Efficacy and safety of fluoxetine versus clomipramine in ambulatory patients with a depressive syndrome in a clinical trial with private practitioners

8 general practitioners and 7 specialists in the field of psychiatry and neurology participated in this study evaluating the results of fluoxetine treatment in outpatients with depression in respect to safety and efficacy. They were familiarized with the requisite instruments by video rater training. The study was designed as a randomised double-blind parallel study involving 139 patients, comparing the effects of a daily dosage of 20 mg fluoxetine, 40 mg fluoxetine and 50 mg clomipramine. The number of patients treated in each group was 45, 46, and 48, respectively and altogether 125 completed the four-week study (five visits). A comparison of overall efficacy ratings showed significant antidepressant efficacy in all three treatment groups. On day 14 of the study (visit 4), patients receiving 40 mg fluoxetine showed significantly (p less than 0.05) better global improvement than patients receiving clomipramine. Treatment was well tolerated by all patients. The frequency of adverse events in response to fluoxetine was lower than under clomipramine treatment. On comparing treatment by psychiatrist and general practitioner no significant differences were found regarding age, sex, number of previous episodes and duration of the recent episode and outcome. Severe depression tended to be treated by psychiatrists; general practitioners prescribed additional medication less frequently.     

Attention-deficit/hyperactivity disorder: diagnostic assessment methods used by advanced practice registered nurses

BACKGROUND: Children presenting with symptoms of attention-deficit/hyperactivity disorder (ADHD) have become highly prevalent in primary care practice; however, advanced practice registered nurses (APRNs) diagnostic methods used to identify and diagnose this disorder are greatly understudied. AIM: This study aimed to identify APRNs recognition and diagnostic practices of children who were suspected of having an ADHD diagnosis. It also addressed APRNs comfort levels with treating and diagnosing ADHD, along with certain diagnostic methods and their perceived accuracy of these methods. METHODS: This nonexperimental exploratory research study used a self-administered questionnaire to gather information about diagnostic methods used by APRNs who diagnose children with ADHD, treat the disorder, or did both. RESULTS AND DISCUSSION: The questionnaires identified that the APRNs were following the American Academy of Pediatrics diagnostic guidelines for diagnosing ADHD in children more closely than other health care providers (pediatricians and family physicians). The results of this study also indicated that most APRNs were very comfortable to comfortable making an ADHD diagnosis (52.5%), and 64.4% reported the same level of comfort with treating ADHD. These findings indicate that the majority of APRNs surveyed who works with children are comfortable with diagnosing and treating ADHD.     

Treatment of patients with airflow obstruction by general practitioners and chest physicians

The study comprised 223 patients with airflow obstruction and/or bronchial hyperreactivity from 29 general practices in the catchment area of Nijmegen University. Fifty-six patients were treated by 19 chest physicians, the remaining 167 by their general practitioners (GPs), without specialist care. The specialists treated more allergic patients than the GP (p less than 0.05). No other relevant differences in sex, age, smoking behaviour, and severity of the disease (symptoms, lung function, and bronchial hyperreactivity) could be observed between these two groups of patients. Chest physicians prescribed almost three times as many drugs as GPs. No immediate response to the prescribed bronchodilators was found in 16% of the patients treated by the GPs, nor in 20% of the patients treated by the specialists. We could identify only a weak relationship between the severity of the disease (symptoms and pulmonary function combined) and the prescribed pharmacotherapy: with growing degrees of severity the GP seems to prescribe more bronchodilators, the specialist more inhaled corticosteroids. Prescribed pharmacotherapy should be based on the combination of symptoms, pulmonary function, bronchial hyperreactivity, and reversibility on the prescribed bronchodilators.     

精神科医生对迟发性运动障碍的认知及临床实践状况调查

目的 探讨精神科医生对迟发性运动障碍（TD）的认知及临床实践状况。方法 应用自行设计的TD知识及态度问卷对106名临沂市精神科医生进行调查。 结果 精神科医生对TD临床表现项目掌握情况最好（86.79%）,发病机制项目掌握情况最差（56.60%）。市级精神科医生对TD基础知识的掌握情况好于县区级精神科医生（P<0.01）。98.11%的精神科医生认为有必要进行TD诊断和治疗的培训,81.13%的医生接受过TD诊断和治疗的培训,其中,仅62.79%的医生接受过正规课程培训,34.92%的医生对TD的诊断和治疗没有信心。91.51%的医生认为在应用抗精神病药物前,应与患者及家属讨论TD发生的危险性,但仅76.42%的医生在临床实践中常规执行。98.11%的医生认为在应用抗精神病药物期间,应监测异常不自主运动,但仅74.52%的医生常规监测,53.77%的医生作监测结果记录。65.10%的医生认为TD是造成医疗纠纷及诉讼的原因之一,76.41%的医生认为没有患者的同意,抗精神病药物不得长期超适应证使用。结论 应加强对精神科医生TD知识的培训,在临床工作中,应严格执行知情告知并常规监测TD的发生。     

Patterns of use of antithrombotic therapy and quality of anticoagulation among patients with non-valvular atrial fibrillation in clinical practice

We conducted a retrospective cohort study of thromboprophylaxis rates and the quality of anticoagulation control among patients with atrial fibrillation (AF) using a large, geographically diverse database of electronic medical records. The study population consisted of 13,709 AF patients treated in US outpatient physician practices. Approximately two-thirds were prescribed warfarin alone or in combination with another drug. Older patients, males, and those with congestive heart failure (CHF) or prior stroke were more likely to receive antithrombotic therapy. Among 6454 patients treated with warfarin who had at least two valid prothrombin time/international normalised ratio test results, approximately half of study days were spent in target range. Female sex, CHF and residence in the Northeast were associated with more time out of range. Our study confirms that, in routine medical practice, warfarin is not prescribed for substantial numbers of eligible patients, and anticoagulation control with warfarin is suboptimal for many of those at risk for thromboembolism.     

COVID-19 and Advanced Practice Registered Nurses: Frontline Update

Coronavirus disease 2019 (COVID-19) emerged in 2019 and rapidly became a global pandemic, infecting millions and killing hundreds of thousands. The disease altered the practices of hospitals, clinics, and patients. These changes have implications for advanced practice registered nurses (APRNs). APRNs must remain current on best practices for treatment and diagnosis of COVID-19 while being cognizant of changes to their scope of practice. As the pandemic continues, APRNs will remain on the front lines treating patients with COVID-19 while also caring for vulnerable populations within the community. To provide high-quality care, APRNs must use a multifaceted approach that heeds ongoing updates to evidence-based practice.     

Mental health work observed: a comparison of the perceptions of psychiatrists and mental health nurses

This study explores mental health nurses' and psychiatrists' perceptions of their work. It was carried out in five mental health Trusts in the West Midlands, UK. Three groups were surveyed: psychiatrists, hospital-based nurses and community mental health nurses (CMHNs). Results showed that CMHNs' sources of job satisfaction and dissatisfaction were more similar to those of psychiatrists than to those of their hospital-based counterparts. All three groups cited the intrinsic worthwhileness of their work, autonomy, the scope for creativity, the variety their job offered and their contact with clients as contributing to their overall job satisfaction. Hospital-based nurses listed the support they received from colleagues as their second source of job satisfaction, whereas CMHNs and psychiatrists cited the provision of care to patients. Excessive administrative duties and the absence of or poor quality of management were perceived by all three groups as sources for dissatisfaction with their work. Hospital nurses cited job insecurity as a principal concern more frequently than CMHNs and psychiatrists. The paper concludes by discussing recommendations for changes to improve the nature of the work in mental health services and in the work environment. Changes must reflect the concerns of the different groups of mental health professionals.     

Healthcare provider perspectives on diagnosing and treating adults with attention-deficit/hyperactivity disorder

Objective: This study examined adult attention-deficit/hyperactivity disorder (ADHD) screening and management patterns among healthcare provider (HCP) subgroups.

Methods: An online survey of US-based HCPs (neurologists, n = 200; nurse practitioners [NPs], n = 100; psychiatrists, n = 201; primary care physicians [PCPs], n = 201) was conducted from May to June 2017. The survey assessed issues relating to adult ADHD screening and management and HCP perceptions of factors influencing patient choice of pharmacotherapy. Participants were required to be experienced in diagnosing and/or treating ADHD in adults (≥5 patients/month for neurologists and NPs; ≥10 patients/month for psychiatrists and PCPs).

Results: Significantly greater percentages of psychiatrists than non-psychiatrists were confident in diagnosing ADHD (P < 0.001) and screened/evaluated for ADHD in patients with depression/anxiety disorders (P < 0.001). Significantly greater percentages of psychiatrists versus non-psychiatrists prescribed once-daily long-acting (LA) stimulants (71.6% vs 62.2%; P = 0.023) or short-acting (SA) stimulants more than once daily (40.3% vs 29.7%; P = 0.009) as first-line therapy. In contrast, a significantly greater percentage of non-psychiatrists than psychiatrists prescribed once-daily SA stimulants (32.9% vs 17.4%; P < 0.001). Psychiatrist and non-psychiatrist HCPs viewed insurance coverage/treatment costs (79.9%), perceived duration of effect (72.2%), and side effects (66.5%) as important factors to patients when choosing treatment. HCPs reported that the greatest mean ± SD percentages of patients changed their treatment regimen in the past 6 months because of perceptions of insufficient duration of effect (35.4% ± 22.1%) and lack of efficacy (30.3% ± 21.0%).

Conclusion: Compared with psychiatrists, non-psychiatrists exhibited less confidence in diagnosing adult ADHD and experienced greater difficulty determining optimal treatment regimens.     

Understanding APRN Distribution in the United States Using NPI Data

This study examined the 2010 Centers for Medicare and Medicaid Services National Plan and Provider Enumeration System's National Provider Identifier (NPI) data to ascertain their usefulness to determine the distribution of advanced practice registered nurses (APRNs) in rural and urban areas of the United States. This study showed that certified registered nurse anesthetists were more likely to practice in rural areas in states with greater practice autonomy. For nurse practitioners, the findings were similar but were of borderline statistical significance. These findings imply that practice autonomy should be considered as a state-level strategy to encourage rural practice by APRNs.     

Do State Restrictions on Advanced Practice Registered Nurses Impact Patient Outcomes for Hypertension and Diabetes Control?

The Institute of Medicine recommends that nurses practice to the full extent of their education and training, yet, state regulations continue to limit the scope of practice for advanced practice registered nurses (APRNs). One reason is the unproven belief that patient outcomes will be inferior if APRNs practice without regulations. This study examined whether the absence of restrictions on APRNs results in inferior outcomes for patients with hypertension or diabetes. We used publicly available data for patients seen in Federally Qualified Community Health Centers during 2013 in 6 states with the most restrictions and in 10 states with the least restrictions.