Patterns of Primary Care Use Prior to a First Diagnosis of Nonaffective Psychotic Disorder in Ontario,Canada: Modèles d’utilisation des soins de première ligne avant un premier diagnostic de trouble psychotique non affectif en Ontario,Canada

Background:Many people experience early signs and symptoms before the onset of psychotic disorder, suggesting that there may be help-seeking prior to first diagnosis. The family physician has been found to play a key role in pathways to care. This study examined patterns of primary care use preceding a first diagnosis of psychotic disorder.Methods:We used health administrative data from Ontario (Canada) to construct a population-based retrospective cohort. We investigated patterns of primary care use, including frequency and timing of contacts, in the 6 years prior to a first diagnosis of psychosis, relative to a general population comparison group matched on age, sex, geographic area, and index date. We used latent class growth modeling to identify distinct trajectories of primary care service use, and associated factors, preceding the first diagnosis.Results:People with early psychosis contacted primary care over twice as frequently in the 6 years preceding first diagnosis (RR = 2.22; 95% CI, = 2.19 to 2.25), relative to the general population, with a sharp increase in contacts 10 months prior to diagnosis. They had higher contact frequency across nearly all diagnostic codes, including mental health, physical health, and preventative health. We identified 3 distinct service use trajectories: low-, medium-, and high-increasing usage.Discussion:We found elevated patterns of primary care service use prior to first diagnosis of psychotic disorder, suggesting that initiatives to support family physicians in their role on the pathway to care are warranted. Earlier intervention has implications for improved social, educational, and professional development in young people with first-episode psychosis.     

Primary carnitine deficiency

Carnitine deficiency can be defined as a decrease of intracellular carnitine, leading to an accumulation of acyl-CoA esters and an inhibition of acyl-transport via the mitochondrial inner membrane. This may cause disease by the following processes. A. Inhibition of the mitochondrial oxidation of long-chain fatty acids during fasting causes heart or liver failure. The latter may cause encephalopathy by hypoketonaemia, hypoglycaemia and hyperammonaemia. B. Increased acyl-CoA esters inhibit many enzymes and carriers. Long-chain acyl-CoA affects mitochondrial oxidative phosphorylation at the adenine nucleotide carrier, and also inhibits other mitochondrial enzymes such as glutamate dehydrogenase, carnitine acetyltransferase and NAD(P) transhydrogenase. C. Accumulation of triacylglycerols in organs increases stress susceptibility by an exaggerated response to hormonal stimuli. D. Decreased mitochondrial acetyl-export lowers acetylcholine synthesis in the nervous system. Primary carnitine deficiency can be defined as a genetic defect in the transport or biosynthesis of carnitine. Until now only defects at the level of carnitine transport have been discovered. The most severe form of primary carnitine deficiency is the consequence of a lesion of the carnitine transport protein in the brush border membrane of the renal tubules. This defect causes cardiomyopathy or hepatic encephalopathy usually in combination with skeletal myopathy. In a patient with cardiomyopathy and without myopathy, we found that carnitine transport at the level of the small intestinal epithelial brush border was also inhibited. The patient was cured by carnitine supplementation. Muscle carnitine increased, but remained too low. This suggests that carnitine transport in muscle is also inhibited. Carnitine transport in fibroblasts was normal, which disagrees with literature reports for similar patients.     

Ocular jellyfish stings.

BACKGROUND: Corneal stings from the sea nettle (Chrysaora quinquecirrha) indigenous to the Chesapeake Bay are usually painful but self-limited injuries, with resolution in 24 to 48 hours. METHODS: Five patients who developed unusually severe and prolonged iritis and intraocular pressure elevation after receiving corneal sea nettle stings were followed for 2 to 4 years. RESULTS: Decreased visual acuity, iritis, and increased intraocular pressure (32 to 48 mmHg) were noted in all cases. Iritis responded to topical corticosteroids and resolved within 8 weeks. Elevated intraocular pressure responded to topical beta blockers and oral carbonic anhydrase inhibitors. Mydriasis (4 of 5 cases), decreased accommodation (2 of 5 cases), peripheral anterior synechiae (2 of 5 cases), and iris transillumination defects (3 of 5 cases) also were noted. Mydriasis and decreased accommodation persisted for 5 months in 1 case and for more than 2 years in another. One patient has chronic unilateral glaucoma. Visual acuity returned to normal in all cases. CONCLUSIONS: The precise relationship between sea nettle venom and the observed clinical responses is not known. Corneal jellyfish stings usually produce a brief and self-limited reaction, but they do have the potential for long-term sequelae.     

Role of lysosomes on human ulcerogenic gastropathies. Effect of zinc ion on the lysosomal stability.

Numerous conditions are involved in the equilibrium between protective and aggressive factors for gastric mucosa injuring. Among them the lysosomal membrane stability plays a very important role in the inflammatory process. Zinc ion is a well-known lysosomal membrane stabilizer. When given orally to animals or even to humans it protects gastric mucosa against erosive lesions induced by a variety of experimental conditions. Compared with the control group (8.45 +/- 1.49 mU/mg) the lysosomes isolated from samples of gastric mucosa obtained from patients suffering of erosive gastropathies, showed a great liability on their membranes (18.37 +/- 4.52 mU/mg). When these patients were treated orally with zinc sulfate (100 mg of zinc element, twice a day, for two weeks) the lysosomes isolated from their gastric mucosa showed a strong reduction on enzymatic activity (5.49 +/- 1.02 mU/mg), probably due to increasing on the membrane stability. Based on these experimental findings we propose the use of zinc ion as an important adjuvant in treatment of erosive gastropathies.     

Stapled hemorrhoidectomy: Initial experience of a Latin American group

The purpose of the present study was to determine the value of circular emorrhoidectomy (procedure for prolapse and hemorrhoids [PPH]) on the basis of data collected prospectively during the initial experience of a group of Latin American surgeons. Between 2000 and 2001, PPH was performed using a circular stapler in 177 patients who had third- and fourth-degree hemorrhoidal disease. The average age of the patients was 47.7 years (range 26 to 85 years). Anal bleeding was the most common preoperative complaint (93.2%) followed by anal pain (60.2 %), anal itching (43%), and constipation (41 %). Hemorrhoids were classified as third degree in 132 patients (74%) and fourth degree in 45 patients (25.4%). Skin tags were detected in 86 patients (48.8%) and rectocele in 14 patients (7.9%). Data collected included patient demographics, type of anesthesia, and specific details of the surgery such as duration of the operation, distance from the staple line to the dentate line, need for complementary hemostasis, and any unexpected occurrences. Postoperative data collected included the degree of pain, which was evaluated on the basis of the type and dosage of analgesics required, laxative consumption, and the presence of bleeding, fever, urinary retention, or hematomas. Each patient completed a written questionnaire addressing these events. Patients returned for follow-up visits on days 7, 15, 30, and 90. Responses to pain, bleeding, fever, anal continence, recurrence of hemorrhoids, and level of satisfaction were compiled. The duration of the procedure ranged from 6 minutes to 2 hours (average 2 3 minutes), and most operations lasted no more than 20 minutes, with the exception of one that lasted 2 hours because of intraoperative bleeding. Intraoperative problems were minor. An additional one or a few sutures were required in 58.7% of patients to achieve perfect hemostasis. In 128 patients (72.3%) the hospital stay was less than 24 hours. Same-day surgery was chosen for 37 patients (20.9%). Pain was controlled with analgesia only using one to six doses of oral dipirona in 126 patients. Five patients were readmitted to the hospital: four for control of bleeding and one for conventional hemorrhoidectomy due to an acute episode of external hemorrhoidal thrombosis. At day 30, patients rated the efficacy of the procedure in alleviating preoperative symptoms as follows: 77.5% excellent; 16% good; 5.3% average, and 1.2% poor. At 3 months postoperatively no patient had had a recurrence of hemorrhoidal prolapse, and there were no instances of stenosis or anal incontinence. Surgeons also rated the efficacy of the procedure as excellent in 75%, good in 19.8%, average in 4.7%, and poor in 0.6%. With proper selection of patients and adequate stapling technique, stapled hemorrhoidectomy may be considered safe; it is easily learned, has a satisfactory degree of pain, and is well accepted by both patients and surgeons. Supported in part by Johnson & Johnson.     

Predictors of clinical and social outcomes after hospitalization in schizophrenia

A prospective cohort study of schizophrenia was carried out in São Paulo, Brazil, in order to investigate clinical and social outcomes in schizophrenia and related psychoses after hospitalization. A sample of 124 individuals who were living in a defined catchment area and had been consecutively admitted to psychiatric hospitals in that area with clinical diagnoses of non-affective functional psychoses was followed up for 2 years. Assessments of clinical status and social adjustment at inclusion and at 2-year follow-up were carried out by means of standardized instruments, the PSE and the DAS. At the end of the follow-up period, 120 subjects (96.8%) were traced, and 103 (83.1%) were re-assessed. At the second assessment, the proportion of subjects with a nuclear syndrome of schizophrenia had halved (from 68.3% to 32.7%), 23.8% were symptom free and 60.2% showed at least one psychotic symptom. Presence of psychotic symptoms at follow-up was best predicted by educational level (less than 4 years of formal education) and an initial DSM-III-R diagnosis of schizophrenia. The distribution of global social adjustment levels at 2-year follow-up was similar to that observed at the outset, with approximately one third of subjects showing good, one third showing intermediate and one third showing poor global social adjustment. Social disability was best predicted by longer duration of illness, worse social adjustment levels at inclusion and lower educational level.     

Prognostic markers in treated hypertensive diabetic patients. 28-month follow-up.

INTRODUCTION: Diabetes mellitus has a prevalence of about 6 to 10% in western populations, with a rising tendency due to inappropriate increases in calorie intake and decreased physical activity. In diabetic patients hypertension (HT) has a prevalence of over 60% and cerebro- and cardiovascular disease is responsible for two-thirds of the mortality in these patients. PATIENTS AND METHODS: We studied prospectively and consecutively 97 patients (age 63 +/- 8; 39-89) with treated type 2 diabetes and HT. The objective was to identify cardio- and cerebrovascular risk markers. The majority of the patients were evaluated by clinical and laboratory examination, 24h ambulatory blood pressure monitoring (ABPM), HbA1c, total cholesterol, HDL-C and triglycerides, microalbuminuria, echocardiogram (left ventricular mass index) and carotid-femoral pulse wave velocity. Later, the patients were re-evaluated using the same diagnostic methodology after a mean follow-up of 28 months. RESULTS: The population was at high risk for cardio- and cerebrovascular disease (60% dyslipidemic, 39% with previous cerebro- or cardiovascular accidents, 73% nondipper, 69% with decreased vascular distensibility [<12 m/sec] and 35% with microalbuminuria) despite treatment. Diabetes was controlled in only 55% of cases and blood pressure (BP) in 10%, although by ABPM it was controlled in 40% of cases. Simultaneous control of diabetes and HT was present in only one third of the patients. At the end of follow-up these values had not changed significantly, which can only be considered positive in respect of reduction in microalbuminuria (due to ACEIs and AIIRAs). Thirty cardio- and cerebrovascular events occurred (5 deaths), related to inadequate control of diabetes at initial evaluation (p=0.012), night-time systolic BP (SBP) and nondipper status (p=0.02) and vascular distensibility at the end of the study (p=0.03). On multiple linear regression (stepwise) analysis the only variable which was significantly associated with cardio- and cerebrovascular mortality and morbidity was night-time SBP. CONCLUSIONS: Overall analysis of the data confirmed the elevated risk of these patients and the importance of more frequent and aggressive control. The study also confirms the importance of evaluation by ABPM in these patients, which may lead to more efficacious, tailor-made treatment.     

Patients with aortic coarctation operated during the first year of life, different surgical techniques and prognostic factors--21 years of experience.

The authors reviewed the clinical files of all patients with coarctation of the aorta (CoAo) operated during the first year of life, in a tertiary center, in order to assess the outcome of different surgical techniques and prognostic factors. MATERIAL AND METHODS: The study included all patients operated from 1 June 1980 to 1 June 2001. They were divided into three groups according to diagnosis: Group I--isolated CoAo (with or without persistent ductus arteriosus (PDA), group II--CoAo plus ventricular septal defect (VSD), and group III--CoAo associated with complex heart defects. The surgical techniques were divided into four groups: Group A--resection of the CoAo with end-to-end anastomosis, group B--Waldhausen technique (subclavian flap), group C--enlargement of the aorta with a patch, and group D--Waldhausen technique plus resection of the CoAo with end-to-end anastomosis. Several parameters were analyzed: sex, age at surgery, other surgical procedures during surgery, reoperation, mortality and outcome (good result, recoarctation). RESULTS: 156 patients were operated during the study period (84.5% of them since 1989). 61.5% were male. Surgery was performed between 3 and 336 days of life. 60.9% patients were included in group I, 32.7% in group II and 6.4% in group III. 25.0% of the patients had group A surgery, 60.2% group B surgery, 7.0% group C surgery and 7.7% group D surgery. The PDA was sectioned in 48.0% of the patients. It was necessary to perform banding of the pulmonary artery, during the first surgery, in 19.9% of cases. 18.6% needed a second operation to close the VSD and for debanding or repair of associated defects. Total mortality was 19.2%. Mortality rate per groups was: Group I--15.8%, group II--21.5%, group III--30.0%, group A--18.0%, group B--19.1%, group C--27.2% and group D--16.7%. In 7.6% of the patients recoarctation was found during follow-up. 40% of the patients are doing well with no medication and minor or no residual defects. 29.4% were lost to follow-up. CONCLUSIONS: Total mortality has decreased over the years with the highest mortality found in Group C and Group III. The best results were achieved in patients with isolated CoAo. Long-term results were generally good with few recoarctations and a good quality of life.     

Further characterization, isolation and identification of the epithelial cell-surface antigen defined by monoclonal antibody AUA1

The human epithelial antigen recognized monoclonal antibody (MAb) AUA1 has been characterized as a cell-surface glycoprotein. It has been isolated from human colonic mucosa by AUA1 affinity separation. N-terminal peptide sequence of this purified material has revealed a 17 amino acid sequence which identifies it with one of a group of similar epithelial/tumor-associated glycoproteins defined by a variety of MAbs. Using the polymerase chain reaction to map the gene encoding this antigen, our previous AUA1 antigen assignment to chromosome 2 has been confirmed.