Transition from Child and Adolescent to Adult Mental Health Services in Young People with Depression: On What Do Clinicians Base their Recommendation?

BACKGROUND: Clinicians in Child and Adolescent Mental Healthcare Services (CAMHS) face the challenge to determine who is at risk of persistence of depressive problems into adulthood and requires continued treatment after reaching the CAMHS upper age limit of care-provision. We assessed whether risk factors for persistence were related to CAMHS clinicians’ transition recommendations. METHODS: Within the wider MILESTONE cohort study, 203 CAMHS users were classified with unipolar depressive disorder by their clinician, and 185 reported clinical levels of depressive problems on the DSM-oriented Depressive Problems scale of the Achenbach Youth Self Report. Logistic regression models were fitted to both subsamples to assess the relationship between clinicians’ transition recommendations and risk factors for persistent depression. RESULTS: Only clinicianrated severity of psychopathology was related to a recommendation to continue treatment for those classified with unipolar depressive disorder (N = 203; OR = 1 45, 95% CI (1.03–2.03), p = 044) and for those with self-reported depressive problems on the Achenbach DSM-oriented Depressive Problems scale (N = 185; OR = 1 62, 95% CI (1.12–2.34), p = 012). CONCLUSION: Transition recommendations and need for continued treatment are based on clinical expertise, rather than self-reported problems and needs

Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome: insights from the LUNG SAFE study

Contains fulltext : 218568.pdf (publisher's version ) (Open Access)BACKGROUND: Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. METHODS: In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 >/= 0.60 during hyperoxemia). RESULTS: Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 250 (12%) had sustained hyperoxemia. Excess FIO2 use occurred in 400 (66%) out of 607 patients with hyperoxemia. Excess FIO2 use decreased from day 1 to day 2 of ARDS, with most hyperoxemic patients on day 2 receiving relatively low FIO2. Multivariate analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FIO2 use and adverse clinical outcomes. Mortality was 42% in patients with excess FIO2 use, compared to 39% in a propensity-matched sample of normoxemic (PaO2 55-100 mmHg) patients (P = 0.47). CONCLUSIONS: Hyperoxemia and excess oxygen use are both prevalent in early ARDS but are most often non-sustained. No relationship was found between hyperoxemia or excessive oxygen use and patient outcome in this cohort. TRIAL REGISTRATION: LUNG-SAFE is registered with ClinicalTrials.gov, NCT02010073

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Shared care and the management of lower urinary tract symptoms.

Contains fulltext : 57780.pdf (publisher's version ) (Closed access)OBJECTIVE: To investigate associations between the level of shared care and the clinical management of patients with uncomplicated lower urinary tract symptoms (LUTS). SUBJECTS AND METHODS: A cross-sectional survey study was conducted comprising all urologists and a random selection of general practitioners (GPs) in the Netherlands. Questionnaire responses were obtained from 182 urologists (70%) and 261 GPs (55%). The first part of the questionnaire established the physicians' characteristics and the second the level of familiarity with the national shared-care guidelines, arrangements between urologists and GPs, and the availability of a shared-care prostate clinic. The third part presented a written case of a 50-year-old man with clinical uncomplicated LUTS, and asked questions about diagnostic and therapeutic care. RESULTS: The clinical management of LUTS by GPs and urologists differed, particularly for diagnostic procedures. Only a minority of GPs (8%) and urologists (18%) had a shared-care clinic at their disposal. Such clinics were associated with an increase in tests ordered by the GP, e.g. creatinine levels (odds ratio, OR 3.83) and PSA levels (OR 5.93), and a decrease in choosing a watchful-waiting strategy for patients with mild symptoms (OR 0.24). Furthermore, urologists more often chose surgical intervention for moderate symptoms (OR 9.80). CONCLUSION: A shared-care clinic may lead to a shift in primary care towards the working style of urologists. This healthcare may not be as cost-effective as expected by policy makers. Prospective studies are needed to provide better insight in the health outcomes and efficiency of shared-care clinics

Phenotypic expansion of visceral myopathy associated with ACTG2 tandem base substitution

Familial visceral myopathy (FVM) is a rare heritable and heterogeneous condition due to impaired smooth muscle function. We identified a family segregating 11 individuals with a spectrum of visceral symptoms involving the small intestine, colon, biliary tract, urinary tract and uterus. Whole-exome sequencing revealed a novel heterozygous tandem base substitution c.806_807delinsAA (p.(Gly269Glu)) in ACTG2, encoding smooth muscle actin γ-2, in affected family members. Variants in ACTG2 were recently identified in FVM with intestinal pseudo-obstruction as well as with the congenital megacystics-microcolon-intestinal hypoperistalsis syndrome. In our family, eight affected members presented with severe complications from the biliary and/or the urinary tracts in addition to gastrointestinal pseudo-obstructions. Furthermore, all affected mothers had a history of assisted deliveries owing to poor progress during labor and weak uterine contractions. The variable involvement of multiple smooth muscle-dependent organs in our family, including the biliary tract and the uterus, add to the phenotypic spectrum associated with ACTG2 missense variants