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Wickersham A, Westbrook J, Colling C, Downs J, Govind R, Kornblum D, Lewis J, Smith P, Ford T. The patient journeys of children and adolescents with depression: a study of electronic health records. Eur Child Adolesc Psychiatry 2024; 33:1093-1101. [PMID: 37227528 PMCID: PMC11032266 DOI: 10.1007/s00787-023-02232-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/15/2023] [Indexed: 05/26/2023]
Abstract
In England, children and adolescents with depression can seek treatment from specialist mental health services. We know little about how they journey through these services, or whether healthcare providers collect sufficient data to accurately appraise this. We aimed to summarise the child and adolescent depression pathway for two healthcare providers. This cohort study used de-identified electronic health records extracted from Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) and South London and Maudsley NHS Foundation Trust (SLaM). We identified referrals between 2015 and 2019 during which the referred patient received their first depression diagnosis aged < 18 years. We described patient demographic and clinical characteristics, and features of the referral. In total, n = 296 (CPFT) and n = 2502 (SLaM) patients had a referral which met eligibility criteria. In both sites, patients were more frequently female (CPFT 79.3%; SLaM 69.3%) and White ethnicity (CPFT 88.9%; SLaM 57.9%) as compared to respective population estimates for the Trusts' catchment areas. Patients typically received their first depression diagnosis during adolescence (median ages 16 in CPFT and 15 in SLaM). The most common comorbidity was anxiety disorder. Referrals were usually routine, to community teams specialising in the child age group. Commonly mentioned interventions included antidepressant medication, cognitive behavioural therapy, and dialectical behaviour therapy. However, pathways varied within and between sites, and the quality and consistency of some data was poor. These findings provide an overview of service pathways experienced by children and adolescents with depression, but also highlight that pathways can vary according to individual need and healthcare provider. More systematic collection of some data, and standardisation in record systems used by different providers, would be beneficial.
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Affiliation(s)
- Alice Wickersham
- CAMHS Digital Lab, Department of Child and Adolescent Psychiatry, King's College London, London, UK.
| | | | - Craig Colling
- CAMHS Digital Lab, Department of Child and Adolescent Psychiatry, King's College London, London, UK
- South London and Maudsley Mental Health NHS Trust, London, UK
| | - Johnny Downs
- CAMHS Digital Lab, Department of Child and Adolescent Psychiatry, King's College London, London, UK
- South London and Maudsley Mental Health NHS Trust, London, UK
| | - Risha Govind
- South London and Maudsley Mental Health NHS Trust, London, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Daisy Kornblum
- South London and Maudsley Mental Health NHS Trust, London, UK
| | - Jonathan Lewis
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Patrick Smith
- Department of Psychology, King's College London, London, UK
- South London and Maudsley Mental Health NHS Trust, London, UK
| | - Tamsin Ford
- Department of Psychiatry, University of Cambridge, Cambridge, UK
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Mason A, Irving J, Pritchard M, Sanyal J, Colling C, Chandran D, Stewart R. Association between depressive symptoms and cognitive-behavioural therapy receipt within a psychosis sample: a cross-sectional study. BMJ Open 2022; 12:e051873. [PMID: 35537795 PMCID: PMC9092128 DOI: 10.1136/bmjopen-2021-051873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/25/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To examine whether depressive symptoms predict receipt of cognitive-behavioural therapy for psychosis (CBTp) in individuals with psychosis. DESIGN Retrospective cross-sectional analysis of electronic health records (EHRs) of a clinical cohort. SETTING A secondary National Health Service mental healthcare service serving four boroughs of south London, UK. PARTICIPANTS 20 078 patients diagnosed with an International Classification of Diseases, version 10 (ICD-10) code between F20 and 29 extracted from an EHR database. PRIMARY AND SECONDARY OUTCOME MEASURES Primary: Whether recorded depressive symptoms predicted CBTp session receipt, defined as at least one session of CBTp identified from structured EHR fields supplemented by a natural language processing algorithm. Secondary: Whether age, gender, ethnicity, symptom profiles (positive, negative, manic and disorganisation symptoms), a comorbid diagnosis of depression, anxiety or bipolar disorder, general CBT receipt prior to the primary psychosis diagnosis date or type of psychosis diagnosis predicted CBTp receipt. RESULTS Of patients with a psychotic disorder, only 8.2% received CBTp. Individuals with at least one depressive symptom recorded, depression symptom severity and 12 out of 15 of the individual depressive symptoms independently predicted CBTp receipt. Female gender, White ethnicity and presence of a comorbid affective disorder or primary schizoaffective diagnosis were independently positively associated with CBTp receipt within the whole sample and the top 25% of mentioned depressive symptoms. CONCLUSIONS Individuals with a psychotic disorder who had recorded depressive symptoms were significantly more likely to receive CBTp sessions, aligning with CBTp guidelines of managing depressive symptoms related to a psychotic experience. However, overall receipt of CBTp is low and more common in certain demographic groups, and needs to be increased.
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Affiliation(s)
- Ava Mason
- Division of Psychiatry, University College London, London, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Jessica Irving
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Megan Pritchard
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley Mental Health NHS Trust, London, UK
| | - Jyoti Sanyal
- South London and Maudsley Mental Health NHS Trust, London, UK
| | - Craig Colling
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley Mental Health NHS Trust, London, UK
| | - David Chandran
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley Mental Health NHS Trust, London, UK
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Irving J, Colling C, Shetty H, Pritchard M, Stewart R, Fusar-Poli P, McGuire P, Patel R. Gender differences in clinical presentation and illicit substance use during first episode psychosis: a natural language processing, electronic case register study. BMJ Open 2021; 11:e042949. [PMID: 33879482 PMCID: PMC8061860 DOI: 10.1136/bmjopen-2020-042949] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 03/09/2021] [Accepted: 03/16/2021] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To determine whether gender differences in symptom presentation at first episode psychosis (FEP) remain even when controlling for substance use, age and ethnicity, using natural language processing applied to electronic health records (EHRs). DESIGN, SETTING AND PARTICIPANTS Data were extracted from EHRs of 3350 people (62% male patients) who had presented to the South London and Maudsley NHS Trust with a FEP between 1 April 2007 and 31 March 2017. Logistic regression was used to examine gender differences in the presentation of positive, negative, depressive, mania and disorganisation symptoms. EXPOSURES FOR OBSERVATIONAL STUDIES Gender (male vs female). MAIN OUTCOMES AND MEASURES Presence of positive, negative, depressive, mania and disorganisation symptoms at initial clinical presentation. RESULTS Eight symptoms were significantly more prevalent in men (poverty of thought, negative symptoms, social withdrawal, poverty of speech, aggression, grandiosity, paranoia and agitation). Conversely, tearfulness, low energy, reduced appetite, low mood, pressured speech, mood instability, flight of ideas, guilt, mutism, insomnia, poor concentration, tangentiality and elation were more prevalent in women than men. Negative symptoms were more common among men (OR 1.85, 95% CI 1.33 to 2.62) and depressive and manic symptoms more common among women (OR 0.30, 95% CI 0.26 to 0.35). After adjustment for illicit substance use, the strength of associations between gender and negative, manic and depression symptoms increased, whereas gender differences in aggression, agitation, paranoia and grandiosity became insignificant. CONCLUSIONS There are clear gender differences in the clinical presentation of FEP. Our findings suggest that gender can have a substantial influence on the nature of clinical presentation in people with psychosis, and that this is only partly explained by exposure to illicit substance use.
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Affiliation(s)
- Jessica Irving
- Department of Psychosis Studies, Institute of Psychiatry Psychology and Neuroscience, London, UK
| | - Craig Colling
- Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Hitesh Shetty
- Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Megan Pritchard
- Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, London, UK
| | - Robert Stewart
- Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, London, UK
| | - Paolo Fusar-Poli
- Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry Psychology and Neuroscience, London, UK
- Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Rashmi Patel
- Department of Psychosis Studies, Institute of Psychiatry Psychology and Neuroscience, London, UK
- Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
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Irving J, Patel R, Oliver D, Colling C, Pritchard M, Broadbent M, Baldwin H, Stahl D, Stewart R, Fusar-Poli P. Using Natural Language Processing on Electronic Health Records to Enhance Detection and Prediction of Psychosis Risk. Schizophr Bull 2021; 47:405-414. [PMID: 33025017 PMCID: PMC7965059 DOI: 10.1093/schbul/sbaa126] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Using novel data mining methods such as natural language processing (NLP) on electronic health records (EHRs) for screening and detecting individuals at risk for psychosis. METHOD The study included all patients receiving a first index diagnosis of nonorganic and nonpsychotic mental disorder within the South London and Maudsley (SLaM) NHS Foundation Trust between January 1, 2008, and July 28, 2018. Least Absolute Shrinkage and Selection Operator (LASSO)-regularized Cox regression was used to refine and externally validate a refined version of a five-item individualized, transdiagnostic, clinically based risk calculator previously developed (Harrell's C = 0.79) and piloted for implementation. The refined version included 14 additional NLP-predictors: tearfulness, poor appetite, weight loss, insomnia, cannabis, cocaine, guilt, irritability, delusions, hopelessness, disturbed sleep, poor insight, agitation, and paranoia. RESULTS A total of 92 151 patients with a first index diagnosis of nonorganic and nonpsychotic mental disorder within the SLaM Trust were included in the derivation (n = 28 297) or external validation (n = 63 854) data sets. Mean age was 33.6 years, 50.7% were women, and 67.0% were of white race/ethnicity. Mean follow-up was 1590 days. The overall 6-year risk of psychosis in secondary mental health care was 3.4 (95% CI, 3.3-3.6). External validation indicated strong performance on unseen data (Harrell's C 0.85, 95% CI 0.84-0.86), an increase of 0.06 from the original model. CONCLUSIONS Using NLP on EHRs can considerably enhance the prognostic accuracy of psychosis risk calculators. This can help identify patients at risk of psychosis who require assessment and specialized care, facilitating earlier detection and potentially improving patient outcomes.
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Affiliation(s)
- Jessica Irving
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Rashmi Patel
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Dominic Oliver
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Craig Colling
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Megan Pritchard
- South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Helen Baldwin
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Daniel Stahl
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Robert Stewart
- South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
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Oliver D, Spada G, Colling C, Broadbent M, Baldwin H, Patel R, Stewart R, Stahl D, Dobson R, McGuire P, Fusar-Poli P. Real-world implementation of precision psychiatry: Transdiagnostic risk calculator for the automatic detection of individuals at-risk of psychosis. Schizophr Res 2021; 227:52-60. [PMID: 32571619 PMCID: PMC7875179 DOI: 10.1016/j.schres.2020.05.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Risk estimation models integrated into Electronic Health Records (EHRs) can deliver innovative approaches in psychiatry, but clinicians' endorsement and their real-world usability are unknown. This study aimed to investigate the real-world feasibility of implementing an individualised, transdiagnostic risk calculator to automatically screen EHRs and detect individuals at-risk for psychosis. METHODS Feasibility implementation study encompassing an in-vitro phase (March 2018 to May 2018) and in-vivo phase (May 2018 to April 2019). The in-vitro phase addressed implementation barriers and embedded the risk calculator (predictors: age, gender, ethnicity, index cluster diagnosis, age*gender) into the local EHR. The in-vivo phase investigated the real-world feasibility of screening individuals accessing secondary mental healthcare at the South London and Maudsley NHS Trust. The primary outcome was adherence of clinicians to automatic EHR screening, defined by the proportion of clinicians who responded to alerts from the risk calculator, over those contacted. RESULTS In-vitro phase: implementation barriers were identified/overcome with clinician and service user engagement, and the calculator was successfully integrated into the local EHR through the CogStack platform. In-vivo phase: 3722 individuals were automatically screened and 115 were detected. Clinician adherence was 74% without outreach and 85% with outreach. One-third of clinicians responded to the first email (37.1%) or phone calls (33.7%). Among those detected, cumulative risk of developing psychosis was 12% at six-month follow-up. CONCLUSION This is the first implementation study suggesting that combining precision psychiatry and EHR methods to improve detection of individuals with emerging psychosis is feasible. Future psychiatric implementation research is urgently needed.
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Affiliation(s)
- Dominic Oliver
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Giulia Spada
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Craig Colling
- National Institute for Health Research, Maudesley Biomedical Research Centre, South London and Maudsley National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Matthew Broadbent
- National Institute for Health Research, Maudesley Biomedical Research Centre, South London and Maudsley National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Helen Baldwin
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom,National Institute for Health Research, Maudesley Biomedical Research Centre, South London and Maudsley National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Rashmi Patel
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom,South London and Maudsley Foundation Trust, London, United Kingdom
| | - Daniel Stahl
- Department of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Richard Dobson
- National Institute for Health Research, Maudesley Biomedical Research Centre, South London and Maudsley National Health Service (NHS) Foundation Trust, London, United Kingdom,Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom,Institute of Health Informatics Research, University College London, London, United Kingdom,Health Data Research UK London, University College London, London, United Kingdom
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom,OASIS Service, South London and Maudsley National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom; National Institute for Health Research, Maudesley Biomedical Research Centre, South London and Maudsley National Health Service (NHS) Foundation Trust, London, United Kingdom; OASIS Service, South London and Maudsley National Health Service (NHS) Foundation Trust, London, United Kingdom; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.
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Morris RM, Sellwood W, Edge D, Colling C, Stewart R, Cupitt C, Das-Munshi J. Ethnicity and impact on the receipt of cognitive-behavioural therapy in people with psychosis or bipolar disorder: an English cohort study. BMJ Open 2020; 10:e034913. [PMID: 33323425 PMCID: PMC7745324 DOI: 10.1136/bmjopen-2019-034913] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES (1) To explore the role of ethnicity in receiving cognitive-behavioural therapy (CBT) for people with psychosis or bipolar disorder while adjusting for differences in risk profiles and symptom severity. (2) To assess whether context of treatment (inpatient vs community) impacts on the relationship between ethnicity and access to CBT. DESIGN Cohort study of case register data from one catchment area (January 2007-July 2017). SETTING A large secondary care provider serving an ethnically diverse population in London. PARTICIPANTS Data extracted for 30 497 records of people who had diagnoses of bipolar disorder (International Classification of Diseases (ICD) code F30-1) or psychosis (F20-F29 excluding F21). Exclusion criteria were: <15 years old, missing data and not self-defining as belonging to one of the larger ethnic groups. The sample (n=20 010) comprised the following ethnic groups: white British: n=10 393; Black Caribbean: n=5481; Black African: n=2817; Irish: n=570; and 'South Asian' people (consisting of Indian, Pakistani and Bangladeshi people): n=749. OUTCOME ASSESSMENTS ORs for receipt of CBT (single session or full course) as determined via multivariable logistic regression analyses. RESULTS In models adjusted for risk and severity variables, in comparison with White British people; Black African people were less likely to receive a single session of CBT (OR 0.73, 95% CI 0.66 to 0.82, p<0.001); Black Caribbean people were less likely to receive a minimum of 16-sessions of CBT (OR 0.83, 95% CI 0.71 to 0.98, p=0.03); Black African and Black Caribbean people were significantly less likely to receive CBT while inpatients (respectively, OR 0.76, 95% CI 0.65 to 0.89, p=0.001; OR 0.83, 95% CI 0.73 to 0.94, p=0.003). CONCLUSIONS This study highlights disparity in receipt of CBT from a large provider of secondary care in London for Black African and Caribbean people and that the context of therapy (inpatient vs community settings) has a relationship with disparity in access to treatment.
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Affiliation(s)
- Rohan Michael Morris
- Division of Health Research, Lancaster University, Lancaster, UK
- Lancashire Care NHS Foundation Trust, Preston, UK
- Pennine Care NHS Foundation Trust, Greater Manchester, England
| | - William Sellwood
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Dawn Edge
- Division of Psychology & Mental Health, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Craig Colling
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Jayati Das-Munshi
- Section of Epidemiology, Department of Health Service & Population Research, King's College London, Institute of Psychiatry, London, UK
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Wang T, Oliver D, Msosa Y, Colling C, Spada G, Roguski Ł, Folarin A, Stewart R, Roberts A, Dobson RJB, Fusar-Poli P. Implementation of a Real-Time Psychosis Risk Detection and Alerting System Based on Electronic Health Records using CogStack. J Vis Exp 2020:10.3791/60794. [PMID: 32478737 PMCID: PMC7272223 DOI: 10.3791/60794] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Recent studies have shown that an automated, lifespan-inclusive, transdiagnostic, and clinically based, individualized risk calculator provides a powerful system for supporting the early detection of individuals at-risk of psychosis at a large scale, by leveraging electronic health records (EHRs). This risk calculator has been externally validated twice and is undergoing feasibility testing for clinical implementation. Integration of this risk calculator in clinical routine should be facilitated by prospective feasibility studies, which are required to address pragmatic challenges, such as missing data, and the usability of this risk calculator in a real-world and routine clinical setting. Here, we present an approach for a prospective implementation of a real-time psychosis risk detection and alerting service in a real-world EHR system. This method leverages the CogStack platform, which is an open-source, lightweight, and distributed information retrieval and text extraction system. The CogStack platform incorporates a set of services that allow for full-text search of clinical data, lifespan-inclusive, real-time calculation of psychosis risk, early risk-alerting to clinicians, and the visual monitoring of patients over time. Our method includes: 1) ingestion and synchronization of data from multiple sources into the CogStack platform, 2) implementation of a risk calculator, whose algorithm was previously developed and validated, for timely computation of a patient's risk of psychosis, 3) creation of interactive visualizations and dashboards to monitor patients' health status over time, and 4) building automated alerting systems to ensure that clinicians are notified of patients at-risk, so that appropriate actions can be pursued. This is the first ever study that has developed and implemented a similar detection and alerting system in clinical routine for early detection of psychosis.
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Affiliation(s)
- Tao Wang
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London;
| | - Dominic Oliver
- Early Psychosis: Interventions and Clinical-detection (EPIC) lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London
| | - Yamiko Msosa
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London
| | - Craig Colling
- National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service (NHS) Foundation Trust
| | - Giulia Spada
- Early Psychosis: Interventions and Clinical-detection (EPIC) lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London
| | - Łukasz Roguski
- Institute of Health Informatics, University College London
| | - Amos Folarin
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London
| | - Robert Stewart
- National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service (NHS) Foundation Trust; Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London
| | - Angus Roberts
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London; National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service (NHS) Foundation Trust
| | - Richard J B Dobson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London; National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service (NHS) Foundation Trust; Institute of Health Informatics, University College London; Health Data Research UK London, University College London
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London; National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service (NHS) Foundation Trust; OASIS service, South London and Maudsley National Health Service (NHS) Foundation Trust; Department of Brain and Behavioral Sciences, University of Pavia
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Colling C, Mueller C, Perera G, Funnell N, Sauer J, Harwood D, Stewart R, Bishara D. 'Real time' monitoring of antipsychotic prescribing in patients with dementia: a study using the Clinical Record Interactive Search (CRIS) platform to enhance safer prescribing. BMJ Open Qual 2020; 9:e000778. [PMID: 32229485 PMCID: PMC7170541 DOI: 10.1136/bmjoq-2019-000778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 02/25/2020] [Accepted: 03/10/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The use of antipsychotic drugs in dementia has been reported to be associated with increased risk of cerebrovascular events and mortality. There is an international drive to reduce the use of these agents in patients with dementia and to improve the safety of prescribing and monitoring in this area. OBJECTIVES The aim of this project was to use enhanced automated regular feedback of information from electronic health records to improve the quality of antipsychotic prescribing and monitoring in people with dementia. METHODS The South London and Maudsley NHS Foundation Trust (SLaM) incorporated antipsychotic monitoring forms into its electronic health records. The SLaM Clinical Record Interactive Search (CRIS) platform provides researcher access to de-identified health records, and natural language processing is used in CRIS to derive structured data from unstructured free text, including recorded diagnoses and medication. Algorithms were thus developed to ascertain patients with dementia receiving antipsychotic treatment and to determine whether monitoring forms had been completed. We used two improvement plan-do-study-act cycles to improve the accuracy of the algorithm for automated evaluation and provided monthly feedback on team performance. RESULTS A steady increase in antipsychotic monitoring form completion was observed across the study period. The percentage of our sample with a completed antipsychotic monitoring form more than doubled from October 2017 (22%) to January 2019 (58%). CONCLUSION 'Real time' monitoring and regular feedback to teams offer a time-effective approach, complementary to standard audit methods, to enhance the safer prescribing of high risk drugs.
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Affiliation(s)
- Craig Colling
- Biomedical Research Centre (BRC), Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Christoph Mueller
- Biomedical Research Centre (BRC), Institute of Psychiatry, Psychology and Neuroscience, London, UK
- Mental Health of Older Adults and Dementia Clinical Academic Group (SLaM), South London and Maudsley NHS Foundation Trust, London, UK
| | - Gayan Perera
- Biomedical Research Centre (BRC), Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Nicola Funnell
- Mental Health of Older Adults and Dementia Clinical Academic Group (SLaM), South London and Maudsley NHS Foundation Trust, London, UK
| | - Justin Sauer
- Biomedical Research Centre (BRC), Institute of Psychiatry, Psychology and Neuroscience, London, UK
- Mental Health of Older Adults and Dementia Clinical Academic Group (SLaM), South London and Maudsley NHS Foundation Trust, London, UK
| | - Daniel Harwood
- Mental Health of Older Adults and Dementia Clinical Academic Group (SLaM), South London and Maudsley NHS Foundation Trust, London, UK
| | - Robert Stewart
- Biomedical Research Centre (BRC), Institute of Psychiatry, Psychology and Neuroscience, London, UK
- Mental Health of Older Adults and Dementia Clinical Academic Group (SLaM), South London and Maudsley NHS Foundation Trust, London, UK
| | - Delia Bishara
- Biomedical Research Centre (BRC), Institute of Psychiatry, Psychology and Neuroscience, London, UK
- Mental Health of Older Adults and Dementia Clinical Academic Group (SLaM), South London and Maudsley NHS Foundation Trust, London, UK
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Colling C, Khondoker M, Patel R, Fok M, Harland R, Broadbent M, McCrone P, Stewart R. Predicting high-cost care in a mental health setting. BJPsych Open 2020; 6:e10. [PMID: 31950891 PMCID: PMC7001466 DOI: 10.1192/bjo.2019.96] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 11/01/2019] [Accepted: 12/04/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The density of information in digital health records offers new potential opportunities for automated prediction of cost-relevant outcomes. AIMS We investigated the extent to which routinely recorded data held in the electronic health record (EHR) predict priority service outcomes and whether natural language processing tools enhance the predictions. We evaluated three high priority outcomes: in-patient duration, readmission following in-patient care and high service cost after first presentation. METHOD We used data obtained from a clinical database derived from the EHR of a large mental healthcare provider within the UK. We combined structured data with text-derived data relating to diagnosis statements, medication and psychiatric symptomatology. Predictors of the three different clinical outcomes were modelled using logistic regression with performance evaluated against a validation set to derive areas under receiver operating characteristic curves. RESULTS In validation samples, the full models (using all available data) achieved areas under receiver operating characteristic curves between 0.59 and 0.85 (in-patient duration 0.63, readmission 0.59, high service use 0.85). Adding natural language processing-derived data to the models increased the variance explained across all clinical scenarios (observed increase in r2 = 12-46%). CONCLUSIONS EHR data offer the potential to improve routine clinical predictions by utilising previously inaccessible data. Of our scenarios, prediction of high service use after initial presentation achieved the highest performance.
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Affiliation(s)
- Craig Colling
- Applied Clinical Informatics Lead, SLaM Biomedical Research Center, South London & Maudsley Foundation NHS Trust, UK
| | - Mizanur Khondoker
- Senior Lecturer in Medical Statistics, University of East Anglia, Norwich Medical School, UK
| | - Rashmi Patel
- MRC UKRI Health Data Research UK Fellow, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, Kings College London; and South London & Maudsley Foundation NHS Trust, UK
| | - Marcella Fok
- Visiting Researcher, Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, Kings College London; and Central and North West London NHS Foundation Trust, UK
| | - Robert Harland
- Clinical Director of Psychosis, Psychosis CAG, South London & Maudsley Foundation NHS Trust, UK
| | - Matthew Broadbent
- Informatics Lead, SLaM Biomedical Research Center, South London & Maudsley Foundation NHS Trust, UK
| | - Paul McCrone
- Professor of Health Economics, School of Health Science, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, UK
| | - Robert Stewart
- Professor of Psychiatric Epidemiology and Clinical Informatics, Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, Kings College London; and South London & Maudsley Foundation NHS Trust, UK
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10
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Oram S, Colling C, Pritchard M, Khondoker M, Fonseca de Freitas D, Ter-Minassian L, Downs J, Lloyd-Evans B, Markham S, Werbeloff N, Chang CK, Johnson S, Hotopf M, Hayes RD. Patterns of use of the Mental Health Act 1983, from 2007-2008 to 2016-2017, in two major London secondary mental healthcare providers. BJPsych Open 2019; 5:e102. [PMID: 31771677 PMCID: PMC7000989 DOI: 10.1192/bjo.2019.84] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Trends in detention under the Mental Health Act 1983 in two major London secondary mental healthcare providers were explored using patient-level data in a historical cohort study between 2007-2008 and 2016-2017. An increase in the number of detention episodes initiated per fiscal year was observed at both sites. The rise was accompanied by an increase in the number of active patients; the proportion of active patients detained per year remained relatively stable. Findings suggest that the rise in the number of detentions reflects the rise of the number of people receiving secondary mental healthcare.
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Affiliation(s)
- Sian Oram
- Senior Lecturer in Women's Mental Health, NIHR Mental Health Policy Research Unit & Section for Women's Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Craig Colling
- Information Manager, NIHR Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, UK
| | - Megan Pritchard
- CRIS Training and Development Lead, NIHR Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, UK
| | - Mizanur Khondoker
- Senior Lecturer in Medical Statistics, Norwich Medical School, University of East Anglia, UK
| | - Daniela Fonseca de Freitas
- Postdoctoral Researcher, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Lucile Ter-Minassian
- Research Worker, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Johnny Downs
- Clinical Lecturer, Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Brynmor Lloyd-Evans
- Senior Lecturer, NIHR Mental Health Policy Research Unit, Division of Psychiatry, UCL, UK
| | - Sarah Markham
- Visiting Researcher, Department of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Nomi Werbeloff
- Senior Research Associate, Division of Psychiatry, UCL; and Camden and Islington NHS Foundation Trust, UK
| | - Chin-Kuo Chang
- Associate Professor, Department of Health and Welfare, University of Taipei, Taiwan
| | - Sonia Johnson
- Professor of Social and Community Psychiatry, NIHR Mental Health Policy Research Unit, Division of Psychiatry, UCL; and Camden and Islington NHS Foundation Trust, UK
| | - Matthew Hotopf
- Professor of General Hospital Psychiatry, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Richard D Hayes
- Senior Lecturer, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
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11
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Colling C, Holthoff-Detto V, Falkai P, Musil R. NADA-Auriculoacupuncture as a Symptomatic Treatment for Agitation in People with Dementia: A Randomized, Controlled, Rater-Blind Pilot Study. J Acupunct Meridian Stud 2018. [DOI: 10.1016/j.jams.2018.08.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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12
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Colling C, Evans L, Broadbent M, Chandran D, Craig TJ, Kolliakou A, Stewart R, Garety PA. Identification of the delivery of cognitive behavioural therapy for psychosis (CBTp) using a cross-sectional sample from electronic health records and open-text information in a large UK-based mental health case register. BMJ Open 2017; 7:e015297. [PMID: 28716789 PMCID: PMC5734297 DOI: 10.1136/bmjopen-2016-015297] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Our primary objective was to identify cognitive behavioural therapy (CBT) delivery for people with psychosis (CBTp) using an automated method in a large electronic health record database. We also examined what proportion of service users with a diagnosis of psychosis were recorded as having received CBTp within their episode of care during defined time periods provided by early intervention or promoting recovery community services for people with psychosis, compared with published audits and whether demographic characteristics differentially predicted the receipt of CBTp. METHODS Both free text using natural language processing (NLP) techniques and structured methods of identifying CBTp were combined and evaluated for positive predictive value (PPV) and sensitivity. Using inclusion criteria from two published audits, we identified anonymised cross-sectional samples of 2579 and 2308 service users respectively with a case note diagnosis of schizophrenia or psychosis for further analysis. RESULTS The method achieved PPV of 95% and sensitivity of 96%. Using the National Audit of Schizophrenia 2 criteria, 34.6% service users were identified as ever having received at least one session and 26.4% at least two sessions of CBTp; these are higher percentages than previously reported by manual audit of a sample from the same trust that returned 20.0%. In the fully adjusted analysis, CBTp receipt was significantly (p<0.05) more likely in younger patients, in white and other when compared with black ethnic groups and patients with a diagnosis of other schizophrenia spectrum and schizoaffective disorder when compared with schizophrenia. CONCLUSIONS The methods presented here provided a potential method for evaluating delivery of CBTp on a large scale, providing more scope for routine monitoring, cross-site comparisons and the promotion of equitable access.
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Affiliation(s)
- Craig Colling
- Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
- South London & Maudsley Foundation NHS Trust, London, UK
| | - Lauren Evans
- Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
- South London & Maudsley Foundation NHS Trust, London, UK
| | - Matthew Broadbent
- Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
- South London & Maudsley Foundation NHS Trust, London, UK
| | - David Chandran
- Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Thomas J Craig
- Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Anna Kolliakou
- Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
- South London & Maudsley Foundation NHS Trust, London, UK
| | - Philippa A Garety
- Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
- South London & Maudsley Foundation NHS Trust, London, UK
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13
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Eisenhardt A, Schneider T, Scheithe K, Colling C, Heidenreich A. [Quality of life of patients with prostate cancer under androgen deprivation with GnRH analogues: Results of the noninterventional study TRIPTOSIX]. Urologe A 2016; 55:176-83. [PMID: 26518305 DOI: 10.1007/s00120-015-3989-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND In Germany, data on the quality of life (QoL) of patients with advanced prostate cancer (PCa) under therapy with gonadotropin-releasing hormone (GnRH) analogues are limited. OBJECTIVES Androgen deprivation (ADT) is a palliative therapy for patients with advanced PCa, which is given over long periods and usually continued in combination with other therapies even after progression of the disease. The present study aimed to assess prospectively (over 1 year) different aspects of patients' QoL therapy with triptorelin in daily practice. PATIENTS AND METHODS This prospective, noninterventional study at 129 centers in Germany included 608 patients with advanced PCa treated with triptorelin. Quality of life was assessed at baseline and after 6 and 12 months, using validated EORTC QLQ-C30 and QLQ-PR25 questionnaires. Predefined subgroup analyses were performed to assess the impact of demographics, anamnestic and clinical parameters on QoL. RESULTS AND DISCUSSION The majority of patients with PCa under therapy with triptorelin showed generally stable global QoL over 1 year; approximately one-quarters of the patients had a clinically relevant improvement of their global QoL. In patients without previous PCa therapy and GnRH analogue treatment, significant improvements in global QoL were seen. At the same time, these patients also reported increased treatment-related symptoms. These data indicate that the perception of global QoL is not only influenced by subjective impairment through ADT-related side effects.
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Affiliation(s)
- A Eisenhardt
- Praxisklinik Urologie Rhein Ruhr, Schulstraße 11, 45468, Mülheim an der Ruhr, Deutschland.
| | - T Schneider
- Praxisklinik Urologie Rhein Ruhr, Schulstraße 11, 45468, Mülheim an der Ruhr, Deutschland
| | - K Scheithe
- GKM Gesellschaft für Therapieforschung, München, Deutschland
| | - C Colling
- Ipsen Pharma GmbH, Ettlingen, Deutschland
| | - A Heidenreich
- Klinik für Urologie, Universitätsklinikum Aachen, Aachen, Deutschland
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14
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Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, Handforth A, Faught E, Calabrese VP, Uthman BM, Ramsay RE, Mamdani MB. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. N Engl J Med 1998; 339:792-8. [PMID: 9738086 DOI: 10.1056/nejm199809173391202] [Citation(s) in RCA: 805] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND METHODS Although generalized convulsive status epilepticus is a life-threatening emergency, the best initial drug treatment is uncertain. We conducted a five-year randomized, double-blind, multicenter trial of four intravenous regimens: diazepam (0.15 mg per kilogram of body weight) followed by phenytoin (18 mg per kilogram), lorazepam (0.1 mg per kilogram), phenobarbital (15 mg per kilogram), and phenytoin (18 mg per kilogram). Patients were classified as having either overt generalized status epilepticus (defined as easily visible generalized convulsions) or subtle status epilepticus (indicated by coma and ictal discharges on the electroencephalogram, with or without subtle convulsive movements such as rhythmic muscle twitches or tonic eye deviation). Treatment was considered successful when all motor and electroencephalographic seizure activity ceased within 20 minutes after the beginning of the drug infusion and there was no return of seizure activity during the next 40 minutes. Analyses were performed with data on only the 518 patients with verified generalized convulsive status epilepticus as well as with data on all 570 patients who were enrolled. RESULTS Three hundred eighty-four patients had a verified diagnosis of overt generalized convulsive status epilepticus. In this group, lorazepam was successful in 64.9 percent of those assigned to receive it, phenobarbital in 58.2 percent, diazepam plus phenytoin in 55.8 percent, and phenytoin in 43.6 percent (P=0.02 for the overall comparison among the four groups). Lorazepam was significantly superior to phenytoin in a pairwise comparison (P=0.002). Among the 134 patients with a verified diagnosis of subtle generalized convulsive status epilepticus, no significant differences among the treatments were detected (range of success rates, 7.7 to 24.2 percent). In an intention-to-treat analysis, the differences among treatment groups were not significant, either among the patients with overt status epilepticus (P=0.12) or among those with subtle status epilepticus (P=0.91). There were no differences among the treatments with respect to recurrence during the 12-hour study period, the incidence of adverse reactions, or the outcome at 30 days. CONCLUSIONS As initial intravenous treatment for overt generalized convulsive status epilepticus, lorazepam is more effective than phenytoin. Although lorazepam is no more efficacious than phenobarbital or diazepam plus phenytoin, it is easier to use.
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Affiliation(s)
- D M Treiman
- Neurology Services of the Veterans Affairs Medical Center in West Los Angeles, Calif, USA
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15
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Jabs T, Tschope M, Colling C, Hahlbrock K, Scheel D. Elicitor-stimulated ion fluxes and O2- from the oxidative burst are essential components in triggering defense gene activation and phytoalexin synthesis in parsley. Proc Natl Acad Sci U S A 1997; 94:4800-5. [PMID: 9114072 PMCID: PMC20805 DOI: 10.1073/pnas.94.9.4800] [Citation(s) in RCA: 340] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Fungal elicitor stimulates a multicomponent defense response in cultured parsley cells (Petroselinum crispum). Early elements of this receptor-mediated response are ion fluxes across the plasma membrane and the production of reactive oxygen species (ROS), sequentially followed by defense gene activation and phytoalexin accumulation. Omission of Ca2+ from the culture medium or inhibition of elicitor-stimulated ion fluxes by ion channel blockers prevented the latter three reactions, all of which were triggered in the absence of elicitor by amphotericin B-induced ion fluxes. Inhibition of elicitor-stimulated ROS production using diphenylene iodonium blocked defense gene activation and phytoalexin accumulation. O2- but not H2O2 stimulated phytoalexin accumulation, without inducing proton fluxes. These results demonstrate a causal relationship between early and late reactions of parsley cells to the elicitor and indicate a sequence of signaling events from receptor-mediated activation of ion channels via ROS production and defense gene activation to phytoalexin synthesis. Within this sequence, O2- rather than H2O2 appears to trigger the subsequent reactions.
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Affiliation(s)
- T Jabs
- Max-Planck-Institut fur Zuchtungsforschung, Abteilung Biochemie, Carl-von-Linne-Weg 10, D-50829 Cologne, Germany
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16
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Singh SN, Fletcher RD, Fisher SG, Singh BN, Lewis HD, Deedwania PC, Massie BM, Colling C, Lazzeri D. Amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia. Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure. N Engl J Med 1995; 333:77-82. [PMID: 7539890 DOI: 10.1056/nejm199507133330201] [Citation(s) in RCA: 916] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Asymptomatic ventricular arrhythmias in patients with congestive heart failure are associated with increased rates of overall mortality and sudden death. Amiodarone is now used widely to prevent ventricular tachycardia and fibrillation. We conducted a trial to determine whether amiodarone can reduce overall mortality in patients with congestive heart failure and asymptomatic ventricular arrhythmias. METHODS We used a double-blind, placebo-controlled protocol in which 674 patients with symptoms of congestive heart failure, cardiac enlargement, 10 or more premature ventricular contractions per hour, and a left ventricular ejection fraction of 40 percent or less were randomly assigned to receive amiodarone (336 patients) or placebo (338 patients). The primary end point was overall mortality, and the median follow-up was 45 months (range, 0 to 54). RESULTS There was no significant difference in overall mortality between the two treatment groups (P = 0.6). The two-year actuarial survival rate was 69.4 percent (95 percent confidence interval, 64.2 to 74.6) for the patients in the amiodarone group and 70.8 percent (95 percent confidence interval, 65.7 to 75.9) for those in the placebo group. At two years, the rate of sudden death was 15 percent in the amiodarone group and 19 percent in the placebo group (P = 0.43). There was a trend toward a reduction in overall mortality among the patients with nonischemic cardiomyopathy who received amiodarone (P = 0.07). Amiodarone was significantly more effective in suppressing ventricular arrhythmias and increased the left ventricular ejection fraction by 42 percent at two years. CONCLUSIONS Although amiodarone was effective in suppressing ventricular arrhythmias and improving ventricular function, it did not reduce the incidence of sudden death or prolong survival among patients with heart failure, except for a trend toward reduced mortality among those with nonischemic cardiomyopathy.
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Affiliation(s)
- S N Singh
- Department of Cardiology, Veterans Affairs Medical Center, Washington, D.C. 20422, USA
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17
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Singh SN, Fletcher RD, Fisher S, Lazzeri D, Deedwania P, Lewis D, Massie B, Singh BN, Colling C. Veterans Affairs congestive heart failure antiarrhythmic trial. CHF STAT Investigators. Am J Cardiol 1993; 72:99F-102F. [PMID: 8237838 DOI: 10.1016/0002-9149(93)90971-e] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This is a prospective, double-blind, placebo-controlled trial to determine the effect of antiarrhythmic drug therapy on mortality in patients with congestive heart failure and ventricular arrhythmia. Patients will be assigned to receive either amiodarone or placebo. Eligible patients include those with ischemic and nonischemic congestive heart failure and with > or = 10 ventricular premature beats per hour. All patients must have shortness of breath with minimal exertion or paroxysmal nocturnal dyspnea, a left ventricular internal dimension (LVIDd) by echocardiogram of > or = 55 mm or a cardiothoracic ratio of > 0.5 and an ejection fraction of < or = 40%. All patients will receive vasodilator therapy, unless they find it intolerable. Patients will be entered into the study for 2.5 years and followed for an additional 2 years. Drug therapy will be continued for all patients throughout the entire study unless adverse reactions occur that necessitate individualized treatment. The expectation is that 674 patients will be entered into the study from 25 participating centers. This sample size will allow for the detection of a 33% decrease in 2-year mortality (20% vs 30%) in the treated patients compared with those in the placebo group, with a power of 0.90 and a 2-sided alpha level of 0.05. Intermittent Holter monitoring, radionuclide ventriculograms, pulmonary function tests, echocardiograms, and blood tests, including arterial blood gases, will be required for each patient.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S N Singh
- Cardiovascular Research, Veterans Affairs Medical Center, Washington, DC 20422
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18
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Nass N, Colling C, Cramer M, Genieser HG, Butt E, Winkler E, Jaenicke L, Jastorff B. Mapping of the epitope/paratope interactions of a monoclonal antibody directed against adenosine 3',5'-monophosphate. Biochem J 1992; 285 ( Pt 1):129-36. [PMID: 1379038 PMCID: PMC1132755 DOI: 10.1042/bj2850129] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A series of systematically modified cyclic AMP (cAMP) analogues, including newly synthesized benzimidazole ribofuranosyl 3',5'-monophosphates was used to map the essential molecular interactions between cAMP and the monoclonal antibody 4/2C2 (mab 4/2C2) directed against 2'-O-succinoyl cAMP [Colling, Gilles, Nass, Moka & Jaenicke (1988) Second Messengers Phosphoproteins 12, 123-133]. Its paratope binds the purine base in syn conformation by dipole-dipole interactions and hydrophobic forces and/or stacking interactions. The ribose phosphate moiety is recognized by a combination of charge interactions and H-bonds to the exocyclic and the 5'-oxygen atoms and a hydrophobic interaction at the 2'-position. There is no regioselectivity for the exocyclic oxygen atoms. Compared with the known types of binding, mab 4/2C2 thus shows a new combination of molecular interactions which may be the basis of its strikingly specific recognition and binding of the cyclic adenylates. On this account mab 4/2C2 may become an important tool in studies on cAMP metabolism.
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Affiliation(s)
- N Nass
- Institute of Biochemistry, University of Cologne, Köln, Federal Republic of Germany
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19
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Mayberg MR, Wilson SE, Yatsu F, Weiss DG, Messina L, Hershey LA, Colling C, Eskridge J, Deykin D, Winn HR. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. Veterans Affairs Cooperative Studies Program 309 Trialist Group. JAMA 1991. [PMID: 1960828 DOI: 10.1001/jama.1991.03470230047029] [Citation(s) in RCA: 490] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine whether carotid endarterectomy provides protection against subsequent cerebral ischemia in men with ischemic symptoms in the distribution of significant (greater than 50%) ipsilateral internal carotid artery stenosis. DESIGN Prospective, randomized, multicenter trial. SETTING Sixteen university-affiliated Veterans Affairs medical centers. PATIENTS Men who presented within 120 days of onset of symptoms that were consistent with transient ischemic attacks, transient monocular blindness, or recent small completed strokes between July 1988 and February 1991. Among 5000 patients screened, 189 individuals were randomized with angiographic internal carotid artery stenosis greater than 50% ipsilateral to the presenting symptoms. Forty-eight eligible patients who refused entry were followed up outside of the trial. OUTCOME MEASURES Cerebral infarction or crescendo transient ischemic attacks in the vascular distribution of the original symptoms or death within 30 days of randomization. INTERVENTION Carotid endarterectomy plus the best medical care (n = 91) vs the best medical care alone (n = 98). RESULTS At a mean follow-up of 11.9 months, there was a significant reduction in stroke or crescendo transient ischemic attacks in patients who received carotid endarterectomy (7.7%) compared with nonsurgical patients (19.4%), or an absolute risk reduction of 11.7% (P = .011). The benefit of surgery was more profound in patients with internal carotid artery stenosis greater than 70% (absolute risk reduction, 17.7%; P = .004). The benefit of surgery was apparent within 2 months after randomization, and only one stroke was noted in the surgical group beyond the 30-day perioperative period. CONCLUSIONS For a selected cohort of men with symptoms of cerebral or retinal ischemia in the distribution of a high-grade internal carotid artery stenosis, carotid endarterectomy can effectively reduce the risk of subsequent ipsilateral cerebral ischemia. The risk of cerebral ischemia in this subgroup of patients is considerably higher than previously estimated.
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Affiliation(s)
- M R Mayberg
- Department of Neurological Surgery, University of Washington, Seattle 98195
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