The Hampshire Depression Project: development and piloting of clinical practice guidelines and education about depression in primary health care

This paper describes the development and piloting of a comprehensive educational programme about recognition and management of depressive illness in primary care. Full evaluation of the effectiveness of the programme is currently underway in a randomized controlled trial, the Hampshire Depression Project (HDP), involving 56 general practices. The programme consists of clinical practice guidelines, practice-based seminars and follow-up sessions. Each part of the programme has been designed to be flexible, clinically oriented and relevant to all members of the multidisciplinary primary care team. The pilot study established the need for a systematic approach to the access of practices and practice teams, and the organization and process of the seminars. Application of this approach was associated with excellent attendance in the main programme.     

Patients Receiving a Primary Unicompartmental Knee Replacement Have a Higher Risk of Revision but a Lower Risk of Mortality Than Predicted Had They Received a Total Knee Replacement: Data From the National Joint Registry for England,Wales, Northern Ireland,and the Isle of Man

BackgroundTo determine unicompartmental (UKR) and total knee replacement (TKR) revision rates, compare UKR revision rates with what they would have been had they received TKR instead, and assess subsequent re-revision and 90-day mortality rates.MethodsUsing National Joint Registry data, we estimated UKR and TKR revision and mortality rates. Flexible parametric survival modeling (FPM) was used to model failure in TKR and make estimates for UKR. Kaplan-Meier estimates were used to compare cumulative re-revision for revised UKRs and TKRs.ResultsTen-year UKR revision rates were 2.5 times higher than expected from TKR, equivalent to 70 excess revisions/1000 cases within 10 years (5861 excess revisions in this cohort). Revision rates were 2.5 times higher for the highest quartile volume UKR surgeons compared to the same quartile for TKR and 3.9 times higher for the lowest quartiles respectively. Re-revision rates of revised TKRs (10 years = 17.5%, 95% confidence interval [CI] 16.4-18.7) were similar to revised UKRs (15.2%, 95% CI 13.4-17.1) and higher than revision rates following primary TKR (3.3%, 95% CI 3.1-3.5). Ninety-day mortality rates were lower after UKR compared with TKR (0.08% vs 0.33%) and lower than predicted had UKR patients received a TKR (0.18%), equivalent to 1 fewer death per 1000 cases.ConclusionUKR revision rates were substantially higher than TKR even when demographics and caseload differences were accounted for; however, fewer deaths occur after UKR. This should be considered when forming treatment guidelines and commissioning services. Re-revision rates were similar between revised UKRs and TKRs, but considerably higher than for primary TKR, therefore UKR cannot be considered an intermediate procedure.     

SUNCT and SUNA: medical and surgical treatments

Cognitive deficits may contribute to falls in Parkinson’s disease (PD) and these deficits may be risk factors for falls. However, their association with falls has been generally studied in patients with continuous gait problems. There have been few studies in PD patients without postural instability. In addition, the effectiveness of various simple bedside cognitive tests in predicting falls has not been established. In this study, we investigated the effectiveness of three bedside cognitive tests in consecutive patients with PD without postural instability. Of the 119 patients, 39 experienced falls during the follow-up period. Of the bedside cognitive assessment methods examined, only the Montreal Cognitive Assessment (MoCA) score was significantly lower in the group of fallers than in the group of non-fallers. This result suggests that the MoCA is effective as a bedside test for evaluating the risk of falls.     

Variability in vitamin D assays impairs clinical assessment of vitamin D status

Background: Measuring serum 25(OH)D concentration is common in clinical practice despite the questionable reliability of assays. Aims: The aim of the present study was to examine agreement in 25(OH)D concentrations measured by different assays and laboratories, and consider related clinical implications. Methods: Serum samples from 813 participants in the Australian Multicentre Study of Environment and Immune Function (the Ausimmune Study) were assayed for 25(OH)D concentration. Duplicate samples from subsets of subjects were sent to different laboratories, two using DiaSorin Liaison (Laboratory A and B) and one using Liquid Chromatography‐Tandem Mass Spectrometry (LC‐MS/MS – selected here as the nominal gold standard). Pairwise within‐assay (both within‐laboratory and between‐laboratories) and between‐assay agreement was examined using Deming regression and Bland‐Altman plots. Common 25(OH)D cut‐points for classification of vitamin D deficiency were used to compare the different assays. Results: 25(OH)D concentrations measured using Liaison were substantially lower at Laboratory A than at Laboratory B (mean bias ?11.60 nmol/L, 95% limits of agreement ?46.39, 23.18). Both Liaison assays returned much lower 25(OH)D concentrations than LC‐MS/MS (mean bias up to ?26.05 nmol/L, 95% limits of agreement of ?13.21, 65.31). For Laboratory A participants, 46% (355/765) were classified as vitamin D deficient (25(OH)D <50 nmol/L) using Liaison compared with 17% (128/765) using LC‐MS/MS. For Laboratory B participants, the respective figures were 36% (76/209) and 20% (41/209). Hence, between 1‐in‐5 and 1‐in‐3 participants were misclassified as ‘deficient’. Conclusion: Bias and variability in 25(OH)D measurements sufficient to affect significantly clinical decision‐making were found both between‐laboratories and between‐assays. The adoption of common standards to allow assay calibration is required urgently.     

Residual ridge resorption, lower denture stability and subjective complaints among edentulous individuals

Residual ridge resorption in the mandible after tooth loss may lead to worsening of complete denture stability and to various subjective complaints. The aim was to evaluate the association between radiologically assessed residual ridge resorption in the mandible, clinically assessed stability of lower complete denture and subjective complaints among elderly denture wearers. The study population consisted of 326 (115 men and 211 women) edentulous subjects aged 60-78years, all of whom were wearing complete dentures in the mandible. Data on subjective complaints were obtained from questionnaires and interviews. Denture stability was assessed clinically. Residual ridge resorption was analysed from panoramic radiographs. The results showed that women were significantly more often satisfied with their lower dentures and reported fewer problems with eating than men. They also had significantly more often residual ridge resorption than men. Among women, residual ridge resorption was significantly associated with poor chewing ability, low satisfaction with dentures and poor denture stability. Among men, residual ridge resorption did not associate with subjective complaints or denture stability. Poor satisfaction with dentures associated significantly with poor denture stability in both genders. In conclusion, these results highlight the importance of denture maintenance treatment. As the extent of residual ridge resorption in the mandible was the most important factor that increased dissatisfaction with lower complete dentures, it is also important to inhibit the progression of resorption by preventing tooth loss or by using implant-retained dentures.     

Differential response to H. pylori eradication therapy of co-existing diffuse large B-cell lymphoma and MALT lymphoma of stomach-significance of tumour cell clonality and BCL10 expression

We recently reported that low-grade mucosa-associated lymphoid tissue lymphoma (MALToma) and diffuse large B-cell lymphoma (DLBCL) with MALToma (DLBCL[MALT]) of stomach are equally responsive to H. pylori eradication therapy (HPET) and that H. pylori-independent status is closely associated with nuclear translocation of BCL10. However, co-existing MALToma and DLBCL components of gastric DLBCL(MALT) may respond differentially to HPET and the underlying mechanism remains unclear. Tumour tissue samples from 18 patients with microdissectable co-existing MALToma and DLBCL cells were studied. The clonality of lymphoma cells was examined by polymerase chain reaction-based amplification of the CDR3 region of the IgH gene and confirmed by DNA sequence analysis. BCL10 expression was determined by immunohistochemistry. Differential response of co-existing MALToma and DLBCL to HPET was defined as complete eradication of one component while the other component remained. Five (27.8%) of the 18 patients showed different IgH gene rearrangements in the two components and three (60%) of these five patients had differential response of MALToma and DLBCL to HPET. By contrast, 13 patients showed identical IgH gene rearrangements and only one (8%) of them had differential response of the two components to HPET (p = 0.044). Further, all four patients with differential response of MALToma and DLBCL to HPET showed nuclear expression of BCL10 in the H. pylori-independent component and cytoplasmic expression of BCL10 in the H. pylori-dependent component while the expression patterns of BCL10 were identical in both of these components in the 14 patients who had similar tumour response to HPET. We conclude that different clonality is a common reason for the differential response of co-existing MALToma and DLBCL of gastric DLBCL(MALT) to HPET and that immunohistochemical examination of BCL10 expression may help to identify the co-existence of these components.