Effect of psychiatry liaison with general practitioners on depression severity in recently hospitalised cardiac patients: a randomised controlled trial

OBJECTIVE: To evaluate the effect on depressive symptoms in cardiac patients of patient-specific advice to general practitioners regarding management of comorbid depression. DESIGN AND SETTING: A randomised controlled trial in four general hospitals in Adelaide, South Australia. PARTICIPANTS: Patients (n = 669) admitted to cardiology units for a range of cardiovascular conditions who were screened and assessed as being depressed according to the Center for Epidemiological Studies Depression Scale (CES-D). INTERVENTION: Inpatient psychiatric review, followed by telephone case conferencing between specialist hospital staff and GPs to provide patient-specific information about the patient's depression and its management, educational material, and ongoing clinical support. MAIN OUTCOME MEASURES: Level of depression severity at 12 months post-hospitalisation. RESULTS: On the basis of intention to treat, intervention patients had lower rates of moderate to severe depression (CES-D > or = 27) after 12 months (25% v 35%, relative risk, 0.72; 95% CI, 0.54-0.96, number needed to treat for benefit, 11). The intervention was most effective in preventing progression from mild depression to moderate to severe depression. The multidisciplinary telephone case conferencing was difficult to implement and, in a post hoc analysis, brief phone advice from a psychiatrist was found to be effective. CONCLUSIONS: Screening hospitalised cardiac patients for depression and providing targeted advice to their GPs reduces depression severity 12 months after hospitalisation.     

Loss of Insulin Resistance after Roux-en-Y Gastric Bypass Surgery: a Time Course Study

Background: Gastric bypass has repeatedly been shown to improve and even cure type 2 diabetes by substantially improving insulin resistance. The mechanism by which it achieves this is not currently known, but some have hypothesized that there may be important humoral effects brought about by the bypass of the stomach, duodenum or proximal jejunum. A better understanding of the time course of the changes in insulin resistance after surgery might assist our understanding of potential mechanisms. Methods: Intravenous glucose tolerance tests (IVGTT) were performed in 26 severely obese patients on the morning of gastric bypass surgery and again 6 days later. In addition insulin resistance was assessed in 71 patients undergoing gastric bypass surgery by the homeostasis model assessment (HOMA) method before surgery, and again at 6 days, 3, 6, 9, and 12 months. Patients were divided into 3 groups for analysis: diabetics, impaired glucose tolerance and normal glucose tolerance. Results: All 3 groups of patients were noted to have insulin resistance prior to surgery. This was greatest in the diabetic patients, as indicated by HOMA. There was marked loss of/improvement in insulin resistance within 6 days of gastric bypass by both IVGTT and HOMA methods in all groups, which was maintained over the 12-month period. The study included 31 diabetic patients, of whom only 3 required medication following hospital discharge. Conclusion: The changes in insulin resistance seen after gastric bypass, which are responsible for the resolution or improvement of type 2 diabetes occur within 6 days of the surgery, before any appreciable weight loss has occurred. This finding has implications for our understanding of the mechanism of insulin resistance in severely obese patients and is consistent with a humoral mechanism emanating from the GI tract.     

Measuring health status: information for primary care decision making

Primary Care Trusts (PCTs), charged with improving the health of their population, need to measure the extent to which patients actually benefit from the health care that is provided for them. One way of achieving this is to measure health status of patients over time. The study described here reports on the feasibility of administering the EQ-5D in general practitioner (GP) surgeries and identifies how the results might be used by practices and PCTs to improve the health of their populations. The study took place in an opportunistic sample of 1942 patients attending GP surgeries. One year later, patients who had provided contact details were sent another EQ-5D together with a request for additional information about their use of health care services in the intervening time period. A total of 770 patients completed this follow-up questionnaire. There were significant age effects associated with variation in self-reported health status and also associated with top-level Read diagnostic codes in some groups of patients. The results showed that EQ-5D could be used by individual GP practices to identify patients with specific health problems. This knowledge can also be used by PCTs and other primary care organisations, to better target scarce health resources.     

Expression of the Ian family of putative GTPases during T cell development and description of an Ian with three sets of GTP/GDP-binding motifs

Reports suggest that two members of the novel immune-associated nucleotide (Ian) GTPase family, Ian1 and Ian5, play roles in T cell development. We performed real-time PCR analysis of the expression of Ian genes of the rat during T cell maturation, in macrophages and in cell lines. We found that all of the genes were expressed at relatively low levels at the early double-negative thymocyte stage but were expressed more strongly at later cell stages. Our study also revealed the fact that the previously reported Ian9, Ian10 and Ian11 genes are, instead, parts of a single gene for which we retain the name Ian9, potentially encoding a GTPase with a highly unusual triplicated structure. Antisera were developed against both Ian1 and Ian9. We established that Ian9 is produced as an approximately 75-kDa protein in both T cells and thymocytes. We observed that levels of both Ian1 and Ian9 proteins are profoundly reduced in T cells from lymphopenic rats as compared with wild-type rats. It was demonstrated that thymocytes and B cells from lymphopenic rats (Ian5 null) did not show enhanced sensitivity to gamma-irradiation-induced apoptosis.     

Life events and hemodynamic stress reactivity in the middle-aged and elderly

Recent versions of the reactivity hypothesis, which consider it to be the product of stress exposure and exaggerated hemodynamic reactions to stress that confers cardiovascular disease risk, assume that reactivity is independent of the experience of stressful life events. This assumption was tested in two substantial cohorts, one middle-aged and one elderly. Participants had to indicate from a list of major stressful life events up to six they had experienced in the previous 2 years. They were also asked to rate how disruptive and stressful they were, at the time of occurrence and now. Blood pressure and pulse rate were measured at rest and in response to acute mental stress. Those who rated the events as highly disruptive at the time of exposure and now exhibited blunted systolic blood pressure reactions to acute stress. The present results suggest that acute stress reactivity may not be independent of stressful life events experience.     

A review of medication administration errors reported in a large psychiatric hospital in the United kingdom

A retrospective analysis of reports of medication administration errors over a period of three and a half years was carried out in a UK psychiatric hospital. A total of 112 errors and "near misses" were studied. The reporting rate increased over time. Psychotropic, intramuscular, and as-needed medications were overrepresented in the error reports. Fifteen percent of the errors had the potential to cause moderate or severe harm to patients. The two most common factors cited by nurses as contributing to error causation were a busy, noisy environment and personal factors, such as feeling tired or unsupported. Physicians were cited as having contributed to some errors.     

Moving forward: negotiating self and external circumstances in recovery

This article presents a framework for understanding the concept of recovery from serious mental illnesses and other life struggles. The framework is based on findings from a longitudinal, qualitative study that involved in-depth interviews with 28 people who experienced serious mental health challenges. The purpose of this article is to clarify the concept of recovery by presenting a grounded theory analysis of the components of recovery. The framework recognizes the experiences of struggle constructed through the words of study participants and captures four main components of recovery: a) a drive to move forward, b) a spiral of positive and negative changes, c) the context of recovery, and d) a dialectical process of ongoing negotiation between self and external circumstances.