Atrial fibrillation and anticoagulation in a stroke unit population

BACKGROUND

Atrial fibrillation (AF) is an important predisposing factor for ischaemic stroke. There is evidence to suggest that even in appropriate candidates warfarin therapy is underutilized. We assessed the prevalence of AF in an Australian stroke unit to determine the degree of undertreatment at presentation.

METHODS

A retrospective analysis of all patients admitted to our Stroke Unit between October 2004 and September 2006 was carried out. All patients with a diagnosis of AF, either new or old, were then selected from this group to determine the overall prevalence and anticoagulation status. Data regarding prior stroke, stroke severity and discharge anticoagulation status were also determined.

RESULTS

Data from a total of 500 patients were analysed. Our results showed that AF-related strokes accounted for a large proportion (28%) of all admissions and were associated with a larger neurological deficit. Most patients (68%) with a prior diagnosis of AF without having obvious contraindications were either not anticoagulated or under-anticoagulated when presenting with an ischaemic stroke or transient ischaemic attack.

CONCLUSION

Our results stress the importance of initiating and maintaining anticoagulation in patients with AF and without obvious contraindications to minimize the risk of subsequent stroke.

Haemophilus influenzae oral whole cell vaccination for preventing acute exacerbations of chronic bronchitis

BACKGROUND

Acute bronchitis leading to ongoing exacerbations is a serious condition predisposed to by viruses, bacteria or environmental factors. It can be fatal. Antibiotic therapy is not particularly useful. An oral Haemophilus influenzae vaccine has been developed.

OBJECTIVES

To assess the effects of an oral, monobacterial whole-cell, killed, nontypeable H. influenzae vaccine in protecting against recurrent acute episodes in chronic bronchitis.

SEARCH STRATEGY

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to January Week 4 2006), EMBASE (1990 to September 2005) and ISI Current Contents (2004 to May 2006).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effects of the H. influenzae vaccine on patients with recurrent acute exacerbations of chronic bronchitis were included when there was overt matching of the vaccine and placebo groups on clinical grounds.

DATA COLLECTION AND ANALYSIS

Three authors extracted data and assessed trial quality independently from original records and publications for incidence and severity of bronchitis episodes and carriage rate of nontypeable H. influenzae measured in the upper respiratory tract every three months following vaccination.

MAIN RESULTS

Six trials were included in the study with a total of 440 participants. The vaccine reduced the incidence of bronchitic episodes at three months after vaccination (rate ratio is 0.69; 95% CI 0.41 to 1.14) and at six months after vaccination (rate ratio 0.82; 95% CI 0.62 to 1.09). If these results been statistically significant, they would have represented a reduction in acute bronchitic attacks for vaccinated individuals of 31% at three months, and 18% at six. The effect had disappeared by nine months. The severity of exacerbations in the treatment group, as measured by requirement to prescribe antibiotics, was likewise reduced by 58% at three months (Peto odds ratio = 0.42; 95% CI 0.16 to 1.13), and by 65% at six months (Peto odds ratio = 0.35; 95% CI 0.16 to 0.75).

AUTHORS' CONCLUSIONS

Vaccinating patients with recurrent acute exacerbations of chronic bronchitis in the autumn may reduce the number and severity of exacerbations over the following winter. A large clinical trial is needed.

Age group differences in psychological distress: the role of psychosocial risk factors that vary with age

BACKGROUND

There is continuing controversy about how age affects depression and anxiety, with a lack of consistent results across studies. Two reasons for this inconsistency are age bias in measures and different patterns of exposure to risk factors across age groups in various studies.

METHOD

Data on anxiety and depression symptoms were collected in a community survey of 7485 persons aged 20-24, 40-44 or 60-64 years. These measures were investigated for factorial invariance across age groups. Data were also collected on a wide range of potential risk factors, including social, physical health and personal factors, with the aim of determining whether these factors might partly or wholly account for age group differences.

RESULTS

The invariance of correlated latent factors representing anxiety and depression was examined across age groups, and a generalized measure of psychological distress was computed. Depression, anxiety and psychological distress showed a decline across age groups for females and a decline from 40-44 to 60-64 years for males. Some of these age differences were accounted for by other risk factors, with the most important being recent crises at work and negative social relationships with family and friends.

CONCLUSION

Psychological distress generally declined across the age range 20-64 years and this was not attributable to measurement bias. Differential exposure to risk factors explained some, but not all, of the age group difference. Therefore other mechanisms that explain the lower level of distress in older age groups remain to be identified.

General practice encounters for psychological problems in rural, remote and metropolitan areas in Australia

OBJECTIVE

Previous Australian research suggests there is very little difference in the prevalence of mental health disorders across rural, remote and metropolitan areas. However, mental health specialists are particularly scarce in rural and remote areas and some researchers have argued that non-metropolitan residents rely heavily on general practitioners (GPs) for mental health care. This article investigated rates of GP services for psychological problems across rural, remote and metropolitan areas.

METHOD

The Bettering the Evaluation and Care of Health (BEACH) program, Medicare and Pharmaceutical Benefits Scheme data were used in this report. Data included all psychological, depression and anxiety problems reported as managed by GPs and prescriptions for mental health medications (written and filled). Problem and medication rates are given per 100 patient encounters and per 1000 population.

RESULTS

Only a few regional differences were evident in the rate of psychological problems and prescriptions for mental health medications per 100 GP-patient encounters. However, rural and remote residents visited GPs less frequently than their metropolitan counterparts. Lower rates of GP encounters for psychological problems were evident for residents of most non-metropolitan areas (per 1000 population). Additionally, GPs prescribed mental health medications at half the rate for residents of remote areas than capital cities.

CONCLUSIONS

General practitioners provide fewer mental health services per capita in non-metropolitan areas. This difference could represent completely untreated psychological problems or fewer follow-up consultations. While non-metropolitan residents have limited access to specialists, rates of GP encounters for psychological problems are also very low.

Cohort Difference in Sexual Orientation: Results from a Large Age-Stratified Population Sample

BACKGROUND

There is some community survey evidence for a cohort difference in female sexual orientation.

OBJECTIVE

To determine whether there is a cohort difference in sexual orientation in Australia.

METHODS

A community survey was carried out with a sample of 7,447 adults from the age groups 20-24, 40-44 and 60-64 years. As part of this survey respondents were asked a question on sexual orientation which was answered privately.

RESULTS

A strong age cohort difference was found for women, with younger women more frequently reporting a homosexual or bisexual orientation. By contrast, no age cohort difference was found for men.

CONCLUSION

These findings suggest that a heterosexual orientation may have become less common in younger cohorts of Australian women. This finding is consistent with data from other recent studies.

Interaction between mother's and father's affection as a risk factor for anxiety and depression symptoms--evidence for increased risk in adults who rate their father as having been more affectionate than their mother

BACKGROUND

Retrospective reports of low care from either parent are found to be associated with increased risk for anxiety and depression in adulthood. Furthermore, fathers are generally reported as having been less caring than mothers, which raises the issue of whether greater care from fathers across the whole population would benefit mental health.

METHODS

A community survey was carried out in Canberra, Australia, with 2404 adults aged 20-24 and 2530 aged 40-44. Respondents retrospectively reported on affection shown by their parents and on other aspects of family functioning. These data were analysed in relation to risk for anxiety and depressive symptoms and neuroticism.

RESULTS

Retrospective reporting of greater affection from both fathers and mothers was generally associated with fewer anxiety and depression symptoms and lower neuroticism. However, there was a significant interaction effect, such that mental health was worse in families where the father was reported to show a higher level of affection but the mother a lower level. Such families were found to have a range of problems, including higher rates of emotional problems in the parents, conflict in the home, parental separation or divorce, and parental mistreatment. These family problems accounted for much of the interaction effect observed.

CONCLUSIONS

Greater affection from the father is not always associated with lower risk for anxiety and depression. Where the father is more affectionate than the mother there tends to be increased family problems and increased risk. It is possible that family problems lead fathers to show increased affection to their children or mothers to show reduced affection.

Haemophilus influenzae oral whole cell vaccination for preventing acute exacerbations of chronic bronchitis

BACKGROUND

Acute bronchitis leading to ongoing exacerbations is a serious condition predisposed to by viruses or bacteria. It can be fatal. Antibiotic therapy has not been particularly useful in clearing bacteria such as nontypeable Haemophilus influenzae (NTHi) because they colonise the upper respiratory tract. An oral NTHi vaccine has been developed to protect against recurrent acute episodes in chronic bronchitis.

OBJECTIVES

To assess the effects of an oral whole cell nontypeable Haemophilus influenzae (NTHi) vaccine in protecting against recurrent acute episodes in chronic bronchitis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003); MEDLINE (1966 to 2003); EMBASE (1990 - 2003); Extramed (1994 to 2003); ISI Current Contents (1993 to 2003); Carl Uncover (1988 to 2003) and contacted investigators of the studies.

SELECTION CRITERIA

Randomised trials comparing the effects of an oral monobacterial NTHi vaccine on patients with recurrent acute exacerbations of chronic bronchitis were included when there was overt matching of the vaccine and placebo groups on clinical grounds.

DATA COLLECTION AND ANALYSIS

Three reviewers extracted data and assessed trial quality independently from original records and publications for incidence and severity of bronchitis episodes and carriage rate of nontypeable Haemophilus influenzae measured in the upper respiratory tract every three months following vaccination.

MAIN RESULTS

Six trials were included in the study with a total of 440 participants. Oral vaccination using a monobacterial whole cell killed nontypeable Haemophilus influenzae significantly reduced the incidence of bronchitic episodes at three months after vaccination (Poisson rate ratio 0.666; 95% confidence interval [CI] 0.500, 0.887; p = 0.005) and perhaps at six months after vaccination (Poisson rate ratio 0.831; 95% CI 0.669, 1.031; p = 0.093). The effect had disappeared by nine months. The severity of exacerbations in the treatment group, as measured by requirement to prescribe antibiotics, was likewise reduced by 58% at three months (Peto odds ratio = 0.42; 95% CI 0.16, 1.13), and by 65% at six months (Peto odds ratio = 0.35; 95% CI 0.16, 0.75).

REVIEWER'S CONCLUSIONS

Vaccination, in the autumn, of patients with recurrent acute exacerbations of chronic bronchitis reduced the number and severity of exacerbations over the winter months. A large clinical trial to assess longer term prognosis is needed.