Evidence into practice: the mental health hurdle is high.
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Australia↗
Biomedical subjects
David Barton
Publications and source records attributed to David Barton.
Risk factor management and depression post-stroke: the value of an integrated model of care.
BACKGROUND AND PURPOSE: Shared care initiatives, albeit commonly utilised in managing other chronic conditions have not been implemented in the area of stroke in Australia. The aims of this project were to adopt a shared care approach for stroke survivors comparing an experimental "shared-care" group with a "treatment-as-usual" control group in reference to the normalization or reversal of vascular risk factors and the detection and management of post-stroke depression. METHODS: A randomised controlled experimental research design was implemented with participants randomized to an intervention or control group and followed over a 12-month period. The treatment group consisted of a randomly selected group of patients, discharged from an acute stroke unit and transferred into the shared care model. Risk factors for stroke and depression were compared between the two groups. RESULTS: Of 97 patients originally included in the study, 17 dropped out. At 12 months, 80 patients remained for analysis (35 in the intervention group and 45 in the control group). The findings demonstrated positive trends for patients within the intervention group that were not found within the control group. The percentage of intervention patients reaching target systolic blood pressure (sBP) of 140 mmHg after 12 months tended to be greater than in the control group (p=0.11, NS). In the intervention group, at 12 months, the total cholesterol greater than 5.18 mmol/L was 12.5% compared to 58.8% at discharge. In contrast this trend was not so distinct in the control group (57.7% to 42.9%). The percentage of patients reaching target (recommended) total cholesterol of 5.18 mmol/L was significantly greater in the shared care patients intervention group relative to the control group (p=0.02). The average number of walks per week was also significantly greater in intervention group compared to the control group (p=0.048). Moreover, 45% of the control group screened as depressed compared with 20% of the intervention group at 12 months (p=0.06). CONCLUSIONS: This study demonstrates that major risk factors for recurrent stroke and vascular disease in general are better managed with the shared care model than with usual post-discharge care. The significantly reduced depression as found on the screening PHQ9 at 12 months indicated that the intervention was beneficial not only in the detection of depression but also treatment.
Blood Pressure↗
Familial vesicoureteral reflux: influence of sex on prevalence and expression.
PURPOSE: Familial clustering of vesicoureteral reflux implies that genetic factors have an important role in the pathogenesis of vesicoureteral reflux. We investigated the impact of sex on familial vesicoureteral reflux. MATERIALS AND METHODS: Between 1998 and 2003 we identified 159 white families with at least 2 children (range 2 to 5) with vesicoureteral reflux confirmed by a voiding cystourethrogram. Families were divided into 3 groups, including group 1 with only boys affected (29 or 18%), group 2 with only girls affected (57 or 36%) and group 3 with boys and girls affected (73 or 46%). Clinical characteristics, reflux grade and associated renal anomalies in these 3 groups were compared using the Mann-Whitney U and chi-square tests for statistical analysis. RESULTS: Sisters of index female patients were at significantly higher risk for vesicoureteral reflux than brothers (p <0.01). Boys in group 1 had a significantly higher grade of vesicoureteral reflux than boys in group 3, and girls in groups 3 and 2 (p = 0.018, <0.001 and <0.0001, respectively). Severe renal scarring was present in 7% of boys in group 1, 6.6% of boys in group 3, 1.3% of girls in group 3 and 1.9% of girls in group 2. Duplex kidneys were present in 15.3% of boys in group 1 but only in 2.3% of boys in group 3 (p <0.01), 5.7% of girls in group 3 and 5.8% of girls in group 2. Age at diagnosis was not significantly different among boys in groups 1 and 3, and girls in group 2 (median 0.9, 0.6 and 1.9 years, respectively). CONCLUSIONS: The risk and severity of vesicoureteral reflux in siblings depends on the sex of the affected child. Brothers of index male patients have higher grade of reflux and higher rate of associated duplex systems. This has implications for genetic counseling and for modeling the inheritance of vesicoureteral reflux.
Child, Preschool↗
Is real reform of the Medicare Benefits Schedule for psychiatrists in Australia economically, socially or professionally desirable?
OBJECTIVE: To propose alternative Medicare Benefits Schedule-based funding models for outpatient psychiatric services in Australia. METHOD: Development of alternative funding schedules for a variety of under-serviced populations. CONCLUSIONS: Consideration of alternative systems is necessary to address the restrictive work practices, inequity and poor distribution of the psychiatric workforce.
Attitude to Health↗
The neuronal noradrenaline transporter, anxiety and cardiovascular disease.
Panic disorder can serve as a clinical model for testing whether mental stress can cause heart disease. Potential neural mechanisms of cardiac risk are the sympathetic activation during panic attacks, continuing release of adrenaline as a co-transmitter in the cardiac sympathetic nerves, and impairment of noradrenaline neuronal reuptake, augmenting sympathetic neural respnses. The phenotype of impaired neuronal reuptake of noradrenaline: an epigenetic mechanism? We suspect that this phenotype, in sensitizing people to heart symptom development, is a cause of panic disorder, and by magnifying the sympathetic neural signal in the heart, underlies increased cardiac risk. No loss of function mutations of the coding region of the norepinephrine transporter (NET) are evident, but we do detect hypermethylation of CpG islands in the NET gene promoter region. Chromatin immunoprecipitation methodology demonstrates binding of the inhibitory transcription factor, MeCP2, to promoter region DNA in panic disorder patients. Cardiovascular illnesses co-morbid with panic disorder. Panic disorder commonly coexists with essential hypertension and the postural tachycardia syndrome. In both of these cardiovascular disorders the impaired neuronal noradrenaline reuptake phenotype is also present and, as with panic disorder, is associated with NET gene promoter region DNA hypermethylation. An epigenetic 'co-morbidity' perhaps underlies the clinical concordance. Brain neurotransmitters. Using internal jugular venous sampling, in the absence of a panic attack we find normal norepinephrine turnover, but based on measurements of the overflow of the serotonin metabolite, 5HIAA, a marked increase (six to sevenfold) in brain serotonin turnover in patients with panic disorder. This appears to represent the underlying neurotransmitter substrate for the disorder. Whether this brain serotonergic activation is a prime mover, or consequential on other primary causes of panic disorder, including cardiac sensitization by faulty neuronal noradrenaline reuptake leading to cardiac symptoms and the enhanced vigilance which accompanies them, is unclear at present.
Animals↗
Single-unit analysis of sympathetic nervous discharges in patients with panic disorder.
Patients with panic disorder are at increased cardiac risk. While the mechanisms responsible remain unknown, activation of the sympathetic nervous system may be implicated. Using isotope dilution methodology, investigations of whole-body and regional sympathetic nervous activity have failed to show any differences between patients with panic disorder and healthy subjects. Using direct recording of single unit efferent sympathetic vasoconstrictor nerve activity by microneurography we examined sympathetic nervous function in patients with panic disorder more precisely than previously reported. The activity of multiunit and single unit vasoconstrictor sympathetic nerves was recorded at rest at the level of the peroneal nerve in 10 patients diagnosed with panic disorder and in nine matched healthy volunteers. Multiunit sympathetic activity was not different between the two groups (26+/-3 bursts min-1 in patients with panic disorder and 28+/-3 bursts min-1 in controls). The firing frequency of single unit vasoconstrictor neurones was also similar between the two groups (0.38+/-0.09 versus 0.22+/-0.03 Hz). However, the probability of firing during a sympathetic burst was higher in patients with panic disorder compared with healthy controls (45+/-5%versus 32+/-3%, P<0.05). When only the neural bursts during which the vasoconstrictor neurone was active were considered, we found that in patients with panic disorder the neurones tended to fire more often in a 'multiple spike' pattern than in the controls (i.e. the probability of the neurone firing twice was 25+/-3% in patients with panic disorder compared with 14+/-3% in controls). Quantification from single vasoconstrictor unit recording provides evidence of a disturbed sympathetic firing pattern in patients with panic disorder.
Action Potentials↗
The effect of positive ion energy on plasma polymerization: a comparison between acrylic and propionic acids.
Using a novel RF biasing technique, the energy of positive ions at a depositing substrate is controlled, independently of other parameters. Under bias conditions which gave the maximum and minimum ion energies, plasmas of propionic and acrylic acid were investigated using mass spectrometry, an ion flux probe, quartz crystal microbalance, and X-ray photoelectron spectroscopy (XPS). For both compounds investigated, the ion energy affects the deposition rate but leaves the neutral gas-phase chemistry and positive ion fluxes unchanged. The chemistry of the polymer deposit for acrylic acid is unaffected by the change in ion energy, but the chemistry of the propionic acid plasma polymer changes markedly. We argue that the results presented are consistent with the hypothesis that, under the plasma conditions explored, the carbon-carbon double bond present in acrylic acid plays a significant role in the formation of the polymer. Conversely, the absence of this bond in propionic acid leads us to conclude that positive ions contribute significantly to film formation for this compound.
Journal Article↗
Occupational allergic contact dermatitis to bisphenol F epoxy resin.
A 30-year-old man presented with eyelid dermatitis and was diagnosed with occupational allergic contact dermatitis to an epoxy resin based on the monomer diglycidyl ether of bisphenol F. He did not react to the standard epoxy resin based on bisphenol A, but reacted to a diluted sample of epoxy resin taken from his workplace, an adhesives manufacturing plant. The diagnosis would not have been made had he not brought samples from work, which were patch tested after appropriate dilution. The material safety data sheet provided additional evidence that the epoxy was not based on bisphenol A. The patient's symptoms subsided after avoidance of the identified product.
Adult↗
Managing panic disorder in general practice.
BACKGROUND: Panic disorder (PD) is common in the community and contributes to significant distress and decreased quality of life for people who suffer from it. Most people with PD will present in the first instance to their general practitioner or hospital emergency department for assistance, often with a focus on somatic symptoms and concerns. OBJECTIVE: This article aims to assist the GP to manage this group of patients by providing an outline of aetiology, approaches to assessment, and common management strategies. DISCUSSION Although GPs have an important role to play in ruling out any causal organic basis for panic symptoms, the diagnosis of PD can usually be made as a positive diagnosis on the basis of careful history taking. Thorough and empathic education is a vital step in management. The prognosis for PD can be improved by lifestyle changes, specific psychological techniques, and the judicious use of pharmacotherapy.
Antidepressive Agents↗
Influence of depression and effect of treatment with sertraline on quality of life after hospitalization for acute coronary syndrome.
Major depressive disorders complicate recovery from acute coronary syndrome in approximately 1 in 5 patients, and have been found to be associated with significant impairments of quality of life and functioning. The aim of the present analysis was to evaluate the efficacy of sertraline in improving quality of life and functioning in patients diagnosed with major depression who had recently been hospitalized for acute coronary syndrome. Three hundred sixty-nine patients hospitalized in the previous month for acute coronary syndrome (myocardial infarction, 74%; unstable angina, 26%) who also met criteria for major depressive disorder were randomized to 24 weeks of double-blind treatment with sertraline (50 to 200 mg/day) or placebo. Quality-of-life and functional status were assessed using the Quality of Life, Enjoyment, and Satisfaction scale (Q-LES-Q) and the Medical Outcomes Study SF-36. Data from the total sample, and the recurrent depression subgroup, were analyzed. Severe baseline impairment was found in the Q-LES-Q and all subscales of the SF-36. A multivariate regression analysis identified depression as the strongest predictor of baseline quality-of-life impairment (partial r, -0.37, p = 0.001). In the recurrent depression group, treatment with sertraline resulted in significantly greater improvement than placebo in the Q-LES-Q total score and SF-36 mental component summary score, as well as the SF-36 role limitations, emotional, and mental health factors. Depression has a substantial negative impact on quality of life and functioning in patients hospitalized for acute coronary syndrome. Sertraline was associated with clinically meaningful improvement in multiple quality-of-life domains in patients with acute coronary syndrome and recurrent depression.
Acute Disease↗
The effect of ion energy upon plasma polymerization deposition rate for acrylic acid.
A novel technique, which allows the importance of ion energy in plasma polymer film growth to be investigated, without perturbation of any other plasma parameter (particle densities or temperatures) or, in principle, perturbation of particle (neutral or ion) fluxes is applied in the plasma polymerisation of acrylic acid and new insight into polymer formation is gleaned.
Journal Article↗
Sertraline treatment of major depression in patients with acute MI or unstable angina.
CONTEXT: Major depressive disorder (MDD) occurs in 15% to 23% of patients with acute coronary syndromes and constitutes an independent risk factor for morbidity and mortality. However, no published evidence exists that antidepressant drugs are safe or efficacious in patients with unstable ischemic heart disease. OBJECTIVE: To evaluate the safety and efficacy of sertraline treatment of MDD in patients hospitalized for acute myocardial infarction (MI) or unstable angina and free of other life-threatening medical conditions. DESIGN AND SETTING: Randomized, double-blind, placebo-controlled trial conducted in 40 outpatient cardiology centers and psychiatry clinics in the United States, Europe, Canada, and Australia. Enrollment began in April 1997 and follow-up ended in April 2001. PATIENTS: A total of 369 patients with MDD (64% male; mean age, 57.1 years; mean 17-item Hamilton Depression [HAM-D] score, 19.6; MI, 74%; unstable angina, 26%). INTERVENTION: After a 2-week single-blind placebo run-in, patients were randomly assigned to receive sertraline in flexible dosages of 50 to 200 mg/d (n = 186) or placebo (n = 183) for 24 weeks. MAIN OUTCOME MEASURES: The primary (safety) outcome measure was change from baseline in left ventricular ejection fraction (LVEF); secondary measures included surrogate cardiac measures and cardiovascular adverse events, as well as scores on the HAM-D scale and Clinical Global Impression Improvement scale (CGI-I) in the total randomized sample, in a group with any prior history of MDD, and in a more severe MDD subgroup defined a priori by a HAM-D score of at least 18 and history of 2 or more prior episodes of MDD. RESULTS: Sertraline had no significant effect on mean (SD) LVEF (sertraline: baseline, 54% [10%]; week 16, 54% [11%]; placebo: baseline, 52% [13%]; week 16, 53% [13%]), treatment-emergent increase in ventricular premature complex (VPC) runs (sertraline: 13.1%; placebo: 12.9%), QTc interval greater than 450 milliseconds at end point (sertraline: 12%; placebo: 13%), or other cardiac measures. All comparisons were statistically nonsignificant (P> or = .05). The incidence of severe cardiovascular adverse events was 14.5% with sertraline and 22.4% with placebo. In the total randomized sample, the CGI-I (P =.049), but not the HAM-D (P =.14), favored sertraline. The CGI-I responder rates for sertraline were significantly higher than for placebo in the total sample (67% vs 53%; P =.01), in the group with at least 1 prior episode of depression (72% vs 51%; P =.003), and in the more severe MDD group (78% vs 45%; P =.001). In the latter 2 groups, both CGI-I and HAM-D measures were significantly better in those assigned to sertraline. CONCLUSION: Our results suggest that sertraline is a safe and effective treatment for recurrent depression in patients with recent MI or unstable angina and without other life-threatening medical conditions.
Angina, Unstable↗
Angiotensin II type 2 receptor gene is not responsible for familial vesicoureteral reflux.
PURPOSE: The renin-angiotensin system has an important role in the development of the kidney and ureter. It has been reported that disruption of the angiotensin II type 2 receptor (AT2) gene leads to congenital anomalies of the kidney and ureter in mice, including vesicoureteral reflux. In humans a single base A to G transition at position -1332 in intron 1 (A-1332G) of the AT2 gene has been reported to occur significantly more often in patients with ureteropelvic junction obstruction and primary obstructive megaureter than in controls. We investigate the incidence of A-1332G transition in patients with primary familial vesicoureteral reflux to determine if AT2 gene is involved in pathogenesis of this disease. MATERIALS AND METHODS: We evaluated the incidence of A-1332G transition in 82 male and 110 female patients, 111 male and 124 female nonaffected family members from 88 families in which 2 or more members had primary vesicoureteral reflux, and 106 male and 107 female controls with no unselected for reflux status. Genomic DNA was extracted from whole blood samples. Polymerase chain reaction method modified for fluorescent detection was used to type all samples for the A-1332G variant. Furthermore, to identify mutations in the coding sequence of the AT2 gene, we selected 61 patients from different families as well as 15 controls with no vesicoureteral reflux status. RESULTS: The incidence of A-1332G transition in male patients with primary familial vesicoureteral reflux and controls was 33% (27 of 82 patients) and 38% (41 of 106 controls), respectively, and, the incidence of A-1332G substituted allele in female patients and controls was 47% (104 of 220 total alleles) and 50% (107 of 214 total alleles), respectively. Moreover, the transmission/disequilibrium test revealed no significant skewing of genotype transmission from mother to children. None of the 61 patients or 15 controls carried by mutations or polymorphisms in the coding sequence of the AT2 gene. CONCLUSIONS: Although the AT2 gene has been reported to have a role in developmental anomalies of the kidney and ureter, our data indicate that it is not involved in the pathogenesis of primary familial vesicoureteral reflux.
Angiotensin II↗
Australian and US responses to electroconvulsive therapy dosage selection.
OBJECTIVE: The practice of electroconvulsive therapy (ECT) varies considerably across sites with a lack of certainty as to what constitutes seizure adequacy. The aim of this study was to trial a method to explore decision making and to describe any differences between Australian and US practitioners. METHOD: Two hundred and thirty-six consultant psychiatrists from Australia and US were asked what dosage of electrical energy they would prescribe after reading a standardized clinical vignette in which an unremarked upon change in seizure tracings followed the first two treatments. RESULTS: Considerable variability in the dosage was found with 17.3% decreasing, 46.8% maintaining and 30% increasing charge. Involvement in administration of ECT was unrelated to this decision. CONCLUSION: Standardized vignettes may be a useful method to assess clinicians' responses in dosage selection.
Adult↗
Destocking as a drought-mitigation strategy: clarifying rationales and answering critiques.
The idea of externally assisted emergency destocking of pastoralists has gained currency in recent years: increasing the incentives for pastoralists to sell animals, or removing the constraints to selling animals in the early stages of drought. We identify two separate rationales put forward by proponents of destocking: environmental benefits and purchasing power/welfare benefits. We consider whether specific recent critiques of 'new range ecology' and specifically of 'tracking policies' do in fact provide arguments against emergency destocking in pastoralist areas. We illustrate some of these themes with a case study of a successful destocking exercise in northern Kenya where a very specific form of support was requested and received by pastoralists themselves. The sorts of destocking that work are likely to have significant effects on pastoralist purchasing power at key points of the drought cycle, but minimal effects on the environment. Clarifying these points will make it easier to promote destocking as a drought-mitigation policy.
Agriculture↗
Iontophoresis versus subcutaneous injection: a comparison of two methods of local anesthesia delivery in children.
The relative efficacy of local lidocaine anesthesia administered by subcutaneous injection and by iontophoresis was studied in 13 pediatric renal dialysis patients (ages 11-19 years: mean age 15.8 years). Each patient served as his own control at 3 assessment periods. Each type of anesthetic delivery method was administered to either of 2 fistula sites. Patients used visual analogue scales to rate pain, anxiety, and satisfaction for each method. Behavioral observations were made by an observer and a nurse. Paired sample t tests were used to compare the 2 drug delivery methods for patient, observer, and nurse ratings across assessment periods. There were no significant differences between methods for ratings of anxiety before or during the procedure. The injection of lidocaine was rated as more painful by the observer and nurse (with a trend for patients) than the use of iontophoresis. But, the patients and nurse rated the injection method as more effective. Iontophoresis was never rated as superior to the injection method, even after turning over control of drug delivery by iontophoresis to the patient (sessions 2 and 3). Patients were more satisfied with iontophoresis at session 2 when they took over control, but lost enthusiasm by session 3. Three subjects withdrew from the study due to cutaneous burns and prolonged anesthesia delivery time with iontophoresis. Iontophoresis appears to be effective in reducing the pain of dialysis needle insertion but requires further investigation before it can be considered a viable alternative to subcutaneous injection.
Adolescent↗
Death takes a holiday--reconsidered.
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Attitude to Death↗