-structured interviews were used to explore nurses' views about specific areas of delirium assessment and management. Purposive sampling was used and interviews conducted until thematic saturation reached. A thematic content analysis was performed from a grounded theory perspective.

RESULTS

A total of 40 participants were included in the study. The analysis revealed four broad analytical themes: (1) superficial recognition and understanding of the operational definition of delirium or recognition of delirium as a syndrome; (2) nursing assessment: investigative versus a problem solving approach; (3) management: maintaining dignity and minimizing chaos; and (4) distress and the effect on others.

DISCUSSION

Nurses have limited knowledge of the features of delirium regardless of their specialty discipline. Delirium was uniformly identified as a highly distressing experience for patients, families and staff alike. The majority of nurses had a superficial understanding of delirium management, and adopted a task-orientated approach aimed at addressing the more noticeable problems. These findings have implications for both education and knowledge translation. Innovative approaches are needed to align health professional behaviours with best evidence delirium care.

Psychiatric disorders in ageing

The ageing of the population brings particular challenges to psychiatric practice. Although the clinical presentation of common psychiatric disorders such as mood and psychotic disorders is largely similar to those in younger adults, late life presentations tend to be more complex as co-morbidity with dementia and physical illness is common. Suicide tends to increase with age in most countries. In this chapter we argue that the aetiology of disorders may be best understood within a stress vulnerability model in which neurobiological and psychosocial factors interplay. We further present that management strategies need to be comprehensive, incorporating physical, social, pharmacological, and psychological treatments appropriate to each case. We close with a call for the use of specialised multi-disciplinary services to improve the overall quality of care.

The relationship of current depressive symptoms and past depression with cognitive impairment and instrumental activities of daily living in an elderly population: the Sydney Memory and Ageing Study

Depressive symptoms are common in the elderly and they have been associated with cognitive and functional impairment. However, relatively less is known about the relationship of a lifetime history of depression to cognitive impairment and functional status. The aim of this cross-sectional study was to assess whether current depressive symptoms and past depression are associated with cognitive or functional impairment in a community-based sample representative of east Sydney, Australia. We also examined whether there was an interaction between current and past depression in their effects on cognitive performance. Eight hundred non-demented aged participants received a neuropsychological assessment, a past psychiatric history interview and the 15-item Geriatric Depression Scale. The Bayer-Activities of Daily Living scale was completed by an informant to determine functional ability. Clinically relevant depressive symptoms were present in 6.1% of the sample and 16.6% reported a history of depression. Participants with current depression had significantly higher levels of psychological distress and anxiety, and lower life satisfaction and performed worse on memory and executive function compared to participants without current depression. After controlling for anxiety the effect on executive function was no longer significant while the effect on memory remained significant. A history of depression was associated with worse executive function, higher levels of psychological distress and anxiety, and lower life satisfaction. After controlling for psychological distress the effect of past depression on executive function was no longer significant. There were no significant interactions between current and past depression in their effects on cognitive performance. There were no differences between participants with or without current depression and with or without past depression on functional abilities. These results support the view that current and past depressive episodes are associated with poorer cognitive performance but not with functional abilities.

Provincial differences in infant deaths in South Africa – an effect of antiretroviral interventions?

Original article

Differing management of people with advanced cancer and delirium by four sub-specialties

INTRODUCTION

Delirium in advanced cancer is prevalent, with limited prospective data to guide management. The aim was to survey current practice of specialists using two contrasting cases of delirium in cancer.

METHODS

A questionnaire was designed to identify investigations and treatment used, in relation to two cases.

RESULTS

Overall response rate (n = 270) was 30%. Place of care: Only 35% of medical oncologists would consider care at home for a patient with reversible delirium compared with 66% of other specialists.

INVESTIGATIONS

85% specialists would order basic bloods, however, medical oncologists were more likely to use oxygen saturation and head computed tomography, psychogeriatricians more likely to order thyroid function and palliative medicine specialists less likely to order chest X-ray and urine culture. Greater than 40% of specialists would do no investigations for terminal delirium.

TREATMENT

Medical oncologists use more pre-emptive therapies and more likely to use a benzodiazepine as agent of choice, and Palliative medicine specialists used significantly more neuroleptics to treat hypoactive symptoms of delirium.

DISCUSSION

The survey emphasise significant areas of variability in the management of delirium in advanced cancer. Furthermore, evidence to guide management in ways that draw on the strengths and knowledge of each specialty is urgently needed.

Zebrafish bmp4 functions during late gastrulation to specify ventroposterior cell fates

Bone morphogenetic proteins (BMPs) are key mediators of dorsoventral patterning in vertebrates and are required for the induction of ventral fates in fish and frogs. A widely accepted model of dorsoventral patterning postulates that a morphogenetic BMP activity gradient patterns cell fates along the dorsoventral axis. Recent work in zebrafish suggests that the role of BMP signaling changes over time, with BMPs required for global dorsoventral patterning during early gastrulation and for tail patterning during late gastrulation and early somitogenesis. Key questions remain about the late phase, including which BMP ligands are required and how the functions of BMPs differ during the early and late gastrula stages. In a screen for dominant enhancers of mutations in the homeobox genes vox and vent, which function in parallel to bmp signaling, we identified an insertion mutation in bmp4. We then performed a reverse genetic screen to isolate a null allele of bmp4. We report the characterization of these two alleles and demonstrate that BMP4 is required during the later phase of BMP signaling for the specification of ventroposterior cell fates. Our results indicate that different bmp genes are essential at different stages. In addition, we present genetic evidence supporting a role for a morphogenetic BMP gradient in establishing mesodermal fates during the later phase of BMP signaling.

Vocally disruptive behaviour in dementia: development of an evidence based practice guideline

Vocally Disruptive Behaviour (VDB) is a term that includes screaming, abusive language, moaning, perseveration, and repetitive and inappropriate requests. It is one of the most challenging behaviours for nursing home staff, caregivers for people with dementia, and other nursing home residents. As with other behavioural disturbances, multiple causal factors have been identified in the literature and individual cases may have a number of interacting factors. There is a lack of consensus about how to treat VDB. Systematic treatment studies are few and there is a lack of empirical data supporting the effectiveness of specific interventions commonly used in clinical practice. This hinders clinicians and may result in the use of inappropriate treatments. Our aim was to systematically review the literature in order to develop a practice guideline for the assessment and management of VDB. The review will examine the typology, risk factors and management of VDB.

The prevalence of "cognitive impairment no dementia" in community-dwelling elderly: a pilot study

OBJECTIVE

To determine the prevalence of "cognitive impairment no dementia" (CIND) and "amnestic mild cognitive impairment" (aMCI) in a population sample of 70-79-year-olds and the risk factors for CIND.

METHOD

Cross sectional population survey.

SETTING

Sutherland Shire, Sydney, Australia.

SUBJECTS

150 community-dwelling 70-79-year-olds were screened by telephone, 42 of whom were assessed at home.

MEASURES

Demographics, subjective ratings of physical and emotional health and memory, cardiovascular risk factors, medications, the Mini-Mental State Examination, Boston Naming Test, Trail Making Tests A and B, Block Design, Rey Auditory Verbal Learning Test (RAVLT), Visual Reproduction, Logical Memory, letter and category fluency, the National Adult Reading Test (NART), the Geriatric Depression Scale (GDS) and the "state" section of the State-Trait Anxiety Inventory (STAI-S).

RESULTS

From the 400 subjects contacted initially, 150 consented to be interviewed and 131 eligible subjects were recruited. Of a 1-in-3 random sample of 42 subjects assessed at home, 14 (33.3%) subjects met criteria for CIND, 1 (2.4%) had possible dementia and the 27 remaining (64.3%) were cognitively normal. Four (9.5%) met criteria for aMCI. Subjects with CIND were older, had lower ranking occupations and were less likely to be currently working than those classified as cognitively normal. Ten subjects with CIND did not meet criteria for aMCI because they lacked subjective memory impairment (n = 3) or had cognitive deficits other than memory (n = 7). All subjects with aMCI met criteria for CIND.

CONCLUSIONS

One-third of individuals in this population sample met criteria for CIND. CIND is a broader definition than aMCI. Further research is needed to determine the longitudinal course and clinical utility of these definitions of cognitive impairment.

The relationship between self-destructive behaviour and nursing home environment

The aim of this study was to explore the relationship between self-destructive behaviour and nursing home environment. We performed a cross-sectional study comprising 647 residents in 11 nursing homes in Sydney, Australia using the Harmful Behaviours Scale (HBS), Abbreviated Mental Test Scale and the Resident Classification Index. The Directors of Nursing completed a questionnaire that rated physical design, staff and resident characteristics and demographics were obtained from nursing home records. On regression analysis a greater number of design features for frail and residents with dementia in general, and increased security measures were associated with greater HBS total score and risk-taking and passive self-harm subscales. A residential environment in which the residents were more functionally dependent and more likely to be in a shared room, managerial policies less geared towards managing difficult behaviour and less staff availability and training were associated with the 'uncooperativeness' factor. There were no significant predictors of the other two factors. The relationship between nursing home environment and self-destructive behaviours and the environment is complex and there needs to be an individualized approach to placement.

Dynamics of the pi(-)p-->pi(0)pi(0)n reaction for p(pi(-))<750 MeV/c

Data are presented for the reaction pi(-)p-->pi(0)pi(0)n in the range from threshold to p(pi(-))=750 MeV/c. The systematics of the data and multipole analyses are examined for sensitivity to a f(0)(600) ("sigma") meson. A one-pion-exchange mechanism is found to be very weak, or absent. The reaction appears to become dominated by sequential pi(0) decays through the Delta(1232) resonance as the beam momentum increases, along with substantial interference effects from several competing mechanisms.

A zebrafish sox9 gene required for cartilage morphogenesis

The molecular genetic mechanisms of cartilage construction are incompletely understood. Zebrafish embryos homozygous for jellyfish (jef)mutations show craniofacial defects and lack cartilage elements of the neurocranium, pharyngeal arches, and pectoral girdle similar to humans with campomelic dysplasia. We show that two alleles of jef contain mutations in sox9a, one of two zebrafish orthologs of the human transcription factor SOX9. A mutation induced by ethyl nitrosourea changed a conserved nucleotide at a splice junction and severely reduced splicing of sox9a transcript. A retrovirus insertion intosox9a disrupted its DNA-binding domain. Inhibiting splicing of thesox9a transcript in wild-type embryos with splice site-directed morpholino antisense oligonucleotides produced a phenotype like jefmutant larvae, and caused sox9a transcript to accumulate in the nucleus; this accumulation can serve as an assay for the efficacy of a morpholino independent of phenotype. RNase-protection assays showed that in morpholino-injected animals, the percent of splicing inhibition decreased from 80% at 28 hours post fertilization to 45% by 4 days. Homozygous mutant embryos had greatly reduced quantities of col2a1 message, the major collagen of cartilage. Analysis of dlx2 expression showed that neural crest specification and migration was normal in jef (sox9a)embryos. Confocal images of living embryos stained with BODIPY-ceramide revealed at single-cell resolution the formation of precartilage condensations in mutant embryos. Besides the lack of overt cartilage differentiation,pharyngeal arch condensations in jef (sox9a) mutants lacked three specific morphogenetic behaviors: the stacking of chondrocytes into orderly arrays, the individuation of pharyngeal cartilage organs and the proper shaping of individual cartilages. Despite the severe reduction of cartilages, analysis of titin expression showed normal muscle patterning in jef (sox9a) mutants. Likewise, calcein labeling revealed that early bone formation was largely unaffected injef (sox9a) mutants. These studies show that jef(sox9a) is essential for both morphogenesis of condensations and overt cartilage differentiation.

Psychosis, depression and behavioural disturbances in Sydney nursing home residents: prevalence and predictors

BACKGROUND

There is wide variation in the rates of behavioural and psychological symptoms of dementia (BPSD) reported in nursing homes.

AIMS

This study aimed to investigate: (1) the prevalence of BPSD in nursing home residents using the BEHAVE-AD; (2) the relationships of BPSD with (a) demographic, (b) dementia, (c) diurnal and (d) nursing home variables; and (3) the inter-relationships between different types of BPSD, as measured by subscales of the BEHAVE-AD.

RESULTS

Over 90% of residents exhibited at least one behavioural disturbance. Specifically, there was evidence of psychosis in 60%, depressed mood in 42% and activity disturbances or aggression in 82% of residents. Younger, more functionally impaired residents with a chart diagnosis of psychosis had higher BPSD rates, as did those residing in larger nursing homes. Individual BPSD were significantly intercorrelated.

CONCLUSIONS

BPSD are ubiquitous in nursing home residents. Behavioural disturbances are frequently associated with psychosis and/or depression. The findings suggest the need for psychogeriatric services to nursing homes and smaller facilities.

Use of psychotropics in Sydney nursing homes: associations with depression, psychosis, and behavioral disturbances

The purpose of this study was to determine the prevalence of psychotropic use in nursing home residents, the extent to which psychotropic dosage is consistent with published guidelines, and the relationships between psychotropic class and psychiatric and behavioral disturbances. Six hundred forty-seven subjects, mean age 82.3 years, residing in 11 nursing homes in the eastern suburbs of Sydney, Australia, were assessed using the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), the Abbreviated Mental Test Scale, and the Even Briefer Assessment Scale for Depression (EBAS-DEP). Details of psychotropic prescription and diagnoses of depression, dementia, and psychosis were obtained from nursing home charts. Psychotropics were prescribed for 333 (51.5%) residents, 381 (58.9%) if "as required" (PRN) use is included. Prescription of multiple psychotropics was present in 148 (22.7%) residents. Antidepressants were prescribed for 19.8% of residents, with subtherapeutic doses less likely in residents on selective serotonin reuptake inhibitors. On logistic regression, the use of antidepressants was predicted by the affective disturbances subscale on the BEHAVE-AD. Only 30.4% of residents with significant depressive symptoms on the EBAS-DEP were prescribed antidepressants. Antipsychotics were prescribed for 21.3% residents at a mean dosage of 73 mg chlorpromazine equivalence. Residents on antipsychotics had significantly higher scores on the delusions, hallucinations, activity disturbance, and aggressiveness subscales of the BEHAVE-AD. On logistic regression, only the activity disturbance subscale and chart diagnoses of dementia and psychosis were significant predictors. Psychosis (58.8%) and behavioral disturbances (91.9%) were more prevalent in residents prescribed antipsychotics than in residents not prescribed antipsychotics (42.5% and 76.6%, respectively). High rates of behavioral and psychological symptoms of dementia remained in residents prescribed antipsychotics and high rates of depressive symptoms in residents prescribed antidepressants, suggesting a role for nonpharmacological strategies.

Case-controlled study of nursing home residents referred for treatment of vocally disruptive behavior

The aim of this study was to identify factors associated with vocally disruptive behavior (VDB) in nursing home patients referred to aged care services for treatment, using a case-control methodology. Characteristics of the VDB, reasons for referral, perceived causal factors, and psychotropic use were noted. Twenty-five subjects and controls were examined with the Screaming Behavior Mapping Instrument, the Cornell Scale for Depression in Dementia, the Dementia Behavior Disturbance Scale, and measures of cognition, functional capacity, social activities, and emotional reactions of nursing staff. VDB was associated with other disturbed behaviors, depression, anxiety, severe dementia, functional impairment, communication difficulties, use of psychotropic medication, social isolation, and emotional distress in the nursing staff. Reasons for referral may relate more to the stress experienced by nursing home staff in managing VDB than to specific attributes of the VDB itself.

The effectiveness of old age psychiatry services

The objective of this study was to review outcomes of acute service delivery in old age psychiatry. Sources of data included Medline, PsycINFO and Cochrane Collaboration databases of English language papers to 1998 on service delivery evaluation in 'old age psychiatry', 'psychogeriatrics' and 'geriatric psychiatry', supplemented by a manual search of references from relevant literature. All controlled trials, audits, and surveys of the outcomes of service delivery in old age psychiatry located in acute hospitals and community settings were included. Service delivery by medical, adult psychiatry and consultation/liaison services were included. With the exception of outreach services to nursing homes, long term institutional care was excluded. All data were extracted by the author. Data quality was assessed by applying an evidence hierarchy. Evaluation strategies were qualitatively reviewed. Controlled trials, audits and surveys were each found to provide important data in the evaluation of service delivery. There is better quality evidence to support the effectiveness of components of old age psychiatry services than other service types. The majority of studies indicate that old age psychiatry services have positive acute treatment outcomes, particularly with depression. There is insufficient evidence to determine which processes of care are associated with better outcomes. Pluralistic evaluations indicate that carers often have unmet needs and are not as positive about outcomes. There have been no controlled comparisons of service delivery provided by other services. In conclusion, controlled trials and audits indicate that old age psychiatry services are effective. Further pluralistic evaluations and comparisons with other services are required.

Psychiatry of old age: from section to faculty

OBJECTIVE

To describe the processes that led to formation of the RANZCP Faculty of Psychiatry of Old Age (FPOA).

METHOD AND RESULTS

Two criteria needed to be fulfilled before Faculty status could be approved. One was to demonstrate a recognised body of knowledge concerning psychiatry of old age, and the other was to be able to offer a comprehensive training program in this subspecialty.

CONCLUSIONS

On 1 January 1999, FPOA came into existence.

The International Psychogeriatric Association--ninth congress. 15-20 August 1999, Vancouver, Canada

In contrast to previous International Psychogeriatric Association (IPA) meetings, there was a preponderance of sessions dedicated to pharmacological management of cognitive decline due to Alzheimer's disease (AD), especially by cholinesterase inhibitors. Donepezil (Eisai Co Ltd) and rivastigmine (Novartis AG) were most frequently featured, while propentofylline (Hoechst AG) has emerged as an agent potentially efficacious in both AD and vascular dementia. A second focus was the treatment of the behavioral and psychological symptoms of dementia (BPSD), particularly by the atypical antipsychotics risperidone (Janssen Pharmaceutica NV), olanzapine (Eli Lilly & Co) and quetiapine (AstraZeneca plc), but also by anticonvulsants. Some attempts were made to redress the balance by examining non-pharmacological treatments. There were surprisingly few presentations on the management of depression. Fortunately, most of the presentations focused on the difficult issue of comorbid depression and medical illness. Overall, there were no major disclosures of new drugs. Most new data was simply a refinement of previously published material.

The Senior Psychiatrist Survey III: attitudes towards personal ageing, life experiences and psychiatric practice

OBJECTIVE

The aim of this study is: to explore whether there is a relationship between the effects of gender, age and perceptions of personal health on psychiatrist's reactions to personal ageing; and to determine the effects of psychiatrist's reactions to personal ageing upon their approach to clinical practice, retirement planning and post-retirement activities.

METHOD

A postal survey was conducted. Respondents were Fellows of the Royal Australian and New Zealand College of Psychiatrists resident in Australia or New Zealand. Of 1086 eligible subjects, 529 participated. The main outcome measures were: Reactions to Ageing Questionnaire (RAQ); self-rated health; location and type of psychiatric practice; the perceived benefits and drawbacks of age on psychiatric practice and case selection; and retirement plans.

RESULTS

Positive attitudes towards personal ageing were significantly associated with old age, males and good or excellent self-rated health. Negative attitudes were associated with working in universities and anticipated retirement due to poor health. Field of practice, anticipated post-retirement activities and approach to clinical practice were not found to have a significant effect on attitudes towards personal ageing.

CONCLUSIONS

The effects of life experiences on psychiatrists' attitudes towards personal ageing are complex. Attitudes towards personal ageing have little impact on psychiatric practice.

The Senior Psychiatrist Survey I: age and psychiatric practice

OBJECTIVE

The aim of this study is to determine the effects of age on the practice, roles, status and attitudes of psychiatrists within the Royal Australian and New Zealand College of Psychiatrists (RANZCP).

METHOD

A postal survey of Fellows of the RANZCP resident in Australia or New Zealand was conducted. The main outcome measures were: age; location and type of psychiatric practice; hours of work; attitudes towards re-accreditation; changes in work practices over the career; and the perceived benefits and drawbacks of age to psychiatric practice and case selection.

RESULTS

Of 1086 eligible subjects, 629 participated. The mean age of the sample was 52.7 years (SD = 13.5). Those psychiatrists favouring re-accreditation were younger. Psychiatrists practising psychotherapy, forensic psychiatry or general psychiatry; working in psychiatric hospitals and private practice were more likely to be older. Older psychiatrists worked shorter hours. There was largely no association between case selection and age. Psychiatrists reporting increased credibility and respect as a benefit of their current age upon their psychiatric practice were older, as were those identifying fatigue and an inability to keep up to date as a drawback of age. Psychiatrists reporting a lack of credibility and respect were younger, as were those who reported increased enthusiasm and optimism.

CONCLUSIONS

Age is associated with benefits and drawbacks to the practice of psychiatry and this may be reflected in the different practice profiles of older and younger psychiatrists.

The Senior Psychiatrist Survey II: experience and psychiatric practice

OBJECTIVE

The aim of this study is to determine the effects of experience on the practice, roles, status and attitudes of psychiatrists within the Royal Australian and New Zealand College of Psychiatrists (RANZCP).

METHOD

A postal survey of Fellows of the RANZCP resident in Australia or New Zealand was conducted. The main outcome measures were: years of psychiatric experience; higher medical qualifications; location and type of psychiatric practice; attitudes about senior psychiatrists and mentorship; changes in work practices over the career; and the perceived benefits and drawbacks of experience on psychiatric practice and case selection.

RESULTS

Of 1086 eligible subjects, 629 participated. Over 96% of respondents, particularly the younger and less experienced, believed that senior psychiatrists have wisdom to offer to junior colleagues. This wisdom principally related to mentorship/supervision. Increased 'respect and tolerance' of patients as a benefit of experience was more likely to be reported by respondents who were more experienced. Respondents more confident about treating younger patients and treating functional psychoses were more likely to be less experienced, as were those reluctant to take on psychotherapy cases. Those respondents reluctant to take on 'dangerous or acting-out patients' were more experienced. The field of psychiatric practice significantly influenced case selection.

CONCLUSIONS

Senior psychiatrists have accumulated wisdom through experience that is sought by junior colleagues via mentorship. It is recommended that the RANZCP should specifically address the needs of early career and senior psychiatrists.

Treatment of vocally disruptive behaviour of multifactorial aetiology

OBJECTIVE

To describe the treatment of vocally disruptive behaviour (VDB) of multifactorial aetiology.

METHOD

Three case reports were used to illustrate the treatment of multifactorial VDB.

RESULTS

A biopsychosocial assessment is required to identify the different aetiologies involved and the way they interact. Acute medical and psychiatric factors may demand that interventions are introduced simultaneously rather than in succession.

CONCLUSION

Successful interventions require the combination of biopsychosocial strategies tailored to the individual case with realistic goals that include the acceptance of a residual level of VDB as a reasonable outcome.

Stress in carers of the elderly. A controlled study of patients attending a Sydney family medical practice

AIM

To examine stress in carers of the elderly who attended a solo family medical practice.

METHOD

Eighty-seven carers were compared with 102 non-caregiving controls. Subjects were asked to complete survey questionnaires either in the surgery or at home. The General Health Questionnaire (CHQ) was used to assess psychological morbidity, the Relative Stress Scale as a measure of subjective burden and information was collected on activities of daily living and instrumental activities of daily living.

RESULTS

No significant difference was found in GHQ scores, reflecting the high level of stress in this family practice sample (mean GHQ = 4.7, standard deviation = 6.2). Psychological morbidity in carers was associated with the provision of assistance with instrumental activities of daily living such as shopping, cooking and finances.

CONCLUSIONS

We suggest that because carers often encounter specific challenges which may be amenable to intervention, general practitioners should familiarise themselves with these issues, determine the caregiving status of their patients and provide information about community services to carers.

Suicidal ideation and the 'wish to die' in dementia patients: the role of depression

OBJECTIVE

To determine the prevalence of self-reported suicidal ideation and the 'wish to die' in dementia patients, their association with depressive symptoms and the type of dementia.

DESIGN

The cohort was formed retrospectively of consecutive referrals between 1985 and 1994 of cognitively impaired patients who met American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, third edition and third edition, revised, criteria for dementia. They were assessed for depression using the 21-item Hamilton Rating Scale for Depression (HRSD) which includes an item on suicide.

SETTING

An outpatient multidisciplinary memory disorders clinic in Sydney, Australia.

PATIENTS

The sample comprised 221 patients with dementia: 148 with Alzheimer's disease according to NINCDS-ADRDA criteria, 24 with vascular dementia diagnosed by a Hachinski ischaemia scale score of seven or more, plus focal neurological signs, symptoms or computed tomography-visible lesions, and 49 with other dementias.

MEASURES

Cognitive impairment was measured by the Mini-Mental State Examination and the Blessed orientation-information-memory-concentration test and dementia scales, depression by the 21-item HRSD, suicidal ideation and the 'wish to die' as defined by the suicide item on the HRSD, functional capacity by the activities of daily living scale and the instrumental activities of daily living scale. Caregiver psychological morbidity was assessed with the General Health Questionnaire.

RESULTS

12 patients (5.4%) felt life was not worth living, seven (3.2%) 'wished to die' or had thoughts of death, two (0.9%) had suicidal ideation or gestures and none had made any suicide attempts. The nine patients who 'wished to die' or had suicidal ideation scored 12 or more on the HRSD. Of these, six were clinically depressed. Suicidal ideation and the 'wish to die' were significantly correlated with the presence of depressive symptoms as measured by the HRSD (suicide item excluded), but only in those with Alzheimer's disease. There were no significant differences in HRSD scores between the dementia groups. Suicidal ideation was unrelated to the presence of insight into loss of memory.

CONCLUSIONS

Suicidal ideation and/or the 'wish to die' is self-reported in 4% of dementia patients attending a memory disorders clinic and is associated with comorbid depressive symptoms, particularly in Alzheimer's disease.

Quantification of factors contributing to length of stay in an acute psychogeriatric ward

OBJECTIVE

To identify variables that predict length of stay (LOS) in an acute psychogeriatric ward; quantify psychiatric, medical and social factors that contribute to LOS; and identify factors that prolong LOS.

DESIGN

Prospective audit of admissions over 12 months.

SETTING

Acute psychogeriatric ward in teaching hospital.

PATIENTS

73 consecutive patients with a total of 88 admissions.

MAIN OUTCOME MEASURES

Main psychiatric, medical and social reasons for admission; Physical Health Schema; total LOS; number of days attributable to psychiatric, medical, social and treatment (non-response and adverse reactions) reasons; DSM-IV diagnosis; global clinical outcome; discharge living arrangements; discharge psychotropic medication.

MAIN RESULTS

Presence of depressive symptoms was the most common psychiatric reason for admission and carer stress the main social reason for admission. Principal diagnosis of major depression and carer stress were significant predictors of LOS and accounted for 24.3% of the variance (p < 0.0001). Physical health and psychiatric comorbidity were not able to predict LOS. The proportion of psychiatric, medical and social reasons involved in LOS varied significantly by principal diagnosis (p < 0.001). Almost 42% of bed days were attributable to delays--for medical, social (eg placement problems), treatment (adverse events, non-response) or hospital system reasons.

CONCLUSIONS

The quantification of factors contributing to LOS in an acute psychogeriatric unit allows for more accurate identification of issues that can be addressed to improve the efficiency of bed utilization.

Adapting to needs in old-age psychiatry

The patient described is a 56-year-old man presenting with chronic depression and eventually found to have Alzheimer's disease. Issues in the diagnosis and evolution of early dementia are discussed. The importance of long-term psychological support to the dementing patient, as well as their carers, is emphasized.

Effect of relaxation music on patient tolerance of gastrointestinal endoscopic procedures

The use of relaxation music as an adjunct to sedation has not been well studied. We tried to determine whether the use of relaxation music can improve patient tolerance of gastrointestinal endoscopic procedures. Fifty-nine patients undergoing gastrointestinal endoscopic procedures were randomly assigned to receive either relaxation music (n = 28) or no music (n = 31) using headphones and a portable compact disc player. Patient anxiety before the procedure, tolerance of the procedure, and willingness to undergo a repeated procedure were self-assessed using a visual analog scale. Patient tolerance was also assessed by the assisting nurse. There was no significant difference in the overall tolerance score between the two groups. However, a significantly higher proportion of patients described the experience of a gastrointestinal endoscopic procedure as being at least moderately unpleasant in the no-music group. Patient acceptance of the relaxation music was high: 82% in the group stated they would have music again if they required another procedure. We conclude that, even in patients who have sedation, relaxation music can reduce the number who find the experience of gastrointestinal endoscopic procedures unpleasant. Therefore we believe it has a role as an adjunct to sedation in gastrointestinal endoscopic procedures.

The older psychiatrist and retirement

OBJECTIVE

To determine the clinical practices, retirement plans and post-retirement professional activities of older psychiatrists, comparing retirees with working psychiatrists.

DESIGN

Postal survey.

PARTICIPANTS

All Fellows of the Royal Australian and New Zealand College of Psychiatrists aged 55 years and over, resident in Australia or New Zealand. Of 468 eligible subjects, 281 (60%) participated.

MAIN OUTCOME MEASURES

Location and type of psychiatric practice; hours of work; retirement plans; anticipated and actual retirement criteria; anticipated and actual post-retirement professional activities; self-rated health.

RESULTS

Working psychiatrists comprised 79% of the sample, being significantly younger (mean 63.8 years) than retirees (mean 72.3 years, p < 0.001). Over 62% of respondents worked principally in general psychiatry. Working psychiatrists were mainly in private practice (61%) and retirees had been in public psychiatry (53%, p < 0.001). Working psychiatrists worked about 41 hours/week, 98 (49%) having reduced their hours in the previous 5 years. Retirement plans had been commenced by 124 (61%). Fatigue (27%) and memory impairment (10%) were reported as age-related changes adversely affecting work capacity, raising concerns of competence. Working psychiatrists more often anticipated deteriorating health (p < 0.001) and family/personal reasons (p < 0.01) as retirement criteria and anticipated involvement in a significantly higher number of post-retirement professional activities than retirees reported (p < 0.001). Retirees rated themselves in significantly poorer health than working psychiatrists (p < 0.001), even when age was partialed out (p < 0.001).

CONCLUSIONS

Most older psychiatrists gradually retire by reducing work hours and developing new interests. The majority of retirees retain involvement in professional activities, but substantially less than anticipated by those still working.

Psychosocial stressors, physical illness and the spectrum of depression in elderly inpatients

OBJECTIVES

To describe all elderly patients hospitalised with principal and secondary diagnoses of depression, and to determine whether a relationship can be demonstrated between psychosocial stressors, physical illness and type of depression.

METHOD

A retrospective chart review of elderly patients admitted to a general hospital psychiatry ward over a 7-year period with principal or secondary diagnoses of depression was undertaken. Four broad diagnostic categories of depression were used: major depression, psychotic depression, minor depression, and organic depression. Chief outcome measures were: number of medical diagnostic categories, presence of psychosocial stressors, global clinical improvement, and length of stay.

RESULTS

Of 228 patients admitted with depression (194 principal diagnoses and 34 secondary diagnoses), 100 had major depression, 47 psychotic depression, 48 minor depression and 33 organic depression. Psychiatric comorbidity occurred in 70%, about half of which was due to organic brain syndrome. Patients with psychotic depression had the fewest medical problems and those with organic depression the most, while patients with minor depression had the highest rate of family and marital problems, comorbid personality dysfunction and suicide attempts. Patients with psychotic depression had the longest admissions, while those with minor depression had the shortest. Overall, 89% showed significant clinical improvement.

CONCLUSIONS

Elderly inpatients have a wide spectrum of depressive disorders with different psychosocial, medical and treatment profiles. Future studies of depression in old age should include all patients with clinical depression.

The PIE-1 protein and germline specification in C. elegans embryos

Totipotent germline blastomeres in Caenorhabditis elegans contain, but do not respond to, factors that promote somatic differentiation in other embryonic cells. Mutations in the maternal gene pie-1 result in the germline blastomeres adopting somatic cell fates. Here we show that pie-1 encodes a nuclear protein, PIE-1, that is localized to the germline blastomeres throughout early development. During division of each germline blastomere, PIE-1 initially associates with both centrosomes of the mitotic spindle. However, PIE-1 rapidly disappears from the centrosome destined for the somatic daughter, and persists in the centrosome of the daughter that becomes the next germline blastomere. The PIE-1 protein contains potential zinc-finger motifs also found in the mammalian growth-factor response protein TIS-11/NUP475 (refs 4-7). The localization and genetic properties of pie-1 provide an example of a repressor-based mechanism for preserving pluripotency within a stem cell lineage.