Using electronic medical records to determine prevalence and treatment of mental disorders in primary care: a database study.

OBJECTIVES: With prevention and treatment of mental disorders a challenge for primary care and increasing capability of electronic medical records (EMRs) to facilitate research in practice, we aim to determine the prevalence and treatment of mental disorders by using routinely collected clinical data contained in EMRs. METHODS: We reviewed EMRs of patients randomly sampled from seven general practices, by piloting a study instrument and extracting data on mental disorders and their treatment. RESULTS: Data were collected on 690 patients (age range 18-95, 52% male, 52% GMS-eligible). A mental disorder (most commonly anxiety/stress, depression and problem alcohol use) was recorded in the clinical records of 139 (20%) during the 2-year study period. While most patients with the common disorders had been prescribed medication (i.e. antidepressants or benzodiazepines), a minority had been referred to other agencies or received psychological interventions. 'Free text' consultation notes and 'prescriptions' were how most patients with disorders were identified. Diagnostic coding alone would have failed to identify 92% of patients with a disorder. CONCLUSIONS: Although mental disorders are common in general practice, this study suggests their formal diagnosis, disease coding and access to psychological treatments are priorities for future research efforts.

Report on the creation of a diabetes register and retinopathy screening outcomes in the Mid-West of Ireland.

BACKGROUND: With concerns that blind registration in Ireland due to diabetic retinopathy is continuing to rise, a structured retinopathy screening service is in the process of being rolled out nationally. AIMS: To report on the validation process for creating a register of diabetics in the Mid-West of Ireland, and findings following retinopathy screening of a representative sample. METHODS: National primary care databases were employed in generating provisional lists of diabetic patients in the Health Service Executive (HSE) Mid-West area. Subsequent engagement with the corresponding general practices over a three year period between 2010 and 2013 facilitated the validation of these lists. A summary of the retinopathy screening outcomes of 1,434 patients and pre-existing screening patterns is reported. RESULTS: The number of patients on the Mid-West diabetes register to date is 11,126. Of the 1,434 patients screened, 288 (20.1 %) had background retinopathy, while 117 (8.2 %) had sight-threatening retinopathy. Seventeen (19.8 %) of the 86 patients identified with maculopathy required treatment with intravitreal injections. Of the 610 patients questioned about previous screening events, 389 (63.8 %) said they had undergone an ocular examination within the previous 12 months. CONCLUSIONS: The HSE Mid-West has over 11,000 patients on its database ready to be screened by the national programme, with the treatment of maculopathy expected to have the largest impact on resources. Although the majority of patients are already undergoing screening in the community in an ad hoc fashion, the rates of sight-threatening retinopathy encountered highlight the timeliness of the full implementation of the national programme.

Care of type 2 diabetes in unresourced general practice: current practice in the Mid-West.

It is estimated that 4.5% of the Irish population have type 2 diabetes. The HSE intends to move the care of uncomplicated type 2 diabetes to General Practice (GP). The study reviewed current General Practice diabetes care in the Irish Mid-West. The files of randomly selected patients from 12 GP teaching practices attached to the University of Limerick were audited. 842 patients were identified (62% male, 38% female). The mean age was 66 years. 75% were GMS patients. A practice protocol was used in 71% of patients. Average Cholesterol (4.3 mmol/l), creatinine (85.3 mmol/l), HbA1c (56.7 mmol/mol) and systolic blood pressure (SBP) (134 mmHg) measurements were well documented and controlled. However the rates of and mean intervals for foot review (60.2%), BMI measurement (52.3%), retinopathy screening (62.0%) and influenza vaccination (63.0%) were unacceptably low. Current management of type 2 diabetes in unresourced general practices is suboptimal although some biochemical parameters are well controlled.

Structured care of diabetes in general practice: a qualitative study of the barriers and facilitators.

This qualitative study explored general practitioner's and practice nurse's perceptions of barriers and facilitators to the proposed transfer of diabetes care to general practice. Qualitative data were collected through five focus groups. Participants included GPs (n = 55) and practice nurses (n = 11) representing urban (44%), rural (29%) and mixed (27%) practices, in the Irish Mid-West region. Barriers and facilitators were mentioned 631 times (100%). Barriers were mentioned 461 times (73%), facilitators 170 times (27%). The most frequently identified barriers were lack of financial incentive (119/631; 19%), lack of access to secondary resources (93/631; 15%), lack of staff and increased workload (59/631; 9%) and time constraints (52/631; 8%). Identified facilitators were access to secondary care (49/631;7.8%), the holistic nature of general practice and continuity of care (48/631;7.6%). Although many are enthusiastic, there remains significant reluctance among GPs and practice nurses to take responsibility for diabetes care without addressing these barriers.

Mumps epidemiology in the mid-west of Ireland 2004-2008: increasing disease burden in the university/college setting.

Mumps is a contagious vaccine-preventable viral disease that is experiencing a revival in students attending second and third level colleges. Large mumps outbreaks have been reported in several countries despite the presence of childhood immunisation programmes over many years, including measles, mumps, and rubella (MMR) vaccination. In 2008, 1,377 cases of mumps were notified in Ireland and 1,734 in the first three months of 2009 (provisional data). This paper reviews the recent epidemiology of mumps in the Mid-West region of Ireland and highlights preventive measures. A substantial proportion of cases were not laboratory-confirmed and it is important that doctors continue to notify suspected cases. In the Irish Mid-West, data from enhanced surveillance shows a high proportion of mumps in the age group 15-24 years. Complications were uncommon and rarely severe. Where data were available, over half of the cases did not recall having received two doses of MMR, but most recalled one dose. Parents should continue to ensure children receive both MMR vaccinations so that uptake is optimal for protection. Steps were taken to increase awareness of the disease in the school, college and university settings. Preventive measures implemented to limit mumps transmission in the school/college setting over recent years included vaccination of close contacts, isolation for five days and hand hygiene.

Optimism and health-related quality of life in adolescents with cancer.

OBJECTIVE: To delineate the relationship between optimism and health-related quality of life (HRQOL) and quality of life (QOL) in adolescents with cancer living in the Bronx, New York. METHODS: Optimism was assessed using the Life Orientation Test, Revised (LOT-R). HRQOL and QOL were measured using the Pediatric Quality of Life Inventory, Cancer Module, Acute Version and The Pediatric Quality of Life Inventory, Generic Core Scale, respectively. Associations between optimism and HRQOL and QOL were assessed using Pearson's product-moment correlations. RESULTS: Twenty-three adolescents participated in this study; the mean age was 16 and the majority was male. This sample was highly optimistic and reported high HRQOL and QOL. Optimism was correlated with less reported pain and hurt, better communication with doctors, higher reported psychological functioning and higher overall QOL. CONCLUSION: Optimism is associated with higher QOL in inner city adolescents with cancer. Further research should assess whether interventions that increase optimism lead to greater QOL in this population.

Carers' views on services for the elderly mentally ill.

BACKGROUND: Recent health policy emphasises the involvement of the consumer and carer in health and social care issues. Demographic projections predict a rise in the number of elderly people in Ireland and the number of elderly people with a mental illness. The identification of gaps in service provision should result in appropriate planning for this group in the future. OBJECTIVE: The aim of the study was to assess carers' opinions of services for the elderly mentally ill in the Limerick area. METHOD: A questionnaire was sent to the carers of patients referred to the Psychiatry of Old Age service. Information was gathered on satisfaction with existing services for the elderly. Carers were also asked to identify which services they felt they needed. RESULTS: The overall response rate was 51%, but the response rate for individual items varied. Both formal and informal services for the elderly are underused. The need for long-term care places was highlighted and carers wished for more information and emotional support. CONCLUSION: This study highlighted the aspects of the service that carers value, which should help guide future service development.

Effect of immunization with a common recall antigen on viral expression in patients infected with human immunodeficiency virus type 1.

BACKGROUND: Activation of the immune system is a normal response to antigenic stimulation, and such activation enhances the replication of human immunodeficiency virus type 1 (HIV-1). We studied the effect of immunization with a common recall antigen on viral expression in HIV-1-infected patients, on the ability to isolate virus, and on the susceptibility to HIV-1 infection of peripheral-blood mononuclear cells (PBMCs) from control subjects not infected with HIV-1. METHODS: Thirteen HIV-1-infected patients and 10 uninfected adults were given a 0.5-ml booster dose of tetanus toxoid. Studies were performed to evaluate changes in the degree of plasma viremia, proviral burden, the ability to isolate HIV-1, and the susceptibility of PBMCs to acute infection in vitro. Two patients underwent sequential lymph-node biopsies for the assessment of viral burden in these tissues. RESULTS: All 13 HIV-1-infected patients had transient increase in plasma viremia after immunization, and the proviral burden increased in 11. These changes did not correlate with the base-line CD4+ T-cell counts. The lymph-node tissue also had increases in the proviral burden and viral RNA after immunization. The virus was more easily isolated from PBMCs from nine of the patients after immunization than before immunization. Despite considerable variability in the results, PBMCs from 7 of the 10 normal subjects were more easily infected in vitro with HIV-1 after immunization than before immunization. CONCLUSIONS: Activation of the immune system by an ongoing antigen-specific immune response to an exogenous stimulus transiently increases the expression of HIV-1 and may enhance the susceptibility of uninfected subjects to HIV-1.

Oral acyclovir to suppress frequently recurrent herpes labialis. A double-blind, placebo-controlled trial.

OBJECTIVE: To determine whether oral acyclovir reduces the incidence of recurrent herpes labialis in otherwise healthy patients with proven frequently recurrent disease. DESIGN: Randomized, double-blind, placebo-controlled, crossover trial. SETTING: Outpatient facility of the Clinical Center, National Institutes of Health, Bethesda, Maryland. PATIENTS: Fifty-six otherwise healthy adults who reported frequently recurrent herpes labialis (> or = 6 episodes/y) were enrolled into the study. During a 4-month observation period, 22 patients had herpes labialis two or more times and were eligible for study treatment. INTERVENTIONS: Twenty-two patients were randomized to receive either acyclovir, 400 mg twice daily, or matched placebo for 4 months. After the first treatment period, patients were given the alternate treatment for another 4 months and were then taken off study medication to observe the first post-treatment recurrence. Recurrent outbreaks were determined by examination and by viral culture. RESULTS: Twenty patients completed blind treatment with both acyclovir and placebo. The median time to first clinically documented recurrence was 46 days for placebo courses and 118 days for acyclovir courses (P = 0.05). The mean number of recurrences per 4-month treatment period was 1.80 episodes per patient during placebo treatment and 0.85 episodes per patient during acyclovir treatment (P = 0.009). The mean number of virologically confirmed recurrences per patient was 1.40 with placebo therapy compared with 0.40 with acyclovir (P = 0.003). CONCLUSIONS: Oral acyclovir, 400 mg twice daily, is effective in suppressing herpes labialis in immunocompetent adults confirmed to have frequently recurrent infection. Treatment with acyclovir in this study resulted in a 53% reduction in the number of clinical recurrences and a 71% reduction in virus culture-positive recurrences compared with placebo therapy.

UV light-induced reactivation of herpes simplex virus type 2 and prevention by acyclovir.

UV B light is a potent stimulus for inducing reactivation of latent herpes simplex virus (HSV) infections. Patients were enrolled in a double-blind placebo-controlled crossover trial to determine whether acyclovir can prevent UV light-induced HSV-2 recurrences. Twenty-four patients with a history of recurrent infection of perigenital sites (e.g., buttock, thigh) were exposed one to four times with 4 minimum erythema doses of UV light. Patients were given acyclovir 200 mg orally five times daily or matched placebo beginning 1 day before each exposure and continuing for 5 days after exposure. There were 13 UV-induced recurrences among 36 placebo treatments and 3 after 38 acyclovir treatments (P = .004). The mean time to recurrence (+/- SE) was 4.8 +/- 0.3 days. HSV-2 lesions developed primarily at the site of UV exposure. The cutaneous distribution and timing of UV-induced recurrences was consistent with a neural localization (dorsal root ganglia) of latent viral infection. This UV light model permits direct examination of events leading to HSV-2 recurrences in humans and can be used to evaluate approaches to prevention.

Prevention of ultraviolet-light-induced herpes labialis by sunscreen.

Sunlight exposure is reported by some patients to precede onset of recurrent herpes labialis. Ultraviolet (UV) B light is known to be a stimulus for the reactivation of herpes simplex virus (HSV) infections. We assessed the effect of a sunblocking agent on UV-light-induced reactivation of recurrent herpes labialis in a double-blind, placebo-controlled crossover trial. 38 patients were exposed on two separate occasions to four minimum erythema doses of UV light at an area of previous labial herpes recurrence. A solution containing sunscreen was applied to the lips before one exposure and a matched placebo before the other. After placebo and UV exposure, herpes labialis developed in 27 (71%) of the 38 patients, with a mean time to recurrence of 2.9 (SEM 0.2) days. In contrast, when sunscreen was applied before UV exposure, no lesions developed, but 1 of the 35 patients shed virus at the exposure site. We conclude that UV light is a potent stimulus for inducing reactivation of herpes labialis, and that application of sunscreen may be effective in the prevention of sunlight-induced recurrent infection.

Nursing recruitment: do health care managers gear strategies to the appropriate audience?

Senior management at Guthrie Healthcare System, a regional referral center located in rural Pennsylvania, discovered several fascinating findings in its nursing recruitment research. Anticipating the consequences of the nursing shortage and seeking to avoid the entrapments of lucrative short-term recruitment enticements, Guthrie directed its recruitment efforts toward developing a supply of new nursing resources. Through the development of a career opportunity program that underwrites baccalaureate nursing education for qualified individuals, Guthrie management uncovered a vast supply of interested, potential nursing student candidates. Intrigued by the possibility of developing this market in the face of a dire nursing shortage, Guthrie Healthcare System management conducted an investigation to analyze the characteristics of these prospective nursing students. The findings of the study identify a large existing pool of qualified potential applicants. Most important, these individuals possess a true interest in nursing. This investigation suggests that removal of financial barriers to a nursing education uncovers a large market of nursing student candidates. Thus a reexamination of recruitment strategies is required to refocus efforts toward reaching this identified market.

1992 career guide. Best jobs for the future. Salary survey.

The best news many workers are looking for when annual review time rolls around this year is that they'll have a job for the foreseeable future. A raise? That's surely hoping for too much. Indeed, some 10 percent of the organizations surveyed by the Wyatt Co., a compensation and benefits consulting firm in New York, have frozen wages this year. About 3 percent plan to do the same in 1992. But salaries have clearly been pummeled harder in some industries than in others. The paychecks of people who work in the retail trade and in the building materials and equipment industry, for example, have barely kept pace with inflation this year. Next year promises more of the same. Those in the legal field, by contrast, enjoyed raises of 8 percent in 1991, and nurse-anesthetists averaged 10 percent. Across the board, salaries in 1991 went up 5.5 percent. But businesses are cynical about the economy's prospects, says Wyatt compensation expert Marsha Cameron, and their planned raises for 1992 average only 5.3 percent. To determine where a profession pays best, U.S. News, in conjunction with Wyatt, took a look at what 18 jobs pay on average at the entry, senior professional and middle manager levels in five regions of the country. The salaries come from Wyatt's survey of more than 3,500 organizations across the United States. New graduates in software engineering may want to send their résumés to Texas and Colorado, for example, where starting salaries, at $34,200, average $6,200 more than in Alabama and Georgia.250+

Reactivation of latent herpes simplex virus infection by ultraviolet light: a human model.

Infection with herpes simplex virus often results in a latent infection of local sensory ganglia and a disease characterized by periodic viral reactivation and mucocutaneous lesions. The factors that trigger reactivation in humans are still poorly defined. In our study, five patients with documented histories of recurrent herpes simplex virus infection on the buttocks or sacrum were exposed to three times their minimal erythema dose of ultraviolet light. Site-specific cutaneous herpes simplex virus infection occurred at 4.4 +/- 0.4 days after exposure to ultraviolet light in 8 of 13 attempts at reactivation. We conclude that ultraviolet light can reactivate herpes simplex virus under experimentally defined conditions. This model in humans should prove useful in evaluating the pathophysiology and prevention of viral reactivation.