Sensitivity, specificity and diagnostic accuracy of novices integrating lung ultrasound into the care of breathless older patients.

Background: Lung ultrasound is frequently used to identify pulmonary oedema, using the 'B line' artefact. A small study in 2011 suggested that novice sonologists had a potential diagnostic accuracy of 85%, when performing the test without reference to other patient information. Aim: We aimed to test the overall diagnostic accuracy of novice clinician sonologists incorporating the 2011 protocol into routine assessment of the patient. Method: A prospective convenience sample of breathless older patients presenting to ED received an 8-view lung scan early in management. Initial ED diagnoses, utilising all information including ultrasound result, were compared against the opinion of a medical expert auditing the patient records after discharge from hospital. Results: The cohort of five novices scanned 63 cases, from which eleven were excluded. Novices using ultrasound differentiated between pulmonary oedema and other causes of breathlessness with a sensitivity of 71% (95%CI 44 to 87), Specificity of 91% (76 to 98), a diagnostic accuracy of 85% (72 to 92), a positive LR of 8.2 (2.7 to 25) and a negative LR of 0.32 (0.15 to 0.68). Discussion: The diagnostic accuracy of emergency department clinicians incorporating novice lung ultrasound into the investigation of breathlessness is consistent with the diagnostic accuracy of scanning performed in parallel to patient care, and is likely to be an improvement on current estimates of conventional ED diagnostic strategies. Clinicians should not be afraid that their learning curve would disadvantage the patient.

Should children and adolescents be tested for Huntington's disease? Attitudes of future lawyers and physicians in Switzerland.

The objective of the study was to identify future lawyers' and physicians' views on testing children for Huntington's disease (HD) against parents' wishes. After receiving general information about HD, patient autonomy and confidentiality, law students and advanced medical students were shown an interview with a mother suffering from HD who is opposed to informing and testing her two children (aged 10 and 16) for HD. Students then filled out questionnaires concerning their agreement with testing. No significant differences were found between medical and law students or between students from different courses concerning the adolescent son. Three quarters of students thought that he should be told about his mother's disease, and 91% thought the adolescent son should have the opportunity of genetic testing for HD himself. However, significant differences were found concerning the 10-year old son, with 44% of law students and 30% of medical students in favour of testing the child for HD. Students raised some important ethical issues in their elective comments. In conclusion, we found highly positive attitudes towards informing a 16-year old of his mother's HD and offering to test him. These attitudes were not in tune with guidelines. Students did not consider several practical and ethical issues of genetic testing of children and adolescents. Specific education should ensure that attitudes are based on sufficiently detailed knowledge about all aspects of genetic testing of children to discourage pressures on persons at risk of HD.

Avoidable breaches of confidentiality: a study among students of medicine and of law.

OBJECTIVES: Avoidable breaches of patient confidentiality due to inadvertence or ignorance occur frequently. The aim of this study was to explore whether participants were able to identify violations of confidentiality and how serious these violations were. DESIGN: After a 2-hour theoretical education session, participants filled out a standardised questionnaire presenting 6 hypothetical cases (e.g. politician's illness mentioned to the doctor's family, violence inflicted by the police mentioned to a lawyer at a dinner party, both without patient consent) and asking whether confidentiality had been violated. Answers were given on a score of 0-3, where 0 = no violation and 3=serious violation. SETTING: University of Geneva, Switzerland. PARTICIPANTS: Three professors of criminal law (representing the gold standard) and convenience samples of 311 law, medical and dental students took part. Main outcome measures Students' answers were compared to the gold standard (answers of criminal law professors). RESULTS: According to our gold standard, a violation of confidentiality took place in all 6 cases (scores: 3, 2, 3, 2, 3, 3; means of students: 1.7, 0.6, 1.0, 0.4, 1.5, 2.6). Most students (88%) mistakenly believed in 1-3 cases that no violation took place. In only 2 cases did more than 90% of participants recognise the violation. Law students attributed significantly lower scores than medical or dental students in 3 cases and higher scores in 1 case. CONCLUSIONS: Despite theoretical education, participants did not fully understand obligations towards patient confidentiality when it came to practical situations, especially when colleagues and authorities (police, those in a judicial context) asked for information. Teaching should address the risk of patient identification and the seriousness of violations in order to motivate doctors to avoid unjustified violations of confidentiality.

Compliance with the wishes of competent patients among future physicians and lawyers: is paternalism a predictable individual or group-specific trait?

A total of 127 fifth-year medical students and 167 first- to fourth-year law students filled in questionnaires composed of 10 hypothetical scenarios, in which competent patients clearly expressed their particular wish, so that not complying with their wishes for reasons referring to the patient's good would have to be characterized as 'hard paternalism'. In most scenarios, attitudes of law and medical students differed significantly. Medical students showed more paternalistic attitudes than law students in the scenarios describing a patient's request for information about prognosis (p = 0.0003), a terminally ill patient's request to stop mechanical ventilation (p = 0.03), and an AIDS patient's request for a potentially harmful experimental drug (p = 0.05). Compliance with the desire of a Jehovah's Witness not to receive a life-saving blood transfusion predicted less paternalistic responses in almost all other cases. The existence of a paternalistic trait in responses is confirmed. However, the trait explains only 20% of variance.

Should a suicidal patient with Huntington's disease be hospitalized against her will? Attitudes among future physicians and lawyers and discussion of ethical issues.

The issue of rational suicide of a competent patient suffering from a hopeless but not terminal disease is controversial. Little is known about how psychiatrists, other physicians or judges make decisions about involuntary hospitalization of such patients, or about their ethical reasoning. The objective of this study was to identify future physicians' and lawyers' views on involuntary hospitalization of a suicidal Huntington's disease (HD) patient and to evaluate whether they are ethically defendable. Five-hundred and ninety-nine law students and advanced medical students reported whether they agree or not to involuntary hospitalize a suicidal HD patient (audio/video recording). No significant differences were found between medical and law students. Forty-four percent of students agreed to hospitalization, 49.3% disagreed. The comments indicate that medical and law students had pessimistic views about the quality of life of an HD patient. Medical students referred more often than law students to patients' autonomy rights and less often to benefits to relatives. Involuntary hospitalization of a suicidal but not terminal HD patient is controversial among future physicians and lawyers. Students underestimated the need for careful evaluation. More open discussion and more ethical teaching on the subject of acceptance of rational suicide for hopelessly, but not yet terminally ill patients are needed.

HIV prevention in prisons. Do international guidelines matter?

BACKGROUND: In spite of the availability of international guidelines, HIV prevention and management of care in prison is still unsatisfactory in many countries. Factors affecting the quality of HIV prevention policies in prison have not yet been elucidated. The present study had two aims: i) to assess national HIV prevention policies in prison in a selected group of countries; and ii) to determine which factors influenced such policies at the country level. METHODS: HIV prevention policies in prison were reviewed comparatively in Moldova, Hungary, Nizhnii Novgorod region of the Russian Federation, Switzerland and Italy. The review of HIV prevention policies in prison was conducted through interviews with government officials, non-governmental organizations, professionals involved in this field, and visits to selected prisons. Information on the health of prisoners, including tuberculosis, sexually transmitted diseases, and other infectious diseases has also been collected. RESULTS: The results indicated that all countries had adopted a policy, irrespective of the burden of HIV infection in the prison system. The content of the policy mirrored the philosophy and strategies of HIV prevention and care in the community. The 1993 WHO Guidelines were fully implemented only in one country out of four (Switzerland), and partially in two (Italy and Hungary). CONCLUSIONS: A greater effort aimed at dissemination of information, provision of technical know-how and material resources could be the answer to at least part of the problems identified. In addition, greater national and international efforts are needed to stimulate the debate and build consensus on harm reduction activities in prison.

El cuestionario de síntomas para la detección de problemas en adultos / The symptoms questionaire for the detection of problems in adults

El cuestionario de síntomas para la detección de problemas mentales en adultos fue diseñado contemplando diferencias transculturales e incluye para su validación una muestra de 400 pacientes y sus familiares como muestra de comparación, provenientes de centros generales de salud de Colombia, la India, Filipinas y Sudán. Se utilizaron punto de corte diferentes para cada área sobre la base del cálculo de sensibilidad y especificidad. El instrumento - que, en la actualidad, se utiliza en diversas partes del mundo - ha demonstrado ser una herramienta de selección sensible, para la identificación e desórdenes mentales en grupos de individuos que acuden a los servicios médicos generales. Asimismo se lo utiliza como parte de un manual de entrenamiento para los trabajadores de atención primaria (AU)

El cuestionario de síntomas para la detección de problemas en adultos / The symptoms questionaire for the detection of problems in adults

El cuestionario de síntomas para la detección de problemas mentales en adultos fue diseñado contemplando diferencias transculturales e incluye para su validación una muestra de 400 pacientes y sus familiares como muestra de comparación, provenientes de centros generales de salud de Colombia, la India, Filipinas y Sudán. Se utilizaron punto de corte diferentes para cada área sobre la base del cálculo de sensibilidad y especificidad. El instrumento - que, en la actualidad, se utiliza en diversas partes del mundo - ha demonstrado ser una herramienta de selección sensible, para la identificación e desórdenes mentales en grupos de individuos que acuden a los servicios médicos generales. Asimismo se lo utiliza como parte de un manual de entrenamiento para los trabajadores de atención primaria

Clomipramine in the treatment of depression and phobic anxiety states

Clomipramine, a chlorinated tricyclic drug, was assessed in 2 groups of outpatients (i) 59 depressed patients in a double blind comparative trial with amitryptiline; and (ii) 7 patients with phobic anxiety states. (i) In the comparative trial no difference in anti-depressant action (assessed by serial Hamilton Rating scores) of clomirpramine and amitryptiline could be demonstrated. Both appeared to relieve depression effectively with maximal anti-depressant action in the second and third weeks of treatment. Patients taking clomipramine, however, had significantly more side effects (p<0.01) and more patients in this group had to be withdrawn for this reason. Postural hypotension was the most serious side effect and occurred in 25 percent of patients taking clomipramine as against 115 of patients taking amitryptiline. (ii) 7 patients with phobic anxiety state with predominantly agoraphobic symptoms ("the agoraphobic syndrome"), who had previously proved resistant to treatment by phenelzine, anxiolytic drugs, supportive psychotherapy and (in 4 cases) desensitisation, were treated with clomipramine orally. 2 patients developed side effects. Of the remaining 5, 3 showed a satisfactory response (in 2 complete alleviation of phobic symptoms with return to normal activities, and in 1 marked alleviation). The other 2 patients showed slight improvements but remained considerably handicapped. Clomipramine (i) has been shown to be an effective anti-depressant drug of comparable efficacy and speed of action to amitryptiline. The higher incidence of side effects, however, make it an anti-depressant of second choice. (ii) appears potentially very useful in the management of agarophobic patients (who are in general resistant to treatment (AU)

The detection of psychiatric illness by questionnaire in Jamaica

The minor psychiatric disorders are common. It has often been claimed that a considerable proportion of patients attending general practitioners, health clinics and hospital clinics suffer from neurotic illness. Paradoxically, psychiatrists see a highly selected sample of psychiatric patients, in which more serious disorders are over-represented. In the past, psychiatric rating schedules and inventories have been designed primarily for use in this selected group of patients. The introduction of a diagnostic self-rating schedule, designed specifically for the detection of minor psychiatric disorders among patients attending general practice (or other "non-psychiatric") clinics, is therefore an innovation of considerable importance. Goldberg has recently described a General Health Questionnaire (GHQ) and demonstrated its reliability and validity in the detection of minor psychiatric disorders among patients in London (U.K.) and Philadelphia (U.S.A.). I have attemped to establish the reliability and validity of the G.H.Q. (shortened version) for use in Jamaica. The G.H.Q. has been administered to: (1) 100 consecutive adult clinic attenders at the Lawrence Tavern Rural Health Clinic. (2) 30 patients attending the psychiatric clinic at U.H.W.I. for treatment of neurotic illness. (3) 30 "normal" controls i.e. rlatives of patients attending non-psychiatric clinics at U.H.W.I. who (a) regarded themselves as psychiatrically well; (b) had no past history of treatment for psychiatric disorders; and (c) showed no obvious behavioural disorder on recruitment. In addition a one-in-four sub-sample of the Lawrence Tavern patients had a standardised psychiatric interview. The results indicate that the shortened version of the G.H.Q. is both reliable and valid for use in Jamaica. It showed high degrees of specificity (81 percent) and sensitivity (89 percent) subject to a minor recalibration (treshold score to be increased from 3/4 to 4/5). It can be recommended for further use in Jamaica and may well be usefull in other English-speaking Caribbean countries. The results also indicate that 20-25 percent of adults attending the Lawrence Tavern Clinic have psychiatric illness (AU)

Marijuana modified mania

A syndrome seen in four Jamaican patients is described in which increased use of marihuana followed the onset of symptoms of a hypomanic nature. At the time of admission to the hospital the patients exhibited persecutory delusions, auditory hallucinations, withdrawal, and thought disorder. Within three to four days after admission, manic or hypomanic symptoms emerged. It is suggested that these patients had mania and that excess marihuana usage was symptomatic of their illness, leading to a transient, marihuana-induced, schizophreniform phase of their manic illness. A plea is made for a broader approach to the psychiatric implications of marihuana use.(AU)