Determinants of adherence to recommendations for depressed elderly patients in primary care: A multi-methods study

Abstract

Objective. It is logical that tailoring implementation strategies to address identified determinants of adherence to clinical practice guidelines should improve adherence. This study aimed to identify and prioritize determinants of adherence to six recommendations for elderly patients with depression. Design and setting. Group and individual interviews and a survey were conducted in Norway. Method. Individual and group interviews with healthcare professionals and patients, and a mailed survey of healthcare professionals. A generic checklist of determinants of practice was used to categorize suggested determinants. Participants. Physicians and nurses from primary and specialist care, psychologists, researchers, and patients. Main outcome measures. Determinants of adherence to recommendations for depressed elderly patients in primary care. Results. A total of 352 determinants were identified, of which 99 were prioritized. The most frequently identified factors had to do with dissemination of guidelines, general practitioners’ time constraints, the low prioritization of elderly patients with depression, and the patients’ or relatives’ wish for medication. Approximately three-quarters of the determinants were from three of the seven domains in the generic checklist: individual healthcare professional factors, patient factors, and incentives and resources. The survey did not provide useful information due to a low response rate and a lack of responses to open-ended questions. Implications. The list of prioritized determinants can inform the design of interventions to implement recommendations for elderly patients with depression. The importance of the determinants that were identified may vary across communities, practices. and patients. Interventions that address important determinants are necessary to improve practice.     

Prioritizing treatment of rare diseases: A survey of preferences of Norwegian doctors

Understanding doctors' preferences for prioritizing treatment of rare diseases can provide an important context for policy makers who must decide whether to exempt rare disease treatments, which are often quite expensive, from standard cost-effectiveness criteria. We surveyed a random sample of 551 Norwegian doctors in November 2011 and compared results to a similar survey of the Norwegian population. Respondents chose whether to prioritize treatment of patients with rare versus common diseases and then decided how to allocate funds between the two groups for each of two scenarios: (1) equal costs per person and (2) higher costs for the rare disease. Respondents were randomized to treatment costs for the rare disease in the second scenario that were either 8 or 25 times higher than treating the common disease. Except for different prevalence, the diseases were described identically. Doctors displayed no general preference for prioritizing treatment of rare diseases, but a large number favored the principle of reserving a small share of funds for rare disease patients. Doctors' responses differed significantly from those of the general population when the rare disease was more costly to treat. A larger share of doctors prioritized the common disease group for treatment while a smaller share expressed indifference. When dividing funds between the two patient groups, doctors allocated a smaller share of funds to the rare disease. Doctors were much less likely than the general population to divide funds equally between the groups. This study indicates that there is little support among Norwegian doctors for prioritizing the treatment of rare diseases.     

First Experience With Rectus Sheath Block for Postoperative Analgesia After Pancreas Transplant: A Retrospective Observational Study

Background

Standard of care for postoperative analgesia after pancreas transplant has been thoracic epidural analgesia (TEA). A high incidence of venous graft thrombosis necessitated a change to a more aggressive anticoagulation protocol. To minimize the risk of epidural hemorrhages, we changed from TEA to rectus sheath block (RSB) in 2017.

In vivo assessment of genotoxic potential of brown shammah (smokeless tobacco) in bone marrow cells of mice

This study was aimed to assess the genotoxicity of brown shammah (BS), a local form of smokeless tobacco, popular in Middle East countries including Yemen, Saudi Arabia and Sudan. The genotoxicity was explored using in vivo chromosomal aberration (CA), micronucleus (MN) and sperm abnormality (SA) assays. In addition, oxidative stress was also determined using various hepatic markers. Swiss albino mice were selected for the study, which were divided in to 5 groups of six animals each. They include, negative control (NC, received only vehicle) as well as positive control group (PC, received vehicle for 2 weeks followed by administration of cyclophosphamide, CP). Depending upon their dose, three BS treated animal groups were BS-100, 300 and 900 mg/kg. Doses of BS were obtained by suspending BS in 0.5% CMC (carboxy methyl cellulose) and orally administered once a day for 2 weeks. Significant augmentation of the average percentage of aberrant metaphase (AM), CA per cells and suppressed mitotic activity was observed on post administration of BS. In addition, BS increased the occurrence of MNPCEs (micronucleated polychromatic erythrocytes) formation, induced cytotoxicity and increased percentage of abnormal sperms as compared to NC. Moreover, BS also induced oxidative stress as the activities of hepatic superoxide dismutase (SOD) and glutathione (GSH) were reduced and malondialdehyde (MDA) content were increased by BS. Cyclophosphamide was utilized as clastogen, showed anticipated positive results and confirmed the sensitivity of test system. Therefore, it may be deduced from the study that the BS possesses genotoxic effects on mice bone marrow and germ cells in vivo.     

Escitalopram in obsessive–compulsive disorder: a randomized,placebo-controlled,paroxetine-referenced,fixed-dose, 24-week study

ABSTRACT

Objective: A randomized, placebo-controlled fixed-dose trial was undertaken to determine the efficacy and tolerability of escitalopram in obsessive–compulsive disorder (OCD), using paroxetine as the active reference.

Research design and methods: A total of 466 adults with OCD from specialized clinical centres, psychiatric hospital departments, psychiatric practices, or general practice were randomized to one of four treatment groups: escitalopram 10?mg/day (n = 116), escitalopram 20?mg/day (n = 116), paroxetine 40?mg/day (n = 119), or placebo (n = 115) for 24 weeks. The primary efficacy endpoint was the mean change in the Yale–Brown Obsessive–Compulsive Scale (Y?BOCS) total score from baseline to week 12. Secondary efficacy endpoints included remission (defined as Y?BOCS total score ≤10), NIMH?OCS, and CGI?S and CGI?I scores at weeks 12 and 24. Tolerability was based on the incidence of adverse events, and on changes in vital signs (blood pressure and pulse).

Main outcome measures; Results: Escitalopram 20?mg/day was superior to placebo on the primary and all secondary outcome endpoints, including remission. Escitalopram 10?mg/day and paroxetine 40?mg/day were also effective on the primary scale as well as some other outcome measures. In the escitalopram 20?mg/day group, the improvement in Y?BOCS total score was significantly better than in the placebo group as early as week 6. The most common AEs in the active treatment groups were nausea (19–27%), headache (17–22%), and fatigue (12–19%). More paroxetine-treated patients withdrew due to adverse events than escitalopram- or placebo-treated patients.

Conclusion: Given that escitalopram 20?mg/day was associated with an earlier onset, higher response and remission rates, improved functioning, and better tolerability than the reference drug, escitalopram deserves to be considered as one of the first-line agents in the pharmacotherapy of OCD for longer-term treatment periods.     

Multiple brown tumours of the upper extremity in a patient with secondary hyperparathyroidism as a result of chronic renal failure

Abstract

A man with chronic renal failure was referred to the hand clinic because of massive osteolytic tumours in his right arm. Secondary hyperparathyroidism and brown tumours were suggested, and he was treated by subtotal parathyroidectomy. Rapid reduction of the vast tumours was noted postoperatively.     

The relationship between mortality and time since divorce,widowhood or remarriage in Norway

The chance of dying within any given year probably depends not only on marital status in that year but also on earlier partnership history. There is still not much knowledge about such effects, however. Our intention is to see how mortality is associated with time since divorce, bereavement and remarriage and time between marital disruption and remarriage. We use register data that include the entire Norwegian population aged 40–89 from 1970 to 2008 (70,701,767 person-years of exposure and 1,484,281 deaths). The excess mortality of divorced men compared to their married counterparts increases with time since divorce, while there is no such trend among divorced women. The pattern is opposite for the widowed, among whom there are indications of a more sharply positive association with time since bereavement for women than for men, though the association is rather weak for both sexes. The remarried have higher mortality than the first-time married, with one surprising exception: men who have remarried after a period of less than 10 years as divorced or widowed have the same mortality as the married. There is no clear association between mortality and time since remarriage. We discuss possible reasons for these patterns.     

Gradual increase in the risk of match injury in Norwegian male professional football: A 6‐year prospective study

The aim of this study was to monitor injury incidence and pattern in Norwegian male professional football over six consecutive seasons and compare the risk of injury between the preseason and competitive season. All time loss injuries were recorded by the medical staff of each club. In total, 2365 injuries were recorded. The incidence of acute injuries was 15.9/1000 match hours [95% confidence interval (CI): 14.9–16.8], 1.9/1000 training hours (95% CI: 1.7–2.0), and 1.4 (95% CI: 1.3–1.5) overuse injuries/1000 h. A linear regression model found an annual increase of 1.06 acute match injuries/1000 h (95% CI: 0.40–1.73), corresponding to a total increase of 49% during the 6‐year study period. When accounting for interteam variation and clustering effects using a general estimating equation model, the increase in injury incidence was 0.92 (95% CI: ?0.11–1.95, P = 0.083). No difference in the risk of acute match injuries (rate ratio (RR): 0.86, 95% CI: 0.73–1.01), acute training injuries (RR: 1.16, 95% CI: 0.99–1.36), or overuse injuries (RR: 1.04, 95% CI: 0.89–1.21) was observed between the preseason and competitive season. In conclusion, the overall risk of acute match injuries in Norwegian male professional football increased by 49% during the study period, although this increase was not fully consistent across teams. We detected no change in the risk of training and overuse injuries or any difference between the preseason and competitive season.