Clinical judgement, case complexity and symptom scores as predictors of outcome in depression: an exploratory analysis.

BACKGROUND: Clinical guidelines for depression in adults recommend the use of outcome measures and stepped care models in routine care. Such measures are based on symptom severity, but response to treatment is likely to also be influenced by personal and contextual factors. This observational study of a routine clinical sample sought to examine the extent to which "symptom severity measures" and "complexity measures" assess different aspects of patient experience, and how they might relate to clinical outcomes, including disengagement from treatment. METHODS: Subjects with symptoms of depression (with or without comorbid anxiety) were recruited from people referred to an established Primary Care Mental Health Team using a stepped care model. Each participant completed three baseline symptom measures (the Personal Health Questionnaire (PHQ), Generalised Anxiety Disorder questionnaire (GAD) and Clinical Outcomes in Routine Evaluation (CORE-10)), and two assessments of "case complexity" (the Minnesota-Edinburgh Complexity Assessment Measure (MECAM) and a local complexity assessment). Clinician perception of likely completion of treatment and patient recovery was also assessed. Outcome measures were drop out and clinical improvement on the PHQ. RESULTS: 298 subjects were recruited to the study, of whom 258 had a sufficient dataset available for analysis. Data showed that the three measures of symptom severity used in this study (PHQ, GAD and CORE-10) seemed to be measuring distinct characteristics from those associated with the measures of case complexity (MECAM, previous and current problem count). Higher symptom severity scores were correlated with improved outcomes at the end of treatment, but there was no association between outcome and complexity measures. Clinicians could predict participant drop-out from care with some accuracy, but had no ability to predict outcome from treatment. CONCLUSIONS: These results highlight the extent to which drop-out complicates recovery from depression with or without anxiety in real-world settings, and the need to consider other factors beyond symptom severity in planning care. The findings are discussed in relation to a growing body of literature investigating prognostic indicators in the context of models of collaborative care for depression.

Do dogs exhibit jealous behaviors when their owner attends to their companion dog?

Jealousy appears to have clear adaptive functions across species: it emerges when an important social relationship with a valued social partner is threatened by third-party that is perceived as a rival. Dyads of dogs living together and their owners were tested adapting a procedure devised to study jealousy in young human siblings. Owners at first ignored both dogs while reading a magazine (Control episode), and then petted and praised one of the dogs while ignoring the other, and vice versa (Experimental episodes). We found several differences in the dogs' behavior between the Experimental episodes and the Control episode, even though only monitoring (gazing at the owner) was exhibited for a significantly greater amount of time in the Experimental episodes. Remarkable individual behavioral differences emerged, suggesting that the dogs' reactions could be influenced by the relationships that they establish with their owner and the companion dog. Overall, current results do not clearly support our prediction that the ignored dogs would exhibit more behaviors aimed at regaining the owner's attention when their owner directed attention and care to a companion dog, compared to the control situation. The great intra- and inter-dyad behavioral variability and the choice to test cohabiting dogs could have prevented the emergence of a clear jealous reaction. These findings do not exclude that dogs may exhibit a primordial form of jealousy in a realistic situation, but an additional research is needed to fully gauge which situations, if any, could trigger jealousy in dogs and to rule out alternative explanations.

Disability, distress and unemployment in neurology outpatients with symptoms 'unexplained by organic disease'.

OBJECTIVES: To determine the disability, distress and employment status of new neurology outpatients with physical symptoms unexplained by organic disease and to compare them with patients with symptoms explained by organic disease. METHODS: As part of a cohort study (the Scottish Neurological Symptoms Study) neurologists rated the extent to which each new patient's symptoms were explained by organic disease. Patients whose symptoms were rated as 'not at all' or only 'somewhat' explained by disease were considered cases, and those whose symptoms were 'largely' or 'completely' explained by disease were considered controls. All patients completed self-ratings of disability, health status (Medical Outcomes Study Short Form 12-Item Scale (SF-12)) and emotional distress (Hospital Anxiety and Depression Scale) and also reported their employment and state financial benefit status. RESULTS: 3781 patients were recruited: 1144 (30%) cases and 2637 (70%) controls. Cases had worse physical health status (SF-12 score 42 vs 44; difference in means 1.7 (95% CI -2.5 to 0.9)) and worse mental health status (SF-12 score 43 vs 47; difference in means -3.5 (95% CI -4.3 to to 2.7)). Unemployment was similar in cases and controls (50% vs 50%) but cases were more likely not to be working for health reasons (54% vs 37% of the 50% not working; OR 2.0 (95% CI 1.6 to 2.4)) and also more likely to be receiving disability-related state financial benefits (27% vs 22%; (OR 1.3, 95% CI 1.1 to 1.6)). CONCLUSIONS: New neurology patients with symptoms unexplained by organic disease have more disability-, distress- and disability-related state financial benefits than patients with symptoms explained by disease.

Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome.

BACKGROUND: Patients whose symptoms are 'unexplained by disease' often have a poor symptomatic outcome after specialist consultation, but we know little about which patient factors predict this. We therefore aimed to determine predictors of poor subjective outcome for new neurology out-patients with symptoms unexplained by disease 1 year after the initial consultation. METHOD: The Scottish Neurological Symptom Study was a 1-year prospective cohort study of patients referred to secondary care National Health Service neurology clinics in Scotland (UK). Patients were included if the neurologist rated their symptoms as 'not at all' or only 'somewhat explained' by organic disease. Patient-rated change in health was rated on a five-point Clinical Global Improvement (CGI) scale ('much better' to 'much worse') 1 year later. RESULTS: The 12-month outcome data were available on 716 of 1144 patients (63%). Poor outcome on the CGI ('unchanged', 'worse' or 'much worse') was reported by 482 (67%) out of 716 patients. The only strong independent baseline predictors were patients' beliefs [expectation of non-recovery (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.40-2.96), non-attribution of symptoms to psychological factors (OR 2.22, 95% CI 1.51-3.26)] and the receipt of illness-related financial benefits (OR 2.30, 95% CI 1.37-3.86). Together, these factors predicted 13% of the variance in outcome. CONCLUSIONS: Of the patients, two-thirds had a poor outcome at 1 year. Illness beliefs and financial benefits are more useful in predicting poor outcome than the number of symptoms, disability and distress.

Symptoms 'unexplained by organic disease' in 1144 new neurology out-patients: how often does the diagnosis change at follow-up?

It has been previously reported that a substantial proportion of newly referred neurology out-patients have symptoms that are considered by the assessing neurologist as unexplained by 'organic disease'. There has however been much controversy about how often such patients subsequently develop a disease diagnosis that, with hindsight, would have explained the symptoms. We aimed to determine in a large sample of new neurology out-patients: (i) what proportion are assessed as having symptoms unexplained by disease and the diagnoses given to them; and (ii) how often a neurological disorder emerged which, with hindsight, explained the original symptoms. We carried out a prospective cohort study of patients referred from primary care to National Health Service neurology clinics in Scotland, UK. Measures were: (i) the proportion of patients with symptoms rated by the assessing neurologist as 'not at all' or only 'somewhat explained' by 'organic disease' and the neurological diagnoses recorded at initial assessment; and (ii) the frequency of unexpected new diagnoses made over the following 18 months (according to the primary-care physician). One thousand four hundred and forty-four patients (30% of all new patients) were rated as having symptoms 'not at all' or only 'somewhat explained' by 'organic disease'. The most common categories of diagnosis were: (i) organic neurological disease but with symptoms unexplained by it (26%); (ii) headache disorders (26%); and (iii) conversion symptoms (motor, sensory or non-epileptic attacks) (18%). At follow-up only 4 out of 1030 patients (0.4%) had acquired an organic disease diagnosis that was unexpected at initial assessment and plausibly the cause of the patients' original symptoms. Eight patients had died at follow-up; five of whom had initial diagnoses of non-epileptic attacks. Seven other types of diagnostic change with very different implications to a 'missed diagnosis' were found and a new classification of diagnostic revision is presented. One-third of new neurology out-patients are assessed as having symptoms 'unexplained by organic disease'. A new diagnosis, which with hindsight explained the original symptoms, rarely became apparent to the patient's primary care doctor in the 18 months following the initial hospital consultation.

An exploratory study of the association between reactive attachment disorder and attachment narratives in early school-age children.

OBJECTIVE: To explore attachment narratives in children diagnosed with reactive attachment disorder (RAD). METHOD: We compared attachment narratives, as measured by the Manchester Child Attachment Story Task, in a group of 33 children with a diagnosis of RAD and 37 comparison children. RESULTS: The relative risk (RR) for children with RAD having an insecure attachment pattern was 2.4 (1.4-4.2) but 30% were rated as securely attached. Within the RAD group, children with a clear history of maltreatment were more likely to be Insecure-Disorganised than children without a clear history of maltreatment. CONCLUSIONS: Reactive attachment disorder is not the same as attachment insecurity, and questions remain about how attachment research informs clinical research on attachment disorders.

[Emotional aspects and quality of life of patients after acoustic neuroma surgery]. / Aspetti emotivi e qualità della vita in pazienti operati di neurinoma del nervo acustico.

UNLABELLED: Acoustic neuromas are rare lesions arising in the internal auditory canal (IAC) and extending in the posterior cranial fossa. Surgical removal is the treatment of choice; peri and postoperative complications are directly related to the size of the tumour. Some Authors think the surgical treatment and related temporary or permanent neurological deficits could change the QoL and the psychological status. PURPOSE: The aim of this analysis is to ascertain if the surgical procedure could significantly worsen the QoL of this population 12 months after the discharge from surgical department. METHODS: By using a questionnaires of Quality of Life aims to evaluate the impact that the disease and the surgical procedure have on this population. SUBJECTS: We have evaluated a sample of 150 subjects one year after the surgical removal of a acoustic neuroma. Data have been collected through questionnaires the Whoqol-Brief, the BDI, the STAI Y1 and Y2 and specific item to assess effects of postoperative dysfunctions. RESULTS: Data reveal a negative effect on QoL, 94% of the subjects show lower score at Whoquol-Brief and in anxiety with scores higher than normative score sample (state-anxiety (t = 5.602 p = .000; trait-anxiety: t = 4.354 p = .000). Higher incidence of depressive disorders have not been found. CONCLUSION: Psychological support to subjects after discharge from acoustic neuroma surgical removal should be tailored to improve quality of life and for a better management of anxiety.

Resistance in 27 Rice Cultivars to Sugarcane Borer (Lepidoptera: Crambidae).

Rice (Oryza sativa L.) is considered one of the most important crops in the world, and the sugarcane borer, Diatraea saccharalis Fabricius (Lepidoptera: Crambidae), is among the key pests damaging the crop in the Americas. The objective of this work was to identify rice genotypes as a source of resistance to D. saccharalis. Rice plants were infested in the greenhouse and subsequently evaluated for damage, larval weight and survival, and stem size. The cultivars 'Bonança', 'Caripuna', 'IR 42', 'Canela de Ferro', 'SWA Norte', 'BR IRGA 409', 'Pepita', 'Serra Dourada', 'Araguaia', 'Xingú', 'Tangará', and 'Soberana' showed antibiosis antixenosis, or both to D. saccharalis. These cultivars may be used as donor sources in the breeding program and used directly by Brazilian farmers as a component of rice-integrated pest management.

Predicting outcomes and complications of percutaneous endoscopic gastrostomy.

BACKGROUND AND STUDY AIMS: Percutaneous endoscopic gastrostomy (PEG) is the preferred route for long-term enteral feeding. Our aims were to prospectively evaluate the outcome ("PEG status") and complications of PEG and to determine whether these can be predicted by patients' baseline characteristics. PATIENTS AND METHODS: We conducted a prospective study in two tertiary hospitals between August 2003 and January 2005, enrolling all patients who were undergoing PEG placement. We completed a questionnaire with details of demographic data, diagnosis, indication for PEG, Charlson's co-morbidity index, Barthel's index, laboratory tests, complications, and date and cause of death. Patients were followed at scheduled appointments. Univariate and multivariate analyses were performed. RESULTS: 168 patients (48% male, 52% female; mean age +/- standard deviation 74 +/- 16 years) underwent PEG using the pull technique. The main indication was neurogenic dysphagia (156 patients, 92.9%). Although most indications were appropriate, in half the cases these were established too late. There were no procedure-related deaths. Major complications occurred in four patients (2.4%); minor complications occurred in 52 patients (31%). No single variable could predict complications. Fifteen patients (9%) had the PEG removed. No single variable was independently associated with PEG removal. The mortality was 6.5% at 30 days, 17.3% at 90 days and 33.9% at 1 year. The C-reactive protein was the only predictive factor of early mortality (< or = 30 days), and Charlson's co-morbidity index was the only predictive factor of late mortality (> 30 days). CONCLUSIONS: PEG placement is an easy and safe procedure, although it is often requested too late. No single variable could predict complications or PEG removal. C-reactive protein was found to be predictive of early mortality and Charlson's index was predictive of late mortality.

The "at-home LLLT" in temporo-mandibular disorders pain control: a pilot study.

OBJECTIVES: The Temporo-Mandibular Disorders (TMD) are a set of dysfunctional patterns concerning the temporo-mandibular joints (TMJ) and the masticatory muscles; its main symptom is pain, probably caused by inflammatory changes in the synovial membrane, alterations in the bone marrow of the mandibular condyle and impingement and compression. The aim of this preliminary study was to investigate the effectiveness in the TMD pain reduction of a new laser device recently proposed by the commerce that, due to its reduced dimensions and to be a class I laser according the ANSI classification, may be used at home by the patient himself. MATERIAL AND METHODS: Twenty-four patients with TMD were randomly selected: the inclusion criteria for the sample was the diagnosis of mono- or bi-lateral TMD, with acute pain restricted to the joint area, associated with the absence of any muscle tenderness during palpation. The patients were randomly assigned to two groups: Group 1 (12 patients): patients receiving real LLLT (experimental group). Group 2 (12 patients): patients receiving inactive laser (placebo group). The treatment was performed once a day for two weeks with an 808 nm diode laser by the patient himself with irradiation of the cutaneous zone corresponding to the TMJ for 15 minutes each side. Each patient was instructed to express its pain in a visual analogue scale (VAS) making a perpendicular line between the two extremes representing the felt pain level. Statistical analysis was realized with GraphPad Instat Software, where P<0.05 was considered significant and P<0.01 very significant. RESULTS: The patient's pain evaluation was expressed in the two study groups before the treatment, 1 week and two weeks after the treatment. The differences between the two groups result extremely significant with p<0.0001 for the comparison of VAS value after 1 and 2 weeks. CONCLUSION: This study, even if it may be considered such a pilot study, investigated a new way to control the pain in the temporo-mandibular diseases by an at home self administered laser device. RESULTS are encouraging but they will have to be confirmed by greater studies.

Identification of polymorphisms within Disrupted in Schizophrenia 1 and Disrupted in Schizophrenia 2, and an investigation of their association with schizophrenia and bipolar affective disorder.

We have undertaken a search for polymorphic sequence variation within Disrupted in Schizophrenia 1 and Disrupted in Schizophrenia 2 (DISC1 and DISC2), which are both novel genes that span a translocation breakpoint strongly associated with schizophrenia and related psychoses in a large Scottish family. A scan of the coding sequence, intron/exon boundaries, and part of the 5' and 3' untranslated regions of DISC1, plus 2.7 kb at the 3' end of DISC2, has revealed a novel microsatellite and 15 novel single nucleotide polymorphisms (SNPs). We have tracked the inheritance of four of the SNPs through multiply affected families, and carried out case-control association studies using the microsatellite and four common SNPs on populations of patients with schizophrenia or bipolar affective disorder versus normal control subjects. Neither co-segregation with disease status nor significant association was detected; however, we could not detect linkage disequilibrium between all these markers in the control population, arguing that an even greater density of informative markers is required to test rigorously for association in this genomic region.

Unexplained swelling symptoms in women (idiopathic oedema) comprise one component of a common polysymptomatic syndrome.

BACKGROUND: Non-menstrually-related swelling symptoms (idiopathic oedema) are common in women. The community prevalence of such symptoms, their association with other symptoms, and their underlying aetiology, are uncertain. AIM: To determine the community prevalence of swelling symptoms and the independent contributions of major risk factors. DESIGN: Comparison of major risk factors in women with and without swelling symptoms. METHODS: We assessed 196 women attending a menopause clinic, 201 women attending a fracture clinic and 201 women attending their general practitioner. Each documented family histories of swelling symptoms and diabetes mellitus, age, height and current weight. Women attending the menopause and fracture clinics also completed Visual Analogue Symptom (VAS) scales documenting the perceived severity of swelling symptoms, and of 20 affective, somatic and functional autonomic symptoms. The independent contributions of risk factors to swelling symptom risk were estimated by logistic regression analysis. RESULTS: Of those attending a fracture clinic or their general practitioner, 28% and 33%, respectively, experienced non-menstrually-related swelling symptoms in the month before interview. Severe (RR 43, 95%CI 16-112, p < 0.001) and moderate (RR 7.8, 95%CI 4-15, p < 0.001) affective symptoms, a family history of swelling symptoms (RR 4.5, 95%CI 2.3-8.8, p < 0.001) and a body mass index (BMI) >or=25 kg/m(2) (RR 4.8, 95%CI 2.5-8.9, p < 0.001) were significantly associated with the presence of mild to severe swelling symptoms (VAS 1-9). The prevalence of swelling symptoms increased from 8% in women with no risk factors to 100% in women with three risk factors, which included severe affective symptoms. DISCUSSION: Affective symptom severity provides the principal independent contribution to swelling symptom risk. BMI >or=25 and a family history of swelling symptoms provide smaller independent contributions. The nature of the mechanisms underlying these associations remains uncertain.

The role of diuretics in the aetiology of idiopathic oedema.

The hypothesis that diuretic use and abuse and other purging behaviours cause idiopathic oedema was investigated in 102 patients. Of 91 symptomatic idiopathic oedema patients tested at referral, 16 (17.6%) had diuretic and four (4.4%) laxative in their urine. None had grossly disturbed serum urea and electrolytes. Examination of primary care records from 41 idiopathic oedema patients who denied current diuretic consumption, and denied or were uncertain about past consumption, showed that 20 had not been prescribed diuretics by their general practitioners at any time; a further 18 had not been prescribed diuretics for between seven months and 12 years before referral. The absence of evidence of plasma volume depletion (as judged by similar concentrations of mean serum urea, creatinine, total protein and albumin in patient and age-matched control groups) suggests that neither systematic diuretic and laxative use or abuse, nor episodic overeating and vomiting were responsible for symptoms of idiopathic oedema in our patients. Idiopathic oedema has a strong genetic basis, and correction of major and minor risk factors for this condition leads to substantial amelioration of symptoms in most cases.

Human stratum corneum penetration by nickel. In vivo study of depth distribution after occlusive application of the metal as powder.

Sequential tape stripping was implemented on three healthy volunteers to examine the surface distribution of nickel through human stratum corneum in vivo following occlusive application of the metal as powder on the volar forearm. Exposure sites were stripped 20 times at intervals from 5 min to 96 h post-dosing and the strips analyzed for metal content by Inductively Coupled Plasma-Mass Spectroscopy with a detection limit for nickel of 0.5 ppb. The gradients of nickel distribution profiles increased proportionally with occlusion time, but after the 10th strip to the 20th strip continued at constant levels. Total nickel removed with 20 stratum corneum strips to the level of the glistening layer after maximum occlusion of 96 h was 41.6 micrograms/cm2 (+/- 12.2; average n = 3). In order to normalize the nickel depth distribution profiles, stratum corneum removed by stripping of untreated skin after occlusion was determined by weighing. Following application of nickel dust over 24 h, analysis of the 20th strip still indicated nickel present at 1.42 micrograms/cm2 (+/- 0.68; average n = 3). These data indicate that, in contact with skin, nickel metal is oxidized to form soluble, stratum corneum-diffusible compounds which may penetrate the intact stratum corneum, presumably by the intercellular route, and have the potential to elicit allergic reactions.

Needs for care from a demand led community psychiatric service: a study of patients with major mental illness.

UNLABELLED: OBJECTIVE--To measure needs for care of patients aged 18-65 years with major mental illness. DESIGN: Identification of everyone in one area seen by a health professional within the previous five years because of a psychotic disorder. Interview of a one in three sample of patients and their main carers with the cardinal needs schedule. SETTING--Hamilton, a socially deprived district of Scotland. SUBJECTS--71 subjects were interviewed from the original sample of 263 patients. MAIN OUTCOME MEASURES--"Cardinal problems" in seven clinical and eight social areas of functioning; these are defined as problems requiring action. "Needs"-cardinal problems for which suitable interventions exist but have not been tried recently. RESULTS--High levels of morbidity were found. 30 interviewed patients (42%; 95% confidence interval 31% to 54%) had one or more clinical needs. 35 (49%; 38% to 61%) had one or more social needs. Skills to deal with all but seven needs in the sample were available at the time of investigation. Patients not being seen by the community mental health team were similar in severity and levels of need to those who were on the community team's caseload. Care was unequivocally and severely inadequate for four patients. Shortcomings in service delivery usually arose from failure to monitor some patients at home. Problems were not due to shortage of acute psychiatric beds nor the absence of an elaborate assertive community care team. CONCLUSIONS--Systematic assessment of needs with research instruments can give valuable insights into the successes and failures of community care of people with major mental illness. Most needs could be dealt with in these patients but in our area (and probably most other parts of the United Kingdom) this would entail diversion of resources from people with less severe disorders.

Tired, weak, or in need of rest: fatigue among general practice attenders.

OBJECTIVES: To determine the prevalence and associations of symptoms of fatigue. DESIGN: Questionnaire survey. SETTING: London general practice. PARTICIPANTS: 611 General practice attenders. MAIN OUTCOME MEASURES: Scores on a fatigue questionnaire and reasons given for fatigue. RESULTS: 10.2% Of men (17/167) and 10.6% of women (47/444) had substantial fatigue for one month or more. Age, occupation, and marital status exerted minor effects. Subjects attributed fatigue equally to physical and non-physical causes. Physical ill health, including viral infection, was associated with more severe fatigue. Women rather than men blamed family responsibilities for their fatigue. The profile of persistent fatigue did not differ from that of short duration. Only one person met criteria for the chronic fatigue syndrome. CONCLUSIONS: Fatigue is a common complaint among general practice attenders and can be severe. Patients may attribute this to physical, psychological, and social stress.

[Epidemiologic study of chronic fatigue in primary care (general practice)]. / Etude épidémiologique de la fatigue chronique en milieu de soins primaires (médecine générale).

The results of a cross sectional study of fatigue in two large samples of patients attending primary care physicians are reported. The level of complaint of fatigue was higher in the prospective sample, which consisted of patients who had been diagnosed as suffering from a viral infection six months earlier. Duration and frequency of experience of fatigue correlated with severity in both samples. Severity, duration and frequency were continuously distributed in these populations. Attribution of fatigue in these two samples was mixed: social stresses, current physical illness and psychological problems all being offered as explanations. 11% of the cross sectional sample and 17% of the prospective sample met study operational criteria for a possible chronic fatigue state. These patients were assessed in greater detail. The majority had a diagnosable psychiatric disorder, predominantly depression. Physical illnesses were not adequate to explain these fatigue states. These studies in primary care do not support a clinical entity of a "chronic fatigue syndrome". Some patients in primary care settings have complaints of fatigue that are both disabling and long lasting, but they do not form a distinct group although the majority are likely however to be suffering from a concurrent psychiatric disorder. In contrast to similar patients with chronic fatigue syndromes attending hospital clinics, primary care patients with complaints of fatigue are much more varied in their ideas of causation with considerable less evidence of disease conviction.

Cardiac effect of short-term experimental weight gain and loss in dogs.

During 12 weeks, 18 normal dogs were fed a high-caloric diet intended to induce obesity (weight-gain phase). For the next 12 weeks (weight-loss phase), all dogs were fed a diet calculated to provide maintenance needs. During this second phase, dogs were randomly assigned to three groups differing only in their exercise regimen: group 1 dogs were not exercised, group 2 dogs were exercised three times each week on a treadmill, group 3 dogs were similarly exercised and outfitted with a vest holding additional weights. Echocardiographic data were obtained at baseline and following both the weight-gain and weight-loss phases. The weight-gain phase of the study was associated with an increase in bodyweight (31.4 per cent), decrease in body density (3.9 per cent) and an increase in left ventricular (LV) myocardial cross-sectional area in all groups. Cardiac hypertrophy was variably reversible during the weight-loss phase, with complete recovery for group 1, partial recovery for group 2 and no recovery in group 3. Regardless of group, weight loss was associated with a significant increase in LV diameter, a reduction of heart rate and an increase in heart rate-corrected isovolumetric relaxation time.