Primary care doctors in acute call-outs to severe trauma incidents in Norway – variations by rural-urban settings and time factors

Background A severely injured patient needs fast transportation to a hospital that can provide definitive care. In Norway, approximately 20% of the population live in rural areas. Primary care doctors (PCDs) play an important role in prehospital trauma care. The aim of this study was to investigate how variations in PCD call-outs to severe trauma incidents in Norway were associated with rural-urban settings and time factors. Methods In this study on severe trauma patients admitted to Norwegian hospitals from 2012 to 2018, we linked data from four official Norwegian registries. Through this, we investigated the call-out responses of PCDs to severe trauma incidents. In multivariable log-binomial regression models, we investigated whether factors related to rural-urban settings and time factors were associated with PCD call-outs. Results There was a significantly higher probability of PCD call-outs to severe trauma incidents in the municipalities in the four most rural centrality categories compared to the most urban category. The largest difference in adjusted relative risk (95% confidence interval (CI)) was 2.08 (1.27–3.41) for centrality category four. PCDs had a significantly higher proportion of call-outs in the Western (RR = 1.46 (1.23–1.73)) and Central Norway (RR = 1.30 (1.08–1.58)) Regional Health Authority areas compared to in the South-Eastern area. We observed a large variation (0.47 to 4.71) in call-out rates to severe trauma incidents per 100,000 inhabitants per year across the 16 Emergency Medical Communication Centre areas in Norway. Conclusions Centrality affects the proportion of PCD call-outs to severe trauma incidents, and call-out rates were higher in rural than in urban areas. We found no significant difference in call-out rates according to time factors. Possible consequences of these findings should be further investigated.publishedVersio

Acute unstable depressive syndrome (AUDS) is associated more frequently with epilepsy than major depression

<p>Abstract</p> <p>Background</p> <p>Depressive disorders are frequent in epilepsy and associated with reduced seizure control. Almost 50% of interictal depressive disorders have to be classified as atypical depressions according to DSM-4 criteria. Research has mainly focused on depressive symptoms in defined populations with epilepsy (e.g., patients admitted to tertiary epilepsy centers). We have chosen the opposite approach. We hypothesized that it is possible to define by clinical means a subgroup of psychiatric patients with higher than expected prevalence of epilepsy and seizures. We hypothesized further that these patients present with an Acute Unstable Depressive Syndrome (AUDS) that does not meet DSM-IV criteria of a Major Depressive Episode (MDE). In a previous publication we have documented that AUDS patients indeed have more often a history of epileptic seizures and abnormal EEG recordings than MDE patients (Vaaler et al. 2009). This study aimed to further classify the differences of depressive symptoms at admittance and follow-up of patients with AUDS and MDE.</p> <p>Methods</p> <p>16 AUDS patients and 16 age- and sex-matched MDE patients were assessed using the Symptomatic Organic Mental Disorder Assessment Scale (SOMAS), the Montgomery and Åsberg Depression Rating Scale (MADRS), and the Mini-Mental State Test (MMST), at day 2, day 4-6, day 14-16 and 3 months after admittance to a psychiatric emergency unit. Life events were assessed with The Social Readjustment Rating Scale (SRRS) and The Life Experience Survey (LES). We also screened for medication serum levels and illicit drug metabolites in urine.</p> <p>Results</p> <p>AUDS patients had significantly higher SOMAS scores (average score at admission 6.6 ± 0.8), reflecting increased symptom fluctuation and motor agitation, and decreased insight and concern compared to MDE patients (2.9 ± 0.7; p < 0.001). Degree of mood depression, cognition, life events, drug abuse and medication did not differ between the two groups.</p> <p>Conclusions</p> <p>AUDS patients present with rapidly fluctuating mood symptoms, motor agitation and relative lack of insight and concern. Seizures, epilepsy and EEG abnormalities are overrepresented in AUDS patients compared to MDE patients. We suggest that the study of AUDS patients may offer a new approach to better understanding epilepsy and its association with depressive disorders.</p> <p>Trial registration</p> <p>NCT00201474</p

Primary care doctors in acute call-outs to severe trauma incidents in Norway–associations with factors related to patients and doctors

Objective Severe trauma patients need immediate prehospital intervention and transfer to a specialised trauma hospital. In Norway, primary care doctors (PCDs) are an integrated part of the prehospital trauma care. The aim of this study was to investigate the degree to which PCDs were involved in prehospital care of severe trauma patients and how factors related to patients and doctors were associated with call-outs to these incidents. Design This was a registry-based study in Norway on severe trauma patients with acute hospital admission during the period 2012–2018. Setting Data was obtained from three Norwegian official registries. Subjects By linking the registries, we studied the actions taken by the PCDs, whether they called out to severe trauma incidents. Main outcome measures In multivariable regression models, we investigated whether factors related to the PCDs (age, sex, specialisation in general practice (GP)) and patients (age, sex, duration of hospital stay, type of injury) were associated with call-outs. Results Out of 4342 severe trauma incidents, PCDs had documented involvement in 1683 (39%) and called out to 644 (15%). Increased proportions of PCD call-outs to severe trauma incidents were significantly associated with lower age of PCD, being a GP specialist, lower patient age, being a male patient, increased length of hospital stay and injuries to the head and the neck. Conclusions PCDs called out to a relatively low proportion of severe trauma patients. Several factors related to patients and doctors were associated with call-outs to severe trauma incidents in Norway.publishedVersio

Motor activity patterns in acute schizophrenia and other psychotic disorders can be differentiated from bipolar mania and unipolar depression

Under embargo until: 02.10.2019The purpose of this study was to compare 24-h motor activity patterns between and within three groups of acutely admitted inpatients with schizophrenia and psychotic disorders (n = 28), bipolar mania (n = 18) and motor-retarded unipolar depression (n = 25) and one group of non-hospitalized healthy individuals (n = 28). Motor activity was measured by wrist actigraphy, and analytical approaches using linear and non-linear variability and irregularity measures were undertaken. In between-group comparisons, the schizophrenia group showed more irregular activity patterns than depression cases and healthy individuals. The schizophrenia and mania cases were clinically similar with respect to high prevalence of psychotic symptoms. Although they could not be separated by a formal statistical test, the schizophrenia cases showed more normal amplitudes in morning to evening mean activity and activity variability. Schizophrenia constituted an independent entity in terms of motor activation that could be distinguished from the other diagnostic groups of psychotic and non-psychotic affective disorders. Despite limitations such as small subgroups, short recordings and confounding effects of medication/hospitalization, these results suggest that detailed temporal analysis of motor activity patterns can identify similarities and differences between prevalent functional psychiatric disorders. For this purpose, irregularity measures seem particularly useful to characterize psychotic symptoms and should be explored in larger samples with longer-term recordings, while searching for underlying mechanisms of motor activity disturbances.acceptedVersio

Vertebral column adaptations in juvenile Atlantic salmon Salmo salar, L. as a response to dietary phosphorus

Deficiency in dietary phosphorus (P) is considered as a nutritional risk factor for the development of vertebral column deformities in farmed Atlantic salmon Salmo salar, L. This mono-factorial study examines how 11-week deficiency and excess of dietary P influence the structure and microstructure of the vertebral bodies in juvenile, freshwater stages of Atlantic salmon. Animals were fed continuously with three diets containing different levels of total P (tP) and soluble P (sP), respectively: low P (LP) = 6.8 g/kg tP, 3.5 g/kg sP, regular P (RP) = 10.0 g/kg tP, 5.6 g/kg sP, and high P (HP) = 13.0 g/kg tP, 9.3 g/kg sP. Animals were analysed for plasma and bone mineral content, vertebral column deformities (x-ray), vertebral centra stiffness, bone mineralisation pattern and vertebral body microanatomy (cells and connective tissue structures). A low (background) level of deformities was observed on a gross morphological level but no increase and no specific type of vertebral column deformity was associated with either of the three groups. While feed intake was comparable among all diet groups animals fed LP showed a 50% reduction in total calcium (Ca) and P content in abdominal vertebrae and opercula. Regular P and HP animals showed similar levels of total Ca and P in abdominal vertebrae and opercula. Animals in all diet groups showed well-developed vertebral bodies. Low P animals had vertebral centra, neural and haemal arches with large areas of non-mineralised bone. Vertebral centra stiffness in LP animals was reduced accordingly. Regular P and HP animals showed comparable values for vertebral centra stiffness. Non-mineralised vertebral body end plates of LP animals developed a slight inward bending and intervertebral ligaments increased in length and thickness. The cellular and extracellular components of the intervertebral joints remained intact without structural alterations that would indicate the development of vertebral centra compression or fusion. Animals from all three diet groups showed active osteoblasts at the vertebral body growth zone. Despite the three-fold decline in plasma inorganic P in LP animals growth continued at the same rate as in RP and HP animals. It is discussed whether the use of a P-reduced diet under a continuous feeding regime can maintain growth without adverse effects for animal health and welfare. This study further discusses that a HP diet relative to an RP diet has no beneficial effect concerning bone formation, bone mineralisation, growth and prevention of vertebral centra deformities in Atlantic salmon parr.publishedVersio

The study protocol of the Norwegian randomized controlled trial of electroconvulsive therapy in treatment resistant depression in bipolar disorder

<p>Abstract</p> <p>Background</p> <p>The treatment of depressive phases of bipolar disorder is challenging. The effects of the commonly used antidepressants in bipolar depression are questionable. Electroconvulsive therapy is generally considered to be the most effective treatment even if there are no randomized controlled trials of electroconvulsive therapy in bipolar depression. The safety of electroconvulsive therapy is well documented, but there are some controversies as to the cognitive side effects. The aim of this study is to compare the effects and side effects of electroconvulsive therapy to pharmacological treatment in treatment resistant bipolar depression. Cognitive changes and quality of life during the treatment will be assessed.</p> <p>Methods/Design</p> <p>A prospective, randomised controlled, multi-centre six- week acute treatment trial with seven clinical assessments. Follow up visit at 26 weeks or until remission (max 52 weeks). A neuropsychological test battery designed to be sensitive to changes in cognitive function will be used. Setting: Nine study centres across Norway, all acute psychiatric departments. Sample: n = 132 patients, aged 18 and over, who fulfil criteria for treatment resistant depression in bipolar disorder, Montgomery Åsberg Depression Rating Scale Score of at least 25 at baseline. Intervention: Intervention group: 3 sessions per week for up to 6 weeks, total up to 18 sessions. Control group: algorithm-based pharmacological treatment as usual.</p> <p>Discussion</p> <p>This study is the first randomized controlled trial that aims to investigate whether electroconvulsive therapy is better than pharmacological treatment as usual in treatment resistant bipolar depression. Possible long lasting cognitive side effects will be evaluated. The study is investigator initiated, without support from industry.</p> <p>Trial registration</p> <p>NCT00664976</p

The Predictive Properties of Violence Risk Instruments May Increase by Adding Items Assessing Sleep

Background: The psychometric instruments developed for short-term prediction of violence in psychiatric inpatients do not include variables assessing sleep. Disturbances in sleep may precede aggression in this setting. We investigated whether adding information on sleep improved the predictive properties of the Brøset Violence Checklist (BVC).Methods: The study population consists of all patients admitted to a psychiatric intensive care unit (PICU) over a 6-month period who were hospitalized for at least one night (n = 50). Sleep observed by staff (521 nights), behavior assessed with the BVC (433 days), and aggressive incidents recorded by the Staff Observation Scale-Revised (n = 14) were included in the analysis.Results: The ability of the BVC to predict aggressive incidents improved from AUCROC 0.757 to AUCROC 0.873 when a combined sleep variable including both sleep duration and night-to-night variations of sleep duration was added to the BVC recordings. The combined sleep variable did not significantly predict aggressive incidents (AUCROC 0.653, p = 0.051).Conclusions: A sleep disturbance variable improves the predictive properties of the BVC in PICUs. Further studies of sleep duration, night-to-night variations in duration of sleep, and aggression are needed

Neurocognitive profiles in treatment-resistant bipolar I and bipolar II disorder depression

Background The literature on the neuropsychological profiles in Bipolar disorder (BD) depression is sparse. The aims of the study were to assess the neurocognitive profiles in treatment-resistant, acutely admitted BD depression inpatients, to compare the neurocognitive functioning in patients with BD I and II, and to identify the demographic and clinical illness characteristics associated with cognitive functioning. Methods Acutely admitted BD I (n = 19) and BD II (n = 32) inpatients who fulfilled the DSM-IV-TR criteria for a major depressive episode were tested with the MATRICS Consensus Cognitive Battery (MCCB), the Wechsler Abbreviated Scale of Intelligence, the National Adult Reading Test, and a battery of clinical measures. Results Neurocognitive impairments were evident in the BD I and BD II depression inpatients within all MCCB domains. The numerical scores on all MCCB-measures were lower in the BD I group than in the BD II group, with a significant difference on one of the measures, category fluency. 68.4% of the BD I patients had clinically significant impairment (>1.5 SD below normal mean) in two or more domains compared to 37.5% of the BD II patients (p = 0.045). A significant reduction in IQ from the premorbid to the current level was seen in BD I but not BD II patients. Higher age was associated with greater neurocognitive deficits compared to age-adjusted published norms. Conclusions A high proportion of patients with therapy-resistant BD I or II depression exhibited global neurocognitive impairments with clinically significant severity. The cognitive impairments were more common in BD I compared to BD II patients, particularly processing speed. These findings suggest that clinicians should be aware of the severe neurocognitive dysfunction in treatment-resistant bipolar depression, particularly in BD I.publishedVersio

Non-adherence to antipsychotic medication, relapse and rehospitalisation in recent-onset schizophrenia

<p>Abstract</p> <p>Background</p> <p>The aims of this study were to describe outcome with respect to persistent psychotic symptoms, relapse of positive symptoms, hospital admissions, and application of treatment by coercion among patients with recent onset schizophrenia being adherent and non-adherent to anti-psychotic medication.</p> <p>Materials and methods</p> <p>The study included 50 patients with recent onset schizophrenia, schizoaffective or schizophreniform disorders. The patients were clinically stable at study entry and had less than 2 years duration of psychotic symptoms. Good adherence to antipsychotic medication was defined as less than one month without medication. Outcomes for poor and good adherence were compared over a 24-month follow-up period.</p> <p>Results</p> <p>The Odds Ratio (OR) of having a psychotic relapse was 10.27 and the OR of being admitted to hospital was 4.00 among non-adherent patients. Use of depot-antipsychotics were associated with relapses (OR = 6.44).</p> <p>Conclusion</p> <p>Non-adherence was associated with relapse, hospital admission and having persistent psychotic symptoms. Interventions to increase adherence are needed.</p> <p>Trial registration</p> <p>Current Controlled Trials NCT00184509. Key words: Adherence, schizophrenia, antipsychotic medication, admittances, relapse.</p