Clinical Correlates of Cardiac Conduction in Bipolar Disorder

Introduction

Patients with bipolar disorder (BD) have an increased risk for cardiovascular morbimortality. Clinical risk factors, specifically for arrhythmias and sudden cardiac death remain understudied.

Objectives

This study was conducted to assess differences in cardiac conduction among BD patients.

Methods

We included patients with BD in a cross-sectional design, confirmed by structured interview, age 18 through 80. Clinical characteristics were obtained using a structured questionnaire or medical records review. ECG intervals duration and morphology were manually assessed by cardiologists and compared among clinical subgroups using Chi-square, Mann-Whitney, and Kruskall-Wallis tests. Exploratory multivariable linear and logistic regression models were fitted to adjust for potential confounders.

Results

We included 117 patients (60.7% women, 76.9% bipolar I, 50% history of psychosis, 22.6% suicide attempts). We found a significantly longer QTc interval in BD patients with hypertension (difference: 9.5 ms, p=0.006), obesity (difference: 25 ms, p=0.001), and metabolic syndrome (difference: 13 ms, p=0.007). Hypertension remained a significant predictor of longer QTc after adjusting for age, gender, and antipsychotic use (estimate 17.718, p=0.018). We observed a significantly shorter PR interval in women (difference: 6 ms, p=0.029), early age of onset (difference 6 ms, p=0.025), non-users of lithium (difference 4 ms, p=0.002), and early trauma (difference 4 ms, p=0.038). Finally, we identified significant correlations between symptom severity, blood glucose and PR interval (r=0.298, p=0.001; r=0.278, p=0.003; respectively).

Conclusions

Patients with BD and hypertension may have an increased risk for QTc prolongation. Careful cardiovascular monitoring may be warranted.

Disclosure

No significant relationships.

Metabolic and performance-related consequences of exercising at and slightly above MLSS

Exercising at the maximal lactate steady state (MLSS) results in increased but stable metabolic responses. We tested the hypothesis that even a slight increase above MLSS (10 W), by altering the metabolic steady state, would reduce exercise performance capacity. Eleven trained men in our study performed: one ramp-incremental tests; two to four 30-minute constant-load cycling exercise trials to determine the PO at MLSS (MLSS_p ), and ten watts above MLSS (MLSS_p+10 ), which were immediately followed by a time-to-exhaustion test; and a time-to-exhaustion test with no-prior exercise. Pulmonary O₂ uptake V.O₂ ) and blood lactate concentration ([La^- ]_b ) as well as local muscle O₂ extraction ([HHb]) and muscle activity (EMG) of the vastus lateralis (VL) and rectus femoris (RF) muscles were measured during the testing sessions. When exercising at MLSS_p+10 , although V.O₂ was stable, there was an increase in ventilatory responses and EMG activity, along with a non-stable [La^- ]_b response (P < 0.05). The [HHb] of VL muscle achieved its apex at MLSS_p with no additional increase above this intensity, whereas the [HHb] of RF progressively increased during MLSS_p+10 and achieved its apex during the time-to-exhaustion trials. Time-to-exhaustion performance was decreased after exercising at MLSS_p (37.3 ± 16.4%) compared to the no-prior exercise condition, and further decreased after exercising at MLSS_p+10 (64.6 ± 6.3%) (P < 0.05). In summary, exercising for 30 min slightly above MLSS led to significant alterations of metabolic responses which disproportionately compromised subsequent exercise performance. Furthermore, the [HHb] signal of VL seemed to achieve a "ceiling" at the intensity of exercise associated with MLSS.

A systematic review of the association between emotions and eating behaviour in normal and overweight adult populations

A systematic review was completed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search of four electronic databases (2004–2015) yielded 60,017 articles, of which 29 met inclusion criteria. Included studies performed poorly on data quality analysis in terms of randomisation and controlling for confounding factors. Participant’s body mass index scores range from 19.73 (standard deviation = 1.54) to 28.4 (standard deviation = 1.4) kg/m2. Where positive and negative affects were compared, food was more likely to be consumed in response to positive affect. With regard to discrete emotions; stress, depression and sadness consistently elicited eating behaviours that fall outside of nutritional recommendations (e.g. increased food intake or poor nutritional food choices). The role of moderators including individual differences in dietary restraint and emotional eating, as well as methodological considerations, such as means of eliciting and measuring emotions, may account for equivocality with regard to some emotion and eating associations. This article concludes with recommendations for future research and implications for practice.

A framework for measuring quality and promoting accountability across silos: the case of mental disorders and co-occurring conditions

BACKGROUND

Quality measures can be effective tools for improving delivery of care and patient outcomes. Co-occurring conditions (COCs), including general medical conditions and substance use disorders, are the rule rather than the exception in patients with serious mental health disorders and lead to substantial morbidity and mortality burden. COCs among persons with mental health disorders are often treated by separate systems ("silos") in the US healthcare system, making it difficult to establish expectations for performance, assign accountability for measure results and ultimately improve quality of care for this group.

OBJECTIVES

A framework for measuring quality of care for COCs is proposed by reviewing the current state of quality for COCs and examples of quality measures based on the Donabedian model.

METHODS AND FRAMEWORK

The framework will also be applied to better define which providers are accountable for quality improvement, to ultimately ensure that quality measures have an impact on improving care for COCs.

Course of hypochondriasis in an international primary care study

Hypochondriasis is frequently defined as a chronic condition distinct from anxiety and depressive disorders. Consecutive primary care attenders (n=25,916) were screened using the General Health Questionnaire and a stratified random sample (n=5447) completed a baseline diagnostic assessment. All patients with significant psychiatric symptoms and a random sample of remaining patients (n=3201) were asked to complete a follow-up diagnostic assessment 12 months later. Of patients meeting an abridged definition of hypochondriasis at baseline, 18% continued to do so at follow-up and an additional 16% continued to report hypochondriacal worries. 45% of those with hypochondriasis at follow-up also met criteria for DSM-IV anxiety or depressive disorder. Follow-up anxiety or depressive disorder was significantly associated with both onset and persistence of hypochondriasis. Hypochondriasis is moderately stable over time. The clear distinction between hypochondriasis and anxiety/depressive disorders suggested by ICD-10 and DSM-IV may be difficult to accomplish in practice.

[Comorbidity of chronic diseases and psychiatric disorders among patients attending public primary care]

BACKGROUND

As a part of the World Health Organization multicentric study of emotional disorders in general medical care, we studied patients who had a chronic medical ailment and a psychiatric disorder, according to ICD-10.

AIM

To report the prevalence of patients with coexisting medical and psychiatric disorders.

PATIENTS AND METHODS

All patients, aged 15 to 65 years old, consulting in primary care outpatient clinics, were interviewed using a general health questionnaire. In a second phase, patients with chronic medical disorders were subjected to the World Health Organization Composite International Diagnostic Instrument.

RESULTS

Sixty nine percent of interviewed Chilean patients had a medical condition, compared to 60.3% of the global study group. Of these, 66% had a coexisting psychiatric diagnosis, compared to 31% of the global study group. The most frequent diagnoses in the Chilean sample were somatization disorders in 25%, harmful alcohol use in 14%, depression in 35% and hypochondriasis in 6%. There was a higher prevalence and odds ratio for psychiatric diagnoses among Chilean women.

CONCLUSIONS

Patients with chronic medical disorders should be considered a high risk group for the coexistence of psychiatric disturbances.

[Improving the quality of clinical interview teaching: evaluation of an intervention with medical students]

BACKGROUND

Quality of clinical interview is a key issue both for patient satisfaction and for diagnostic efficiency. Its adequacy relates to better clinical diagnosis treatment plans and patient compliance.

AIM

To measure the quality of interviews performed by medical students in three Chilean medical schools before receiving specific training on the subject and to compare the scores obtained after introductory courses on interview.

MATERIAL AND METHODS

The interviews were videotaped and then evaluated using an objective scale, that measures 33 skills grouped in six areas: opening, problem exploration, non verbal facilitation, interpersonal patient reaction and closing. The students were assigned to an experimental group that received an interactive workshop with role-plays, vignettes and videotape feedback, and to a non intervention group that received the usual bedside training on medical interviews.

RESULTS

Both groups shared the same skill level before the training, with better scores on nonverbal, patient reaction and problem exploration, and worse ones on closing and interpersonal skills. Comparing pre and post-test results, the overall score improved in the experimental group (from 33.2 to 38.3, p = 0.002) and worsened among non intervened students. There were statistically significant changes for opening (p < 0.002), problem exploration (p < 0.05), non verbal facilitation (p < 0.0001) and closing (p < 0.0001).

CONCLUSIONS

It is important to train students not only in specific knowledge contents but in the process of interview. This training should encourage the development of empathy and closing skills.

An international study of the relation between somatic symptoms and depression

BACKGROUND AND METHODS

Patients with depression, particularly those seen by primary care physicians, may report somatic symptoms, such as headache, constipation, weakness, or back pain. Some previous studies have suggested that patients in non-Western countries are more likely to report somatic symptoms than are patients in Western countries. We used data from the World Health Organization's study of psychological problems in general health care to examine the relation between somatic symptoms and depression. The study, conducted in 1991 and 1992, screened 25,916 patients at 15 primary care centers in 14 countries on 5 continents. Of the patients in the original sample, 5447 underwent a structured assessment of depressive and somatoform disorders.

RESULTS

A total of 1146 patients (weighted prevalence, 10.1 percent) met the criteria for major depression. The range of patients with depression who reported only somatic symptoms was 45 to 95 percent (overall prevalence, 69 percent; P=0.002 for the comparison among centers). A somatic presentation was more common at centers where patients lacked an ongoing relationship with a primary care physician than at centers where most patients had a personal physician (odds ratio, 1.8; 95 percent confidence interval, 1.2 to 2.7). Half the depressed patients reported multiple unexplained somatic symptoms, and 11 percent denied psychological symptoms of depression on direct questioning. Neither of these proportions varied significantly among the centers. Although the overall prevalence of depressive symptoms varied markedly among the centers, the frequencies of psychological and physical symptoms were similar.

CONCLUSIONS

Somatic symptoms of depression are common in many countries, but their frequency varies depending on how somatization is defined. There is substantial variation in how frequently patients with depression present with strictly somatic symptoms. In part, this variation may reflect characteristics of physicians and health care systems, as well as cultural differences among patients.

[Comparative study of the frequency and features of emotional disturbances in patients in primary care clinics]

BACKGROUND

Psychological problems are a frequent cause of consultation in primary care outpatient clinics.

AIM

To report the results for Santiago de Chile of the World Health Organisation multicentric collaborative study on Psychological Symptoms in General Health Care.

PATIENTS AND METHODS

The results of 1453 patients that attended three primary care clinics in East Metropolitan Santiago were compared with those of patients studied in 15 other centers throughout the world. Two hundred fifty three cases were studied in detail with a structured diagnostic interview (CIDI-PHC). The capacity of general physicians to recognise emotional disorders as well as their management of psychological cases was also assessed.

RESULTS

Among the 253 patients studied in detail, 53% of patients had a definite psychiatric diagnosis, compared with 24% of patients, as an average, in other countries. There was a higher prevalence of depression, generalised anxiety disorder, neurasthenia and harmful use of alcohol. Chilean physicians recognised 74.1% of patients with psychiatric conditions, as compared with 48.9% of physicians abroad. Tranquilizing agents were the most often prescribed medications (40%) followed by antidepressants (18%).

CONCLUSIONS

There is a high prevalence of emotional disorders in patients consulting at the primary care level.

[Patients cared for at the mental health unit of a primary care office: morbidity study]

Establishing the frequency of mental disorders among patients cared for at the mental health unit of a primary care outpatient clinic of Santiago, Chile, is intended. In this connection, 618 medical records have been screened retrospectively (i.e. a whole universe excepting patients under age 15). A great majority of patients--with an absolute ratio of female patients (88.8%) were referrals from physicians' offices. The most frequent disorders were anxiety disorders and adjustment disorders. Comments are made on (a): the scarcity of referrals from larger general hospitals, and (b) the need for mechanisms apt at an early detection of the most frequent disorders to be set up.

[Psychiatric patients from general hospitals: pathways followed before consultation]

A survey of all patients who consulted at the Psychiatric Service of a general hospital during a one month period was used to evaluate factors influencing the referral of the patient to the specialist. A preponderance of young females was observed. Patients presenting with somatic symptoms, anxiety or depression were usually referred from another physician, while patients with psychotic disorders and problems related to alcohol abuse were first seen by the specialist. Almost half of the patients had been previously treated, usually with anxiolytic drugs and the median time between the first consult and the referral was 52 weeks. Better systems for derivation of these patients must be developed.

Exploration and attachment behaviour in infant guinea pigs

Abstract

Individual infant guinea pigs were tested oncde a week during the first 4 weeks of life in a square enclosure which was separated from a smaller enclosure (confinement cage) by a wire-mesh partition. In the Experimental condition (E) the mother and siblings of the subject were present in the confinement cage during testing - while in the Control condition (C) the confinement cage was empty during testing. The young guinea pigs tested in the presence of the mother and siblings displayed a much greater level of activity (i.e. exploratory behaviour) than did those tested with the empty confinement cage. They thus appeared to use the mother and/or siblings as a base from which to explore a novel environment. Exploratory behaviour in condition E showed a significant increase between weeks I and 2 (possibly due to the waning of an initial immobility reaction), and a gradual decline over weeks 3 and 4 (believed to be due to habituation to the test enclosure). In condition C, there were no significant differences in activity between trials. The guinea pigs tested in the presence of the mother and siblings spent significantly more time near the wire partition separating the test enclosure from the confinement cage than did the control subjects - for whom the confinement cage was empty. Subjects in condition E spent significantly more time in the proximity of the mother and siblings during weeks 2-4 as compared to week I. The responsiveness of the young guinea pigs to conspecifics therefore appears to have increased over the first 2 weeks post-partum. The possible adaptive significance of the interaction between exploration and attachment behaviour was discussed.