Cardiovascular risk screening of patients with serious mental illness or use of antipsychotics in family practice.

BACKGROUND: Patients with serious mental illness (SMI) and patients on antipsychotics (AP) have an elevated risk for cardiovascular diseases. In the Netherlands, the mental healthcare for these patients is increasingly taken care of by family practitioners (FP) as a result of a shift from secondary to primary care. Therefore, it is essential to increase our knowledge regarding the characteristics of this patient group and the (somatic) care provided by their FPs. The aim was to examine the rate of cardiovascular risk screening in patients with SMI or the use of AP in family practice. METHODS: We performed a retrospective cohort study of 151.238 patients listed in 24 family practices in the Netherlands. From electronic medical records we extracted data concerning diagnoses, measurement values of CVR factors, medication and frequency of visits over a 2 year period. Primary outcome was the rate of patients who were screened for CVR factors. We compared three groups: patients with SMI/AP without diabetes or CVD (SMI/AP-only), patients with SMI/AP and diabetes mellitus (SMI/AP + DM), patients with SMI/AP and a history of cardiovascular disease (SMI/AP + CVD). We explored factors associated with adequate screening using multilevel logistic regression. RESULTS: We identified 1705 patients with SMI/AP, 834 with a SMI diagnosis, 1150 using AP. The screening rate for CVR in the SMI/AP-only group (n = 1383) was adequate in 8.5%. Screening was higher in the SMI/AP - +DM (n = 206, 68.4% adequate, OR 24.6 (95%CI, 17.3-35.1) and SMI/AP + CVD (n = 116, 26.7% adequate, OR 4.2 (95%CI, 2.7-6.6). A high frequency of visits, age, the use of AP and a diagnosis of COPD were associated with a higher screening rate. In addition we also examined differences between patients with SMI and patients using AP without SMI. CONCLUSION: CVR screening in patients with SMI/AP is performed poorly in Dutch family practices. Acceptable screening rates were found only among SMI/AP patients with diabetes mellitus as comorbidity. The finding of a large group of AP users without a SMI diagnosis may indicate that FPs often prescribe AP off-label, lack information about the diagnosis, or use the wrong code.

Psoas hematoma in the elderly patient, a diagnostic challenge, a case report.

BACKGROUND: A psoas hematoma is an uncommon condition in patients on anticoagulant therapy and patients with bleeding disorders. It can present itself with non-specific symptoms, as anemia, pain and hemodynamically instability. The CT angioscan is the diagnostic test of choice. CASE PRESENTATION: We report a series of 3 cases of iliopsoas hematoma in older patients. These patients were all on anticoagulant therapy and presented with non-specific symptoms as pain in back or groin, anemia and weakness of the leg. These symptoms could be well explained by other, concurrent diseases. Moreover in one case it was not possible to obtain a reliable history due to cognitive impairment of the patient. In our cases the diagnosis of a psoas hematoma was made after performing many diagnostics or found fortuitously. All three patients recovered well after (temporarily) ceasing of anticoagulant therapy. DISCUSSION: The diagnosis of a psoas hematoma is difficult, especially in elderly patients as illustrated in these cases. The symptoms of a psoas hematoma are often aspecific and can also be explained by other, comorbid diseases. Moreover, elderly patients often have an unusual presentation of illness and the presence of cognitive impairment compromises the reliability of a patients history. It is important to be aware of this diagnosis and perform a CT-scan when a psoas hematoma is possible. CONCLUSION: A psoas hematoma is easily overlooked in older patients due to an unusual presentation of illness, comorbidity and cognitive impairment.

Reestruturação produtiva e qualificação: reflexões sobre a experiência brasileira / Productive reorganization and qualification: reflections about the urbanization experience

Aborda as transformações do trabalho nas últimas décadas e as questões surgidas a partir dessas transformações, como, qualificação, organização da produção, treinamento e formação profissional