Axis I and II disorders as long-term predictors of mental distress: a six-year prospective follow-up of substance-dependent patients

<p>Abstract</p> <p>Background</p> <p>A high prevalence of lifetime psychiatric disorders among help-seeking substance abusers has been clearly established. However, the long-term course of psychiatric disorders and mental distress among help-seeking substance abusers is still unclear. The aim of this research was to examine the course of mental distress using a six-year follow-up study of treatment-seeking substance-dependent patients, and to explore whether lifetime Axis I and II disorders measured at admission predict the level of mental distress at follow-up, when age, sex, and substance-use variables measured both at baseline and at follow-up are controlled for. </p> <p>Methods</p> <p>A consecutive sample of substance dependent in- and outpatients (n = 287) from two counties of Norway were assessed at baseline (T1) with the Composite International Diagnostic Interview (Axis I), Millon's Clinical Multiaxial Inventory (Axis II), and the Hopkins Symptom Checklist (HSCL-25 (mental distress)). At follow-up (T2), 48% (137/287 subjects, 29% women) were assessed with the HSCL-25, the Alcohol Use Disorders Identification Test, and the Drug Use Disorders Identification Test. </p> <p>Results</p> <p>The stability of mental distress is a main finding and the level of mental distress remained high after six years, but was significantly lower among abstainers at T2, especially among female abstainers. Both the number of and specific lifetime Axis I disorders (social anxiety disorder, generalized anxiety disorder, and somatization disorder), the number of and specific Axis II disorders (anxious and impulsive personality disorders), and the severity of substance-use disorder at the index admission were all independent predictors of a high level of mental distress at follow-up, even when we controlled for age, sex, and substance use at follow-up.</p> <p>Conclusion</p> <p>These results underscore the importance of diagnosing and treating both substance-use disorder and non-substance-use disorder Axis I and Axis II disorders in the same programme.</p

European Regional Differences in All-Cause Mortality and Length of Stay for Patients with Hip Fracture

Background: Today’s healthcare systems face challenges involving rising need and demand for healthcare as well as concerns about cost containment, misuse of medical services and unwarranted variations in medical practices. Given the stretched budgets for healthcare, there is a need to improve healthcare performance and to make competent use of limited resources. To support organisations in improving performance, benchmarking is a valuable tool for several reasons. First, it is an effective substitute for competition in the public sector. Second, through benchmarking, performance differences between organisations in various measures are revealed, and for those performing less optimally, possible improvement areas may be discovered. Third, benchmarking is useful for evaluating the impact of healthcare reforms on performance. Coupled with big data from patient registers and other administrative registers, benchmarking thus can offer opportunities for finding ideal structures in the provision and financing of healthcare. Aim: The overall aim of this thesis was to show how benchmarking can be applied to assess healthcare performance with the use of register data. Methods: The four studies included in the thesis were based on two comprehensive patientlevel datasets, with data obtained from multiple registers. Study I applied international benchmarking, with the performance for the surgical treatment of hip fractures being assessed between and within seven European countries. Regression analyses were used to explore associations between age- and sex-adjusted mortality rates and length of stay (LOS) and selected country- and region-level variables. In Studies II–IV, a national perspective was considered in the assessment of the performance of elective hip replacement surgery in Sweden. In Study II, the orthopaedic departments’ productivity development between 2005 and 2012 was measured by the Malmquist Productivity Indices. The indices were further decomposed into changes in efficiency and technology. In Studies III and IV, a quasi-experimental research design was applied to assess the effects of a healthcare reform involving competition and financial incentives introduced in the capital region in 2009. In both studies, difference-in-difference analysis was used to estimate the causal effects on LOS and various measures of subjective and objective quality. In Study III, the difference-in-difference analyses were also stratified by hospital type to examine whether the reform had heterogenous effects across hospital types. In Study IV, an entropy balancing algorithm was further applied to make the intervention and control groups comparable. Findings: Study I revealed marked differences in age- and sex-adjusted LOS and mortality rates for hip fracture patients, across and within included countries. Variations were found to be associated with the availability of national clinical guidelines, the share of males in the region and country-specific effects. In Study II, differences in the development of productivity, efficiency and technology in the provision of hip replacement surgery across and within the orthopaedic departments were revealed. The overall results indicated a slight positive productivity development over the study period, which was primarily due to catch-up effects (improvements in efficiency), rather than changes in technology. The findings from Study III indicated that the reform led to the LOS of the surgical admission not decreasing at the same rate as before, and to reduction of the adverse event rate within 90 days following surgery. These effects were driven mainly by university and central hospitals. Furthermore, the reform brought no changes in patient satisfaction with the outcome of the surgery (Study III and Study IV) or gains in various patient-reported outcome measures at oneand six-year follow-ups (Study IV). Conclusions: The thesis has demonstrated how benchmarking can be applied to assess healthcare performance with the use of register data, with the four studies contributing with various perspectives and measurements at different levels of healthcare systems. First, the thesis has exemplified how performance measurement can be applied to identify and analyse performance gaps. Considerable variations in the performance of orthopaedic care between and within units of analysis were revealed at the departmental and international levels. This implies that there is room for improvement and that stakeholders should learn from best practices. Second, the thesis has demonstrated how benchmarking can be useful in the assessment of healthcare reforms. The findings indicated that the studied reform reduced the adverse event rate, led to LOS not decreasing at the same rate as before and had no effect on patient-reported outcome measures. These findings contribute to the general knowledge about the effects of market elements and financial incentives and can be used to inform decisionmaking. Future perspectives should focus on how this information can and should be used in practice to change organisations’ behaviour and to improve healthcare performance

De novo desmin-mutation N116S is associated with arrhythmogenic right ventricular cardiomyopathy

Klauke B, Kossmann S, Gaertner A, et al. De novo desmin-mutation N116S is associated with arrhythmogenic right ventricular cardiomyopathy. HUMAN MOLECULAR GENETICS. 2010;19(23):4595-4607.Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart muscle disease, frequently accompanied by sudden cardiac death and terminal heart failure. Genotyping of ARVC patients might be used for palliative treatment of the affected family. We genotyped a cohort of 22 ARVC patients referred to molecular genetic screening in our heart center for mutations in the desmosomal candidate genes JUP, DSG2, DSC2, DSP and PKP2 known to be associated with ARVC. In 43% of the cohort, we found disease-associated sequence variants. In addition, we screened for desmin mutations and found a novel desmin-mutation p. N116S in a patient with ARVC and terminal heart failure, which is located in segment 1A of the desmin rod domain. The mutation leads to the aggresome formation in cardiac and skeletal muscle without signs of an overt clinical myopathy. Cardiac aggresomes appear to be prominent, especially in the right ventricle of the heart. Viscosimetry and atomic force microscopy of the desmin wild-type and N116S mutant isolated from recombinant Escherichia coli revealed severe impairment of the filament formation, which was supported by transfections in SW13 cells. Thus, the gene coding for desmin appears to be a novel ARVC gene, which should be included in molecular genetic screening of ARVC patients