Can diagnostic triage by general practitioners or rheumatology nurses improve the positive predictive value of referrals to early arthritis clinics?

Objectives: To determine whether diagnostic triage by general practitioners (GPs) or rheumatology nurses (RNs) can improve the positive predictive value of referrals to early arthritis clinics (EACs).

Methods: Four GPs and two RNs were trained in the assessment of early in?ammatory arthritis (IA) by four visits to an EAC supervised by hospital rheumatologists. Patients referred to one of three EACs were recruited for study and assessed independently by a GP, an RN and one of six rheumatologists. Each assessor was asked to record their clinical ?ndings and whether they considered the patient to have IA. Each was then asked to judge the appropriateness of the referral according to predetermined guidelines. The rheumatologists had been shown previously to have a satisfactory level of agreement in the assessment of IA.

Results: Ninety-six patients were approached and all consented to take part in the study. In 49 cases (51%), the rheumatologist judged that the patient had IA and that the referral was appropriate. The assessments of GPs and RNs were compared with those of the rheumatologists. Levels of agreement were measured using the kappa value, where 1.0 represents total unanimity. The kappa value was
0.77 for the GPs when compared with the rheumatologists and 0.79 for the RNs. Signi?cant stiffness in the morning or after rest and objective joint swelling were the most important clinical features enabling the GPs and RNs to discriminate between IA and non-IA conditions.

Conclusion: Diagnostic triage by GPs or RNs improved the positive predictive value of referrals to an EAC with a degree of accuracy approaching that of a group of experienced rheumatologists.

Rates of childhood trauma in a sample of patients with schizophrenia as compared with a sample of patients with non-psychotic psychiatric diagnoses

Despite strong evidence of high rates of childhood and adult trauma in schizophrenia, the area remains under-researched. Our objectives in the study were first, to examine the rates of exposure to childhood, adult and lifetime (child plus adult) trauma in a population with schizophrenia and a population with non-psychotic psychiatric diagnoses and second, to examine the effect of trauma on the symptoms of schizophrenia. Two groups, those with schizophrenia (n = 40), and those with a non-psychotic diagnosis (n = 30), were recruited. Data were collected for demographic, psychiatric and trauma histories for all participants and on psychosocial functioning and psychiatric symptomatology for the patients with schizophrenia. Childhood exposure to trauma was significantly more common in the schizophrenia group (t = 5.196, df = 68, p <0.001, Eta squared = 0.28), with the strongest relationship being childhood physical assault. In the schizophrenia group a history of trauma was significantly related to poor communication skills (r = -0.529, p <0.001) and depressive symptoms (r = 0.443, p = 0.004). Evidence that childhood exposure to trauma is more common in a population with schizophrenia is consistent with other studies and raises the possibility that such trauma is of etiological importance. Further research is required to replicate those findings, to elucidate possible pathways by which the experience of trauma may contribute to the development of schizophrenia, and to explore the relationship between a history of childhood trauma and the experience of depressive symptoms in schizophrenia.

Teenagers in adult psychiatric inpatient care in Northern Ireland

Objectives: To investigate the nature and pattern of teenage admissions (13-18yrs) to the 14 adult psychiatric units in Northern Ireland (NI) between 1989 and 1995.