Predicting onset of major depression in general practice attendees in Europe: extending the application of the predictD risk algorithm from 12 to 24 months.

BACKGROUND: PredictD is a risk algorithm that was developed to predict risk of onset of major depression over 12 months in general practice attendees in Europe and validated in a similar population in Chile. It was the first risk algorithm to be developed in the field of mental disorders. Our objective was to extend predictD as an algorithm to detect people at risk of major depression over 24 months. Method Participants were 4190 adult attendees to general practices in the UK, Spain, Slovenia and Portugal, who were not depressed at baseline and were followed up for 24 months. The original predictD risk algorithm for onset of DSM-IV major depression had already been developed in data arising from the first 12 months of follow-up. In this analysis we fitted predictD to the longer period of follow-up, first by examining only the second year (12-24 months) and then the whole period of follow-up (0-24 months). RESULTS: The instrument performed well for prediction of major depression from 12 to 24 months [c-index 0.728, 95% confidence interval (CI) 0.675-0.781], or over the whole 24 months (c-index 0.783, 95% CI 0.757-0.809). CONCLUSIONS: The predictD risk algorithm for major depression is accurate over 24 months, extending it current use of prediction over 12 months. This strengthens its use in prevention efforts in general medical settings.

Spiritual and religious beliefs as risk factors for the onset of major depression: an international cohort study.

BACKGROUND: Several studies have reported weak associations between religious or spiritual belief and psychological health. However, most have been cross-sectional surveys in the U.S.A., limiting inference about generalizability. An international longitudinal study of incidence of major depression gave us the opportunity to investigate this relationship further. METHOD: Data were collected in a prospective cohort study of adult general practice attendees across seven countries. Participants were followed at 6 and 12 months. Spiritual and religious beliefs were assessed using a standardized questionnaire, and DSM-IV diagnosis of major depression was made using the Composite International Diagnostic Interview (CIDI). Logistic regression was used to estimate incidence rates and odds ratios (ORs), after multiple imputation of missing data. RESULTS: The analyses included 8318 attendees. Of participants reporting a spiritual understanding of life at baseline, 10.5% had an episode of depression in the following year compared to 10.3% of religious participants and 7.0% of the secular group (p<0.001). However, the findings varied significantly across countries, with the difference being significant only in the U.K., where spiritual participants were nearly three times more likely to experience an episode of depression than the secular group [OR 2.73, 95% confidence interval (CI) 1.59­4.68]. The strength of belief also had an effect, with participants with strong belief having twice the risk of participants with weak belief. There was no evidence of religion acting as a buffer to prevent depression after a serious life event. CONCLUSIONS: These results do not support the notion that religious and spiritual life views enhance psychological well-being.

Predicting the onset of major depression in primary care: international validation of a risk prediction algorithm from Spain.

BACKGROUND: The different incidence rates of, and risk factors for, depression in different countries argue for the need to have a specific risk algorithm for each country or a supranational risk algorithm. We aimed to develop and validate a predictD-Spain risk algorithm (PSRA) for the onset of major depression and to compare the performance of the PSRA with the predictD-Europe risk algorithm (PERA) in Spanish primary care. METHOD: A prospective cohort study with evaluations at baseline, 6 and 12 months. We measured 39 known risk factors and used multi-level logistic regression and inverse probability weighting to build the PSRA. In Spain (4574), Chile (2133) and another five European countries (5184), 11 891 non-depressed adult primary care attendees formed our at-risk population. The main outcome was DSM-IV major depression (CIDI). RESULTS: Six variables were patient characteristics or past events (sex, age, sex×age interaction, education, physical child abuse, and lifetime depression) and six were current status [Short Form 12 (SF-12) physical score, SF-12 mental score, dissatisfaction with unpaid work, number of serious problems in very close persons, dissatisfaction with living together at home, and taking medication for stress, anxiety or depression]. The C-index of the PSRA was 0.82 [95% confidence interval (CI) 0.79-0.84]. The Integrated Discrimination Improvement (IDI) was 0.0558 [standard error (s.e.)=0.0071, Zexp=7.88, p<0.0001] mainly due to the increase in sensitivity. Both the IDI and calibration plots showed that the PSRA functioned better than the PERA in Spain. CONCLUSIONS: The PSRA included new variables and afforded an improved performance over the PERA for predicting the onset of major depression in Spain. However, the PERA is still the best option in other European countries.

An international risk prediction algorithm for the onset of generalized anxiety and panic syndromes in general practice attendees: predictA.

BACKGROUND: There are no risk models for the prediction of anxiety that may help in prevention. We aimed to develop a risk algorithm for the onset of generalized anxiety and panic syndromes. METHOD: Family practice attendees were recruited between April 2003 and February 2005 and followed over 24 months in the UK, Spain, Portugal and Slovenia (Europe4 countries) and over 6 months in The Netherlands, Estonia and Chile. Our main outcome was generalized anxiety and panic syndromes as measured by the Patient Health Questionnaire. We entered 38 variables into a risk model using stepwise logistic regression in Europe4 data, corrected for over-fitting and tested it in The Netherlands, Estonia and Chile. RESULTS: There were 4905 attendees in Europe4, 1094 in Estonia, 1221 in The Netherlands and 2825 in Chile. In the algorithm four variables were fixed characteristics (sex, age, lifetime depression screen, family history of psychological difficulties); three current status (Short Form 12 physical health subscale and mental health subscale scores, and unsupported difficulties in paid and/or unpaid work); one concerned country; and one time of follow-up. The overall C-index in Europe4 was 0.752 [95% confidence interval (CI) 0.724-0.780]. The effect size for difference in predicted log odds between developing and not developing anxiety was 0.972 (95% CI 0.837-1.107). The validation of predictA resulted in C-indices of 0.731 (95% CI 0.654-0.809) in Estonia, 0.811 (95% CI 0.736-0.886) in The Netherlands and 0.707 (95% CI 0.671-0.742) in Chile. CONCLUSIONS: PredictA accurately predicts the risk of anxiety syndromes. The algorithm is strikingly similar to the predictD algorithm for major depression, suggesting considerable overlap in the concepts of anxiety and depression.

What may stimulate general practitioners to undertake screening and brief intervention for excess alcohol consumption in Slovenia? A focus group study.

Screening and brief intervention (SBI) presents an effective early response by healthcare professionals to their patients' alcohol-related problems. This qualitative research study used focus group discussions with general practitioners (GPs) to identify incentives that may increase the use of SBI in Slovene general practice. Seven categories of actions that may improve the use of SBI were identified: motivation, professional institution, financial support, adequate knowledge and skills, community support, workload (i.e. relief from the burden of current obligations in order to allow more time for prevention), and record keeping (suitable medical documentation). Several of these actions can be changed by the GPs themselves (motivation, adequate knowledge and skills, and record keeping), while the remaining four require more extensive community action on the part of society as a whole, e.g. government intervention. The results of this study will guide future changes in the way that prevention strategies for excess alcohol consumption will be implemented in Slovenia.

Agreement in patient-physician communication in primary care: a study from Central and Eastern Europe.

OBJECTIVE: Efficient patient-physician collaboration is proven to have a direct benefit on health care outcomes through improved compliance, appointment keeping and use of preventive services. The aim of this study was to evaluate the patient-physician agreement on communication during primary care consultations and consider possible discrepancies. METHODS: A cross-sectional survey using self-administered questionnaires was performed in primary care in four European countries (Lithuania, Slovenia, Serbia and Russia). Post-consultation evaluations of doctor-patient communication were made by patients and physicians and were compared with pre-consultation expectations of the patient. Discrepancies in these evaluations were determined for the entire database, and within groups of expectations, using factor analysis. RESULTS: One thousand three hundred and thirty-two sets of questionnaires were collected by the study team. In this sample, in more than 90% of consultations physicians and patients agreed about meeting patient expectations. Discrepancies were more likely to be identified when the patients were consulting the physician for the first time or had not seen that physician for more than 12 months (up to 26.1%). There is a significantly lower correlation between the physician recognising patient's unmet expectations for all factors if the physician had been working in Primary Care for between 6 and 10 years (8.6%). The results demonstrate that physicians working more than 16 years in practice are less likely to recognise that they have failed to meet the expectations of patients who are seeking reassurance (9%). CONCLUSION: Personal continuity of care is associated with a lower discrepancy between the opinions of patients and physicians regarding meeting patient expectations during consultations in primary care. The highest agreement is within first 6 years in practice, which may reflect long-term effects of training. PRACTICE IMPLICATIONS: Primary care physicians should put more emphasis on identifying and addressing patient expectations in primary care consultation, including agreement with patient. Existing discrepancies may be considered to be indicators of potential opportunities to improve physician's performance and overall quality of care.

Sleep-disordered breathing in patients with Chiari malformation: improvement after surgery.

Sixteen consecutive patients with Arnold-Chiari malformation type I and syringomyelia underwent full-night polysomnography (PSG). Sleep apnea syndrome (apnea-hypopnea index > 10) was diagnosed in 12 of 16 patients with 48% of central apneas. In six patients with sleep apnea syndrome, PSG was repeated an average of 203 days after decompression surgery. Postoperative PSG showed a decrease in the central apnea index from 14.9 +/- 5.5 to 1.3 +/- 0.6 (p = 0.03).

Binding affinities for sulfonamide inhibitors with matrix metalloproteinase-2 using a linear response method.

Due to their involvement in many pathological conditions, matrix metalloproteinases (MMPs), are very attractive therapeutic targets. Our study focuses on one of them, MMP-2, which is involved in tumor progression and metastasis. Recently, the solution structure of the catalytic domain of MMP-2 complexed with a hydroxamic acid inhibitor (SC-74020) was published by Feng et al. Using the Hanessian group published binding affinity data and the structure published by Feng as a basis, we have built a binding affinity model by targeting the S(2)' pocket of the enzyme with a set of nine alpha-N-sulfonylamino hydroxamic acid derivatives. Two binding geometries of each ligand have been generated corresponding to two binding modes denoted A and B, respectively, of which the first one is targeting the S(2)' pocket and the second one the S(1) pocket. For the binding affinity model developed for mode A the computed activities show a rmsd of 0.583 kcal/mol as compared with the experimental data, and a correlation coefficient r(2) of 0.779, while in the case of the binding mode B a rmsd of 0.834 kcal/mol and correlation coefficient r(2) of 0.500, respectively, were obtained. In conclusion, our data suggest a higher probability for the Phe(76) gated S(2)' open form pocket to accommodate the substituent alpha versus the wide solvent exposed S(1) subsite, probability which some research groups could have overlooked due to extensive use in their calculations of non revealing S(2)' pocket open state crystallographic structures instead of NMR ones.

Meeting patient's expectations in primary care consultations in Lithuania.

OBJECTIVE: Patient satisfaction with health care services is considered an important factor of health care. Although research on patient satisfaction has become standard in Western Europe, in countries such as Lithuania the concept of patient satisfaction is still a relatively new one. This study aimed to investigate how the meeting of patients' expectations is related to increased satisfaction with medical consultation. STUDY DESIGN: The methodology used by Williams et al. in the UK was applied to the Lithuanian health care setting. Forty physicians from 22 primary health care centres attending courses on general practice at Vilnius University were recruited for the study. Every third adult patient coming to a practice during a 5-day period was invited to participate in the study. In all, 609 patients coming to meet their physician regarding health problems were included in the study sample. The patients were asked to complete three standardized questionnaires: the Patient Intentions Questionnaire prior to the consultation, and the Expectations Met Questionnaire and Medical Interview Satisfaction Scale after the consultation. Cronbach's alpha statistic was used for the validation of the questionnaires and principal components analysis was used to determine the factors of patient expectations. RESULTS: The response rate was 78%. ANALYSIS: of 460 sets of questionnaires revealed that satisfaction with medical consultation is higher among patients who have a greater number of expectations met. Physicians' success in meeting different types of patient expectations also had different influences on patient satisfaction. The most important expectations to be met were "understanding and explanation", followed by expectations of "emotional support", while "getting information" was less important. CONCLUSIONS: The most frequently reported expectations on the Patient Intentions Questionnaire were for "getting information" and "understanding and explanation" of the patients' health problem items, and the least mentioned were for emotional support items. Patients with more expectations met were found to have significantly higher scores on the satisfaction index. Satisfaction with the consultation is best predicted by meeting the patient's expectations for understanding and explanation, and for emotional support. Providing desired information to the patient as well as meeting the patient's expectations for diagnostic procedures and treatment is less associated with patient satisfaction.

Correlation between the predicted and the observed biological activity of the symmetric and nonsymmetric cyclic urea derivatives used as HIV-1 protease inhibitors. A 3D-QSAR-CoMFA method for new antiviral drug design.

The predicted inhibition constant (Ki) and the predicted inhibitor concentration (IC90) of the HIV-1 protease (HIV- 1 PR) inhibitors: symmetric and nonsymmetric - benzyl, ketone, oxime, pyrazole, imidazole, and triazole cyclic urea derivatives, were obtained by the 3D-CoMFA (Comparative Molecular Field Analysis) method. The CoMFA statistical parameters: cross-validate correlation coefficient (q2), higher than 0.5, and the fitted correlation coefficient (r2), higher than 0.90 validated the predicted biological activities. The best predictions were found for the trifluoromethyl ketoxime derivative (log 1/Ki predict = 8.42), the m-pyridineCH2 pyrazole derivative (log 1/Ki predict = 9.77) and the 1,2,3 triazole derivative (log 1/Ki predict = 7.03). We attempted to design a new potent HIV-1 protease inhibitor by addition of o-benzyl to the (p-HOPhCH2) pyrazole 12f derivative inhibitor. A favorable steric area surrounded the o-benzyl, suggesting a possible new potent HIV-1 protease inhibitor.

Feasibility of testing for Chlamydia trachomatis in a general population sexual behaviour survey in Slovenia.

Our objective was to assess the feasibility of integrating first void urine (FVU) specimens testing for Chlamydia trachomatis genitourinary infection into a general population sexual behaviour survey. A total of 752 randomly selected respondents aged 18 to 54 were enrolled into the survey. Face to face interviewing with self-administered sensitive questions was used. Overall survey response rate was 77.4%. A convenience sub-sample of 83 respondents were invited to provide FVU specimens for confidential testing for C. trachomatis genitourinary infection. Fifty-five complied. This resulted in 66% FVU specimen participation rate among targeted respondents. Two specimens tested positive by Amplicor polymerase chain reaction. High feasibility study overall response rate indicated good acceptability of the survey. It proved feasible to collect FVU specimens for C. trachomatis testing in the small sub-sample. Consequently, we proceeded with integration of testing for C. trachomatis into the ongoing main survey.

Frequent attenders in general practice: quality of life, patient satisfaction, use of medical services and GP characteristics.

OBJECTIVE: To determine the predictors of frequent attendance in general practice. DESIGN: A postal survey using a questionnaire including instruments for measuring patient satisfaction (EUROPEP), quality of life (EUROQOL), anxiety and depression (DUKE-AD). SETTING: Primary health care in Slovenia. PATIENTS: A representative sample of 2160 adult patients. MAIN OUTCOME MEASURES: Number of contacts with the health care services, levels of self-care, patient satisfaction scores, quality of life scores, well-being scores, presence of chronic condition. RESULTS: Frequent attenders were more likely to have lower educational status, were more satisfied with their GP, had higher scores of anxiety and depression, and lower perceived quality of life. They were more likely to have a chronic disease. Frequent attenders were less likely to try self-care and more likely to use health services. They were more likely to visit more experienced GPs, GPs working a greater distance from other GPs and GPs who did not use the appointment system. The multivariable modelling explained 19.7% of the variation; 16.9% was attributed to patient characteristics and 3.1% to GP characteristics. CONCLUSIONS: The study confirmed that lower education levels, chronicity and higher use of other health services are predictors of higher attendance.

Attitudes towards information system security among physicians in Croatia.

To examine attitudes about information system security among Croatian physicians a cross-sectional study was performed on a representative sample of 800 Croatian physicians. An anonymous questionnaire comprising 21 questions was distributed and statistical analysis was performed using a chi-square test. A 76.2% response rate was obtained. The majority of respondents (85.8%) believe that information system security is a new area in their work. In general, physicians are not informed about European directives, conventions, recommendations, etc. Only a small number of physicians use personal computers at work (29%). Those physicians who have a personal computer use it mainly for administrative reasons. Most healthcare institutions (89%) do not have a security manual and the area of information system security is left to individual interest and initiative. Only 25% of physicians who have a personal computer use any type of password. A high percentage of physicians (22%) has never thought about the problem of personal data being used by organizations (e.g. police, banks) without legal background; a small, but still significant percentage of physicians (5.6%) has even agreed with such use. Results indicate that for the vast majority of physicians, information system security is a new area in their daily work, one which is left to individual interest and initiative. They are not familiar with the ethical, technical and legal backgrounds which have been defined for that area within the Council of Europe and the European Union. New aspects: This is the first study performed in Central and Eastern Europe dealing with information system security, performed on a representative nationwide sample of all the physicians.

Private practice in Slovenia after the health care reform.

BACKGROUND: Slovenia is one of the many post-socialist countries which started its reorientation of the health care system in the early 1990s. One of the aspects of the reform was the introduction of independent practice, which is performed either as a purely private practice on the basis of out of pocket payment or through contract with the National Health Insurance. A combination of both is also possible. In 1992 and 1993 the first physicians started to work in that way. The physicians that took this opportunity belonged to three main groups: dentists, primary health care physicians and secondary care specialists. The groups differ regarding their style of work and possibilities for running a profitable service. No studies have been done to evaluate the success of their decision. OBJECTIVES: The aim of the study was to evaluate the motives for leaving salaried posts, practice organization, perceived improvements and satisfaction with their choice of the practitioners who started to work independently in Slovenia in 1992 and 1993. METHODS: An anonymous questionnaire was sent to all self-employed physicians that started their independent practice in 1992 and 1993. A 54.5% response rate was achieved. The analysis of non-responders has shown that they did not differ significantly according to sex, location of practice, speciality or method of payment, from the responders. RESULTS: The analysis shows that the reported reasons for choosing independent practice are not different across the groups. Possibility for greater income was not reported as a major reason for leaving public service. There are important differences in organization of work: general practitioners reported spending more time on patient contacts and administration than the other two groups; they also work exclusively for the National Health Insurance, which is not the case for the other two groups. The perceived areas of improvement differ substantially. Regardless, the overall satisfaction with their choice is high (over 90% would make the same decision again), the general practitioners are the most dissatisfied group. CONCLUSIONS: The analysis shows that self-employed physicians in Slovenia represent three different groups with different positions regarding how they earn their money. Their expectations have largely been met, since they claim that the doctor/patient relationship is better, as well as some conditions for the patients. A follow-up study that would take into account the long-term effects of privatization, and analysis of economic functioning and patient satisfaction would be necessary in order to verify these claims.

Slovenian experience on health care reform.

The health care system in Slovenia has undergone significant changes since 1992. The objectives were primarily economic and not medical, since the level of medical services rendered has been fairly high and there were limited needs for improvements. Many changes, such as privatization, have not yet achieved their main objective - improved efficiency and quality. We have, however, observed many positive results, such as the awareness of medical staff that the quality of the national health care system should not be taken as granted but should be based and developed on extremely careful planning. Health care reform packages are being designed primarily to address one important problem: cost containment. An important part of the reform was moving the major part of the health care budget outside of the state budget to make it more transparent and controllable and its use more subject to its primary intention.

General practice in the curriculum in Slovenia.

Specific education in primary care in Slovenia developed in 1966, when vocational training for general practitioners was introduced. However, general practice never gained academic acceptance and was not introduced as a separate subject at undergraduate level. With the reform of medical education in Slovenia starting in 1987, family medicine was finally introduced as a specific subject in the final year. The new curriculum introduced a strong emphasis on practice-based teaching and in 1995 the first university department of family medicine was formally established. This article reports the first evaluation of the programme, based on qualitative and quantitative analysis of questionnaires, from students and the general practitioners who were their tutors. The programme was very well accepted by the students, who enjoyed working independently in a friendly environment where their tutors were more facilitators than teachers. The main problem is recognition of tutors by the medical and educational establishment, which will motivate tutors to perform additional educational tasks in the future.

Primary health care reform in Slovenia: first results.

The paper explains the main features of the primary health care system and its reform in Slovenia. The reform that has started in 1992, was characterized by the following main changes: introducing the national health insurance scheme as opposed to budget financing, a new contrast between providers and the national health insurance and a possibility of independent contracting with the national health insurance. The data show that the number of consultations per person per year has increased, especially in general practice. A possible explanation to that would be the fact that people had to visit their physicians in order to register with a specific PHC physician. It remains to be seen whether the high level of new attendances will remain in the following year or whether this is just a temporary situation.

Frequent attenders in general practice: a study from Slovenia.

To compare frequent with infrequent attenders at GPs' surgeries in a rural area in Slovenia with respect to morbidity, type of contact with the GP, referral pattern and the prescriptions given, a random sample of 623 records from a population-based register was analysed retrospectively. The frequent attenders had a higher proportion of contacts for malignant disease, mental disorder, and gastrointestinal disease. They also had a greater probability for a "superficial contact", were more likely to be referred to a specialist, were less likely to receive a psychotropic drug, and were more likely to receive a prescription for an antibiotic. We conclude that there are differences in morbidity between the two groups. The high referring pattern and the high proportion of "superficial contacts" of the frequent attenders may reflect poor doctor/patient relationship of this group.