Clinical pharmacy input for hospital inpatients according to disease state

This study measured the clinical activities performed and times taken by hospital pharmacists to provide medication monitoring services to individual medical and surgical patients. Linking these data to hospital Patient Administration Systems showed how clinical pharmacy manpower needs are guided by patient partition, disease complexity and Diagnosis Related Group classification.

Reliability of the mood disorder questionnaire : comparison with the structured clinical interview for the DSM-IV-TR in a population sample

Objective: The Mood Disorder Questionnaire (MDQ) is a widely used self-report screening instrument for the detection of bipolar disorder in clinical populations. The aim of the present study was therefore to investigate the reliability of this instrument.

Methods: Screening results using the MDQ were compared with results obtained using the Structured Clinical Interview for DSM-IV-TR Research Version, Non-patient edition (SCID) in a community-based sample of 1066 women. Trained personnel, who were blind to the results of the MDQ screen, conducted clinical interviews.

Results: Using the MDQ, 21 women screened positive for bipolar disorder, and using the SCID diagnoses, 24 women were confirmed with a diagnosis of bipolar disorder. Six women were detected on both instruments. Compared to the SCID, the sensitivity for the MDQ was 25%, specificity 99%, positive predictive value 28%, negative predictive value 98%, and a demonstrated kappa of 0.25. The MDQ failed to detect any of the 11 participants in the study with bipolar II disorder and missed seven of 13 participants with bipolar I disorder or bipolar not otherwise specified. Of the 21 women who screened positive using the MDQ, 19 had current or past psychopathologies other than bipolar disorder.

Conclusion: The MDQ has substantial limitations for detection of bipolar disorder, in particular bipolar II disorder, in non-clinical populations.

From neuroprogression to neuroprotection : implications for clinical care

• Bipolar disorder follows a staged trajectory in which persistence of illness is associated with a number of clinical features such as progressive shortening of the inter-episode interval and decreased probability of treatment response.

• This neuroprogressive clinical process is reflected by both progressive neuroanatomical changes and evidence of cognitive decline.

• The biochemical foundation of this process appears to incorporate changes in inflammatory cytokines, cortisone, neurotrophins and oxidative stress. There is a growing body of evidence to suggest that these markers may differ between the early and late stages of the disorder.

• The presence of a series of tangible targets raises the spectre of development of rational neuroprotective strategies, involving judicious use of current therapies and novel agents. Most of the currently used mood stabilisers share effects on oxidative stress and neurotrophins, while novel potentially neuroprotective agents are being developed. These developments need to be combined with service initiatives to maximise the opportunities for early diagnosis and intervention.

Early intervention in bipolar disorders : clinical, biochemical and neuroimaging imperatives

In the absence of clear targets for primary prevention of many psychiatric illnesses, secondary prevention becomes the most feasible therapeutic target, and is best encompassed by the concept of early intervention. This construct encompasses the goals of minimising diagnostic delay and the prompt initiation of clinically appropriate therapy. This paper develops the rationale for early intervention in bipolar disorder. Three interrelated themes are discussed; the clinical data supporting the value of prompt diagnosis and treatment in bipolar disorder, the putative biochemical mechanisms underlying the pathophysiological processes, and the parallel concept of neuroprotection, and the developing neuroimaging data that supports early intervention. Early initiation of appropriate therapy may potentially facilitate improved clinical outcomes, and further might allow the secondary prevention of the sequelae of untreated illness, which include the deleterious impact on family relationships, psychosexual and vocational development, identity and self-concept and self-stigma.

Olanzapine / fluoxetine combination for treatment resistant depression : efficacy and clinical utility

Antidepressant monotherapy is a first-line treatment for depression; however, not all sufferers will adequately respond to treatment. When treating a patient with treatment-resistant depression, the clinician needs to consider all factors which may contribute to an inadequate response to an antidepressant. These include accuracy of diagnosis and medication adherence, as well as the patient’s personality, lifestyle, life events and social circumstances. If it is determined that treatment resistance is due to failure of efficacy of antidepressant monotherapy, then an augmentation strategy using an atypical antipsychotic may be considered. Treatment using olanzapine/fluoxetine combination (OFC) is one of many options. Four randomized, acute-phase trials have suggested OFC is useful for reducing Montgomery–Åsberg Depression Rating Scale scores after inadequate response to antidepressant monotherapy. OFC has been useful at doses of olanzapine/fluoxetine 6/25, 6/50, 12/25 and 12/50 mg/day, with 1/5 mg/day suggested to be an ineffective dose. Treatment with OFC has been associated with some side effects, including weight gain and the metabolic syndrome, somnolence, dry mouth, increased appetite and headache. Treatment decisions therefore need to be made to balance the risks and benefits.

Financial crisis, Social pathologies and 'generalised perversion' : questioning Zizek's diagnosis of the times

Slavoj Zizek's work has been highly influential in the formulation of an emerging consensus among Lacanian social researchers, that we live in a society of generalised perversion whose initial fruits are the corrosion of democracy and the recent financial crisis. This position rests upon a notion of modern subjectivity that connects ‘commodity fetishism’ with clinical perversion in a pathological configuration, so that social theoretical identification of crisis tendencies, evaluative language about moral problems and diagnostic categories from the Lacanian clinic can be combined in a single figure. In this article, we question the series of conceptual links that constitute this position, tracing them from Zizek’s critique in his short work on the global financial crisis and his broader restatement of this analysis in the recent Living in the End Times, through the moment of his announcement of the notion of ‘generalised perversion’ in The Ticklish Subject, all the way back to fundamental propositions outlined in his earliest work. Our argument progresses through three claims. First, we show in the evolution of this position that it leads Zizek to equivocate in his diagnosis of contemporary society between two mutually exclusive categories (‘psychosis’ and ‘perversion’), indicating an antinomy in his work that is resolved in favour of ‘generalised perversion’ on empirical, not logical, grounds. Secondly, we offer a critical resolution of the antinomy through a critique of what we argue is Zizek’s mistaken over-extension of psychoanalytic reason beyond its legitimate scope of application. Finally, we point to some of the political implications of the way that Zizek speculatively resolves his logical difficulties, by analysing the consequences of his claim that generalised social perversion - the problem to be solved - involves a dethroning of the communal ego ideal. A communitarian streak, implicit in the potential conflation of moral denunciation with psychoanalytic diagnosis that the rhetoric of ‘perversion’ invokes, runs through Zizek’s work on capitalism, we propose in conclusion.

Clinical applications of aptamers and nucleic acid therapeutics in haematological malignancies

Haematological malignancies result from a heterogeneous mix of genetic mutations and chromosome aberrations and translocations. Targeted therapies, such as the anti-CD20 antibody rituximab, or the BCR-ABL1 inhibitor imatinib, have proven to be effective treatments in the management of some of these malignancies, though relapsing or refractory disease is still common. Nucleic acid-based therapies have also entered the clinical arena, providing an alternative, complementary approach. The forerunner of these therapies were the antisense oligonucleotides, but their scope has expanded to include short-interfering RNA (siRNA), microRNA, decoy oligonucleotides and aptamers. These can be used either as monotherapeutics, in conjunction with current chemotherapy regimens, or in combination with each other to improve therapeutic efficacy. Not only can these nucleic acid-based therapies silence target genes, they also have the potential of restoring gene function. While challenges remain in delivering effective doses of nucleic acid in vivo, these are steadily being met, suggesting an optimistic future in the treatment of haematological malignancies. This review summarizes the application of nucleic acid-based therapeutics, particularly aptamers, in the diagnosis and treatment of haematological malignancies.

Bayesian networks and decision trees in the diagnosis of female urinary incontinence

This study compares the effectiveness of Bayesian networks versus Decision Trees in modeling the Integral Theory of Female Urinary Incontinence diagnostic algorithm. Bayesian networks and Decision Trees were developed and trained using data from 58 adult women presenting with urinary incontinence symptoms. A Bayesian Network was developed in collaboration with an expert specialist who regularly utilizes a non-automated diagnostic algorithm in clinical practice. The original Bayesian network was later refined using a more connected approach. Diagnoses determined from all automated approaches were compared with the diagnoses of a single human expert. In most cases, Bayesian networks were found to be at least as accurate as the Decision Tree approach. The refined Connected Bayesian Network was found to be more accurate than the Original Bayesian Network accurately discriminated between diagnoses despite the small sample size. In contrast, the Connected and Decision Tree approaches were less able to discriminate between diagnoses. The Original Bayesian Network was found to provide an excellent basis for graphically communicating the correlation between symptoms and laxity defects in a given anatomical zone. Performance measures in both networks indicate that Bayesian networks could provide a potentially useful tool in the management of female pelvic floor dysfunction. Before the technique can be utilized in practice, well-established learning algorithms should be applied to improve network structure. A larger training data set should also improve network accuracy, sensitivity, and specificity.

Working around a contested diagnosis : borderline personality disorder in adolescence

This discourse analytic study sits at the intersection of everyday communications with young people in mental health settings and the enduring sociological critique of diagnoses in psychiatry. The diagnosis of borderline personality disorder (BPD) is both contested and stigmatized, in mental health and general health settings. Its legitimacy is further contested within the specialist adolescent mental health setting. In this setting, clinicians face a quandary regarding the application of adult diagnostic criteria to an adolescent population, aged less than 18 years. This article presents an analysis of interviews undertaken with Child and Adolescent Mental Health Services (CAMHS) clinicians in two publicly funded Australian services, about their use of the BPD diagnosis. In contrast with notions of primacy of diagnosis or of transparency in communications, doctors, nurses and allied health clinicians resisted and subverted a diagnosis of BPD in their work with adolescents. We delineate specific social and discursive strategies that clinicians displayed and reflected on, including: team rules which discouraged diagnostic disclosure; the lexical strategy of hedging when using the diagnosis; the prohibition and utility of informal ‘borderline talk’ among clinicians; and reframing the diagnosis with young people. For clinicians, these strategies legitimated their scepticism and enabled them to work with diagnostic uncertainty, in a population identified as vulnerable. For adolescent identities, these strategies served to forestall a BPD trajectory, allowing room for troubled adolescents to move and grow. These findings illuminate how the contest surrounding this diagnosis in principle is expressed in everyday clinical practice.

Training improves interobserver reliability for the diagnosis of scaphoid fracture displacement

Background The diagnosis of displacement in scaphoid fractures is notorious for poor interobserver reliability.

Questions/purposes We tested whether training can improve interobserver reliability and sensitivity, specificity, and accuracy for the diagnosis of scaphoid fracture displacement on radiographs and CT scans.

Methods Sixty-four orthopaedic surgeons rated a set of radiographs and CT scans of 10 displaced and 10 nondisplaced scaphoid fractures for the presence of displacement, using a web-based rating application. Before rating, observers were randomized to a training group (34 observers) and a nontraining group (30 observers). The training group received an online training module before the rating session, and the nontraining group did not. Interobserver reliability for training and nontraining was assessed by Siegel’s multirater kappa and the Z-test was used to test for significance.

Results There was a small, but significant difference in the interobserver reliability for displacement ratings in favor of the training group compared with the nontraining group. Ratings of radiographs and CT scans combined resulted in moderate agreement for both groups. The average sensitivity, specificity, and accuracy of diagnosing displacement of scaphoid fractures were, respectively, 83%, 85%, and 84% for the nontraining group and 87%, 86%, and 87% for the training group. Assuming a 5% prevalence of fracture displacement, the positive predictive value was 0.23 in the nontraining group and 0.25 in the training group. The negative predictive value was 0.99 in both groups.

Conclusions Our results suggest training can improve interobserver reliability and sensitivity, specificity and accuracy for the diagnosis of scaphoid fracture displacement, but the improvements are slight. These findings are encouraging for future research regarding interobserver variation and how to reduce it further.

Treatment and outcomes of an Australian cohort of outpatients with bipolar 1 or schizoaffective disorder over twenty-four months : implications for clinical practice

Background The Bipolar Comprehensive Outcomes Study (BCOS) is a 2-year, prospective, non-interventional, observational study designed to explore the clinical and functional outcomes associated with ‘real-world’ treatment of participants with bipolar I or schizoaffective disorder. All participants received treatment as usual. There was no study medication.

Methods Participants prescribed either conventional mood stabilizers (CMS; n = 155) alone, or olanzapine with, or without, CMS (olanzapine ± CMS; n = 84) were assessed every 3 months using several measures, including the Young Mania Rating Scale, 21-item Hamilton Depression Rating Scale, Clinical Global Impressions Scale – Bipolar Version, and the EuroQol Instrument. This paper reports 24-month longitudinal clinical, pharmacological, functional, and socioeconomic data.

Results On average, participants were 42 (range 18 to 79) years of age, 58%; were female, and 73%; had a diagnosis of bipolar I. Polypharmacy was the usual approach to pharmacological treatment; participants took a median of 5 different psychotropic medications over the course of the study, and spent a median proportion of time of 100%; of the study on mood stabilizers, 90%; on antipsychotics, 9%; on antidepressants, and 5%; on benzodiazepines/hypnotics. By 24 months, the majority of participants had achieved both symptomatic and syndromal remission of both mania and depression. Symptomatic relapse rates were similar for both the CMS alone (65%;) and the olanzapine ± CMS (61%;) cohorts.

Conclusions Participants with bipolar I or schizoaffective disorder in this study were receiving complex medication treatments that were often discordant with recommendations made in contemporary major treatment guidelines. The majority of study participants demonstrated some clinical and functional improvements, but not all achieved remission of symptoms or syndrome.

Early diagnosis and treatment of necrotizing fasciitis can improve survival : an observational intensive care unit cohort study

Background
The aim of this study was to describe the clinical characteristics, causative pathogens, clinical management and outcomes of patients presenting to a tertiary adult Australian intensive care unit (ICU) with a diagnosis of necrotizing fasciitis (NF).
Methods
This retrospective observational study was conducted in a 19-bed, level III, adult ICU in a 450-bed tertiary, regional hospital. Clinical databases were accessed for patients diagnosed with NF and admitted to The Geelong Hospital ICU between 1 February 2000 and 1 June 2011. Information on severity of sepsis, surgical procedures and microbiological results were collected.
Results
Twenty patients with NF were identified. The median age was 52.5 years and 38% were female. The overall mortality rate was 8.3%. Common co-morbidities were diabetes (21%) and heart failure (17%), although 50% of patients had no co-morbidities. Group A Streptococcus was the identified pathogen in 11 (46%) patients, and Streptococcus milleri group in 5 (21%) patients. Hyperbaric oxygen therapy was not used in the majority of patients. The initial antibiotics administered were active against subsequently cultured bacteria in 83% of patients. Median time to surgical debridement was 20 h. Diagnosis and management was delayed in the nosocomial group.
Conclusions
This study reports physiological data, aetiology and therapeutic interventions in NF for an adult tertiary hospital. We demonstrate one of the lowest reported mortality rates, with early surgical debridement being achieved in the majority of patients. The main delay was found to be in the diagnosis of NF.

Diagnosis of myalgic encephalomyelitis : where are we now?

Introduction: The World Health Organization has classified myalgic encephalomyelitis (ME) as a neurological disease since 1969 considering chronic fatigue syndrome (CFS) as a synonym used interchangeably for ME since 1969. ME and CFS are considered to be neuro-immune disorders, characterized by specific symptom profiles and a neuro-immune pathophysiology. However, there is controversy as to which criteria should be used to classify patients with “chronic fatigue syndrome.”

Areas covered: The Centers for Disease Control and Prevention (CDC) criteria consider chronic fatigue (CF) to be distinctive for CFS, whereas the International Consensus Criteria (ICC) stresses the presence of post-exertion malaise (PEM) as the hallmark feature of ME. These case definitions have not been subjected to rigorous external validation methods, for example, pattern recognition analyses, instead being based on clinical insights and consensus.

Expert opinion: Pattern recognition methods showed the existence of three qualitatively different categories: (a) CF, where CF evident, but not satisfying full CDC syndrome criteria. (b) CFS, satisfying CDC criteria but without PEM. (c) ME, where PEM is evident in CFS. Future research on this “chronic fatigue spectrum” should, therefore, use the abovementioned validated categories and novel tailored algorithms to classify patients into ME, CFS, or CF.