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Truedson P, Ott M, Wikström H, Maripuu M, Lindmark K, Werneke U. Monoaminoxidase inhibitors as a cause of serotonin syndrome – a systematic case review based on meta-analytic principles. Eur Psychiatry 2021. [PMCID: PMC9470874 DOI: 10.1192/j.eurpsy.2021.968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Serotonin syndrome (SS) is a toxic state characterized by increased serotonin activity. It has been suggested that severe serotonin syndrome usually involves monoaminoxidase inhibitors (MAOIs). Objectives To quantify in how far severe SS is associated with MAOIs. Methods Systematic review and quantitative analysis of all SS cases published between 1 January 2004 and 31 December 2014. Severe SS was defined as cases, either requiring intensive care or resulting in death. Cases were included if they met the diagnostic criteria for SS according to at least one of the three diagnostic criteria systems (Hunter, Radomski and Sternbach). Results Of the 299 included cases, 118 (39%) met the definition for severe SS. Eight cases had insufficient information to enable severity classification. Of the severe cases, 48 (40%) involved a MAOI. Of these, 67% related to psychiatric MAOIs, such as phenelzine and moclobemide and 33% to a somatic MAOI, such as methylene blue and linezolid. Of the remaining 173 non-severe SS cases, 24 cases (13%) involved a MAOI. In these, 12% related to a psychiatric MAOI and 83% to a somatic MAOI. One case (4%) had a combination of both. The odds ratio for MAOI involvement in severe versus non-severe serotonin syndrome was 4.3 (CI 2.4 – 7.5; p < 0.001). Conclusions In the majority of published case reports, drugs other than MAOIs are involved in serotonin syndrome, even in severe cases. MAOIs are, however, more common in severe serotonin syndrome than in non-severe cases. Conflict of interest M. Ott: scientific advisory board member of Astra Zeneca, Sweden. U. Werneke: received funding for educational activities on behalf of Norrbotten Region; Astra Zeneca, Eli Lilly, Janssen, Novartis, Otsuka/Lundbeck, Servier, Shire, Sunovion. Others: None
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Lieber I, Ott M, Öhlund L, Lundqvist R, Eliasson M, Sandlund M, Werneke U. Lithium-associated hypothyroidism: Reversible after lithium discontinuation? Eur Psychiatry 2021. [PMCID: PMC9470828 DOI: 10.1192/j.eurpsy.2021.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The association between lithium and thyroid dysfunction has long been known. Yet it is not known whether lithium-associated hypothyroidism is reversible, once lithium treatment has been stopped. Objectives To determine whether lithium-associated hypothyroidism was reversible in patients who subsequently discontinued lithium. Methods Retrospective cohort study in the Swedish region of Norrbotten into the effects and side- effects of lithium treatment and other drugs for relapse prevention (LiSIE). For this particular study, we reviewed medical records between 1997 and 2015 of patients treated with lithium. Results Of 1340 patients screened, we identified 90 patients with lithium-associated hypothyroidism who subsequently discontinued lithium. Of these, 27% had overt hypothyroidism at the time when thyroid replacement therapy was initiated. The mean delay from lithium start to thyroid replacement therapy start was 2.3 (SD 4.7) years. Fifty percent received thyroid replacement therapy within 10 months of starting lithium. Of 85 patients available for follow up, 35 (41%) stopped thyroid replacement therapy after lithium discontinuation. Six patients reinstated thyroid replacement therapy subsequently. Only one of these had overt hypothyroidism, occurring 13 days after stopping lithium and 11 days after stopping thyroid replacement therapy. Conclusions Lithium-associated hypothyroidism seems reversible in most patients, once lithium has been discontinued. In such cases, thyroid replacement therapy discontinuation could be attempted much more often than currently done. Based on the limited evidence of our study, we can expect hypothyroidism to recur early after discontinuation of thyroid replacement therapy if at all. Disclosure MO: scient adv. board member Astra Zeneca Sweden; UW: educ. activities Norrbotten Region: Astra Zeneca, Eli Lilly, Janssen, Novartis, Otsuka/Lundbeck, Servier, Shire and Sunovion. All others: none.
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Öhlund L, Ott M, Bergqvist M, Oja S, Lundqvist R, Sandlund M, Renberg ES, Werneke U. Psychiatric hospital utilisation following lithium discontinuation in patients with bipolar I or II disorder: A mirror-image study based on the lisie retrospective cohort. Eur Psychiatry 2021. [PMCID: PMC9471182 DOI: 10.1192/j.eurpsy.2021.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Evidence for lithium as a maintenance treatment for bipolar disorder type II remains limited since most treatment-prevention studies focus on bipolar disorder type I or do not distinguish between types of bipolar disorder. Objectives To compare the impact of lithium discontinuation on hospital utilisation in patients with bipolar disorder type I or schizoaffective disorder and patients with bipolar disorder type II or other bipolar disorder. Methods Mirror-image study, examining hospital utilisation within two years before and after lithium discontinuation as part of LiSIE, a retrospective cohort study into effects and side-effects of lithium for the maintenance treatment of bipolar disorder as compared to other mood stabilisers. Results For the whole sample, the number of admissions increased from 86 to 185 admissions after lithium discontinuation, with the mean number of admissions/patient/review period doubling from 0.44 to 0.95 (p < 0.001). The number of bed days increased from 2218 to 4240, with the mean number of bed days/patient/review period doubling from 11 to 22 (p = 0.025). This increase in admissions and bed days was exclusively attributable to patients with bipolar disorder type I or schizoaffective disorder. Conclusions Our findings suggest that due to a higher relapse risk in patients with bipolar disorder type I or schizoaffective disorder there is a need to apply a higher threshold for discontinuing lithium than for patients with bipolar disorder type II or other bipolar disorder. Disclosure Michael Ott has been a scientific advisory board member of Astra Zeneca Sweden, Ursula Werneke has received funding for educational activities on behalf of Norrbotten Region (Masterclass Psychiatry Programme 2014–2018 and EAPM 2016, Luleå, Sweden): Astra
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Werneke U, Maripuu M, Bendix M, Öhlund L, Widerstrom M. Death associated with coronavirus (COVID-19) infection in individuals with severe mental disorders in sweden during the early months of the outbreak. Eur Psychiatry 2021. [PMCID: PMC9470453 DOI: 10.1192/j.eurpsy.2021.339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Individuals with severe mental disorder (SMD) have a higher risk of somatic comorbidity and mortality than the rest of the population. Objectives To assess whether individuals with SMD had a higher risk of death associated with a COVID-19 infection (COVID-19 associated death) than individuals without SMD. Methods Exploratory analysis with a cross-sectional design in the framework of a population-based register study covering the entire Swedish population. The Swedish Board for Health and Welfare (Socialstyrelsen) provided anonymised tabulated summary data for further analysis. We compared numbers of COVID-19 associated death in individuals with SMD (cases) and without SMD (controls). We calculated the odds ratio (OR) for the whole sample and by age group and four potential risk factors, namely diabetes, cardiovascular disease, hypertension, chronic lung disease. Results The sample comprised of 7,923,859 individuals, 103,999 with SMD and 7,819,860 controls. There were 130 (0.1%) COVID-19 associated deaths in the SMD group and 4945 (0.06%) in the control group, corresponding to an OR of 1.98 (CI 1.66-2.35; p < 0.001). The odds were fourfold in the age group between 60 and 79 years. Cardiovascular diseases increased the odds by 50%. Individuals with SMD without any of the risk factors under study had three-folds odds of COVID-19 associated death. Conclusions Our preliminary results suggest that individuals with SMD are a further group at increased risk of COVID-19 associated death. The factors contributing to this increased mortality risk require clarification. Disclosure Ursula Werneke has received funding for educational activities on behalf of Norrbotten Region (Masterclass Psychiatry Programme 2014-2018 and EAPM 2016, Luleå, Sweden): Astra Zeneca, Eli Lilly, Janssen, Novartis, Otsuka/Lundbeck, Servier, Shire and Sunovi
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Öhlund L, Ott M, Lundqvist R, Sandlund M, Renberg ES, Werneke U. Self-injurious behaviour in patients with bipolar disorder and attention deficit hyperactivity disorder after central stimulant start– a retrospective study based on the lisie cohort. Eur Psychiatry 2021. [PMCID: PMC9471232 DOI: 10.1192/j.eurpsy.2021.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Currently, our understanding remains limited of how co-occurring bipolar disorder and attention deficit hyperactivity disorder (ADHD) should be treated. Objectives To evaluate the impact of central stimulant treatment on self-injurious behaviour in patients with a dual diagnosis of bipolar disorder or schizoaffective disorder and ADHD. Methods Retrospective cohort study (LiSIE) into effects and side-effects of lithium as compared to other mood stabilisers. Here, using a mirror-image design, we compared suicide attempts and non-suicidal self-injury events within 6 months and 2 years before and after central stimulant treatment start. Results Of 1564 eligible patients, 206 patients met inclusion criteria; having a dual diagnosis of bipolar disorder or schizoaffective disorder and ADHD at first central stimulant initiation. In these, suicide attempts and non-suicidal self-injury events decreased significantly within both 6 months (p = 0.004) and 2 years (p = 0.028) after central stimulant start. After multiple adjustments, this effect was preserved 2 years after central stimulant start (OR 0.63, 95% CI; 0.40 – 0.98, p = 0.041). Conclusions Central stimulant treatment may reduce the risk of self-injurious behavior in patients with a dual diagnosis of bipolar disorder or schizoaffective disorder and ADHD. However, to reduce the risk of manic switches, concomitant mood stabilising treatment remains warranted. Disclosure Michael Ott has been a scientific advisory board member of Astra Zeneca Sweden, Ursula Werneke has received funding for educational activities on behalf of Norrbotten Region (Masterclass Psychiatry Programme 2014–2018 and EAPM 2016, Luleå, Sweden): Astra
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Truedson P, Lindmark K, Ström M, Maripuu M, Werneke U. ECG changes associated with lithium intoxication – a study based on the lisie project. Eur Psychiatry 2021. [PMCID: PMC9470429 DOI: 10.1192/j.eurpsy.2021.333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IntroductionIt currently remains unclear in how far supratherapeutic lithium serum concentrations can affect the cardiac conduction system. Prolonged QT interval, arrhythmias and cardiac death have all been anecdotally reported, but the systematic studies are few.ObjectivesTo examine ECG changes occurring with supratherapeutic lithium concentrations that have given rise to lithium toxicity.MethodsWe examined all episodes of lithium intoxication defined as serum lithium level (≥ 1.5 mmol/L). We analyzed ECG before, during and after intoxication and recorded ECG changes. These, we then assessed according to type of intoxications, clinical and other pharmacological characteristics. The study is based on 20-year data (1997-2020) from the retrospective cohort study (LiSIE) in the Swedish region of Norrbotten.ResultsOf 1101 patients treated with lithium, 77 patients had experienced lithium intoxications. 12 patients had more than one episode of intoxication, yielding 91 episodes. 39 had ECG available both as reference and during lithium intoxication. We found no statistically significant prolongation of the QTc interval during lithium intoxication, compared to respective reference ECG (p = 0.364). Heart rate during lithium intoxication was significantly lower, mean 73 beats/min (SD 16,8, range 43 - 112), compared to the reference ECG, mean 79 beats/min (SD 15,3, range 48-112; p = 0.006). No patient died. All findings were independent of whether an intoxication was acute or chronic.ConclusionsIn our study, heart rate was significantly lower during episodes of intoxication. However, this decrease was of no clinical relevance in most cases. Lithium intoxication was not associated with prolonged QT time.DisclosureM. Ott: scientific advisory board member of Astra Zeneca, Sweden. U. Werneke: received funding for educational activities on behalf of Norrbotten Region; Astra Zeneca, Eli Lilly, Janssen, Novartis, Otsuka/Lundbeck, Servier, Shire, Sunovion. Others: None
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Abstract
OBJECTIVE To establish whether lithium or anticonvulsant should be used for maintenance treatment for bipolar affective disorder (BPAD) if the risks of suicide and relapse were traded off against the risk of end-stage renal disease (ESRD). METHOD Decision analysis based on a systematic literature review with two main decisions: (1) use of lithium or at treatment initiation and (2) the potential discontinuation of lithium in patients with chronic kidney disease (CKD) after 20 years of lithium treatment. The final endpoint was 30 years of treatment with five outcomes to consider: death from suicide, alive with stable or unstable BPAD, alive with or without ESRD. RESULTS At the start of treatment, the model identified lithium as the treatment of choice. The risks of developing CKD or ESRD were not relevant at the starting point. Twenty years into treatment, lithium still remained treatment of choice. If CKD had occurred at this point, stopping lithium would only be an option if the likelihood of progression to ESRD exceeded 41.3% or if anticonvulsants always outperformed lithium regarding relapse prevention. CONCLUSION At the current state of knowledge, lithium initiation and continuation even in the presence of long-term adverse renal effects should be recommended in most cases.
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Affiliation(s)
- U Werneke
- Division of Psychiatry, Department of Clinical Sciences, Umeå University, Sweden.
| | - M Ott
- Division of Internal Medicine, Department of Nephrology, Sunderby HospitalLuleå, Sweden
| | - E Salander Renberg
- Division of Psychiatry, Department of Clinical Sciences, Umeå UniversityUmeå, Sweden
| | - D Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, Institute of Pharmaceutical Sciences, King's CollegeLondon, UK
| | - B Stegmayr
- Institute of Public Health and Clinical Medicine, Umeå UniversityUmeå, Sweden
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Lakhanpaul M, MacFaul R, Werneke U, Armon K, Hemingway P, Stephenson T. An evidence-based guideline for children presenting with acute breathing difficulty. Emerg Med J 2009; 26:850-3. [DOI: 10.1136/emj.2008.064279] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Affiliation(s)
- U Werneke
- Department of General Adult Psychiatry, Sunderby Hospital, 97180 Luleå, Sweden.
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Ladenheim D, Horn O, Werneke U, Phillpot M, Murungi A, Theobald N, Orkin C. Potential health risks of complementary alternative medicines in HIV patients. HIV Med 2008; 9:653-9. [PMID: 18631258 DOI: 10.1111/j.1468-1293.2008.00610.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the prevalence and purpose of complementary alternative medicines (CAMs) use in people receiving treatment for HIV infection. To identify and quantify potential health risks of CAM use in this population and to explore options for improved pharmacovigilance. METHODS Cross-sectional questionnaire survey of 293 patients receiving antiretroviral (ARV) therapy at three specialist HIV out-patient clinics in central London, UK. The use of herbal medicines and supplements was explored, and potentially adverse side effects or significant drug interactions with conventional therapies were identified. RESULTS Of the 293 patients included, 61% (n=179) were taking herbal remedies or supplements and 35% (n=103) were using physical treatments. Twenty-seven per cent (n=80) used a combination of both. Twenty per cent (n=59) potentially compromised their HIV management through using CAM therapy. Ten per cent (n=29) were advised to stop their CAMs and 15% (n=43) were made aware of potential drug interactions and adverse effects and were advised to monitor their care. CONCLUSIONS There are potentially significant health risks posed by the concomitant use of CAMs in patients taking ARV therapy. Medical practitioners need to be able to identify CAM use in HIV-positive patients and recognize potential health risks. Patients should be encouraged to disclose CAM use to their clinicians and other healthcare professionals.
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Werneke U. Review: Adding Chinese herbal medicine to antipsychotics may improve some outcomes in schizophrenia, but more high quality trials are needed. Evidence-Based Mental Health 2008; 11:19. [DOI: 10.1136/ebmh.11.1.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
OBJECTIVE Many patients with depression suffer from sexual dysfunction and sexual dysfunction is a recognized side-effect of antidepressants. The aim of this review was to examine the prevalence of psychosexual dysfunction associated with antidepressants, and to review treatment options which are specific to the affected component of sexual functioning and antidepressants. METHOD Comprehensive literature review using Medline and Cochrane databases. RESULTS Up to 70% of patients with depression may have sexual dysfunction. Tricyclic antidepressants, selective-serotonin reuptake inhibitors and venlafaxine are most and the non-serotonergic antidepressants and duloxetine least likely to produce sexual dysfunction. Pharmacological treatment options include antidepressants less likely associated or 'antidotes' to reverse sexual dysfunction. CONCLUSION Sexual dysfunction may be a preventable or treatable side-effect of antidepressants. Patients need routinely to be asked about sexual function to identify problems early. If sexual dysfunction is ignored it may maintain the depression, compromise treatment outcome and lead to non-compliance.
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Affiliation(s)
- U Werneke
- Department of Psychiatry, Homerton University Hospital, London, UK. [corrected]
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Werneke U, McCready R. Complementary alternative medicine and nuclear medicine therapy and diagnosis. Nucl Med Commun 2004. [DOI: 10.1097/00006231-200404000-00068] [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: 11/25/2022]
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Abstract
Many cancer patients use complementary alternative medicines (CAMs) but may not be aware of the potential risks. There are no studies quantifying such risks, but there is some evidence of patient risk from case reports in the literature. A cross-sectional survey of patients attending the outpatient department at a specialist cancer centre was carried out to establish a pattern of herbal remedy or supplement use and to identify potential adverse side effects or drug interactions with conventional medicines. If potential risks were identified, a health warning was issued by a pharmacist. A total of 318 patients participated in the study. Of these, 164 (51.6%) took CAMs, and 133 different combinations were recorded. Of these, 10.4% only took herbal remedies, 42.1% only supplements and 47.6% a combination of both. In all, 18 (11.0%) reported supplements in higher than recommended doses. Health warnings were issued to 20 (12.2%) patients. Most warnings concerned echinacea in patients with lymphoma. Further warnings were issued for cod liver/fish oil, evening primrose oil, gingko, garlic, ginseng, kava kava and beta-carotene. In conclusion, medical practitioners need to be able to identify the potential risks of CAMs. Equally, patients should be encouraged to disclose their use. Also, more research is needed to quantify the actual health risks.
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Affiliation(s)
- U Werneke
- Homerton Hospital, East Wing, Department of Psychiatry, Homerton Row, London E9 6SR, UK.
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Armon K, MacFaul R, Hemingway P, Werneke U, Stephenson T. The impact of presenting problem based guidelines for children with medical problems in an accident and emergency department. Arch Dis Child 2004; 89:159-64. [PMID: 14736635 PMCID: PMC1719811 DOI: 10.1136/adc.2002.024406] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [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: 11/04/2022]
Abstract
AIMS To evaluate the impact of presenting problem based guidelines in managing children with either diarrhoea (with or without vomiting) or seizure (with or without fever). METHODS This prospective observational study with an intervention was based on a paediatric accident and emergency (A&E) department in Nottingham. All patients (either GP or self referred) were acute attenders aged 0-15 years, with a medical presenting problem during 4 months in the spring of 1997 and 1999. Five hundred and thirty-one diarrhoea attendances (292 before guideline implementation and 239 after) and 411 seizure attendances (212 before guideline implementation and 199 after) were recorded. Evidence based and consensus ratified guidelines developed for the study were implemented using care pathway documentation. Process (documentation, time in the department, investigations, treatment) and outcome (admission to hospital, returns to A&E) data were collected from case notes. RESULTS The percentage of children investigated with blood tests fell significantly (haematology requests in diarrhoea presentations from 11% to 4%, biochemistry in seizure presentations from 29% to 17%). Intravenous infusions in diarrhoea presenters fell (9% to 1%), and more appropriate oral fluids were used. Management time in A&E was reduced (diarrhoea presenters: median of 55-40 minutes, seizure presenters: 80-55 minutes, but remained static for other presenting problems). Marked improvements in documentation were seen. Admission rates for diarrhoea attenders increased (27% to 34%) but remained the same for seizure (69% v 73%). CONCLUSIONS The implementation of a presenting problem based guideline as a care pathway was associated with improvements in the quality of care by: improved documentation; reduced invasive investigations; more appropriate treatment, and reduced time spent in A&E.
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Affiliation(s)
- K Armon
- Norfolk and Norwich University Hospital, Norwich, UK.
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Abstract
OBJECTIVE Although psychiatrists are aware of weight gain induced by atypical antipsychotics, only few studies on behavioural interventions in this patient group are published. This review aims to summarize the evidence on effectiveness of behavioural interventions for weight gain in the general population and in-patients treated with atypical antipsychotics. METHOD Medline and Cochrane databases search for evidence on effectiveness of behavioural interventions. RESULTS In general, behavioural approaches including, diet, exercise and drug treatments may be effective. There were only 13 studies of behavioural interventions for patients taking antipsychotic medication. No study met the criteria for a RCT. Calorie restriction in a controlled ward environment, structured counselling combined with cognitive behavioural therapy and counselling on life style and provision of rewards may potentially lead to weight loss. CONCLUSION Currently only limited, methodologically flawed, evidence is available that behavioural interventions in overweight patients treated with antipsychotics, although intuitively appealing, actually work.
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Affiliation(s)
- U Werneke
- Centre for the Economics in Mental Health, Institute of Psychiatry, Maudsley Hospital, London, UK.
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Armon K, Stephenson T, MacFaul R, Hemingway P, Werneke U, Smith S. An evidence and consensus based guideline for the management of a child after a seizure. Emerg Med J 2003; 20:13-20. [PMID: 12533360 PMCID: PMC1726000 DOI: 10.1136/emj.20.1.13] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [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: 11/04/2022]
Abstract
OBJECTIVE An evidence and consensus based guideline for the management of the child who presents to hospital having had a seizure. It does not deal with the child who is still seizing. The guideline is intended for use by junior doctors, and was developed for this common problem (5% of all paediatric medical attenders) where variation in practice occurs. OPTIONS Assessment, investigations (biochemistry, lumbar puncture, serum anticonvulsant levels, EEG in particular), and/or admission are examined. OUTCOMES The guideline aims to direct junior doctors in recognising those children who are at higher risk of serious intracranial pathology including infection, and conversely to recognise those children at low risk who are safe to go home. EVIDENCE A systematic review of the literature was performed. Articles were identified using the electronic data bases Medline (from 1966 to June 1998), Embase (from 1980 to June 1998) and Cochrane (to June 1998), and selected if they investigated the specified clinical question. Personal reviews were excluded. Selected articles were appraised, graded, and synthesised qualitatively. Statements of recommendation were made. CONSENSUS An anonymous, postal Delphi consensus development was used. A national panel of 30 medical and nursing staff regularly caring for these children were asked to grade their agreement with the statements generated. They were sent the relevant original publications, the appraisals, and literature review. On the second and third rounds they were asked whether they wished to re-grade their agreement in the light of other panellists' responses. Consensus was defined as 83% of panellists agreeing with the statement. Recommendations in brief: For afebrile seizures all children should have their blood pressure recorded, but no other investigations are routine although a seizing or somnolent child should have blood glucose measured; all children under 1 year should be admitted. For seizures with fever, clinical signs indicating the need to treat as meningitis are given. Children should be admitted if they are under 18 months old, have had a complex seizure, or after pretreatment with antibiotics. VALIDATION The guideline has undergone implementation and evaluation in a paediatric accident and emergency department, the results of which will be published separately. Only one alteration was made to the guideline as a result of this validation process, which is included here.
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Affiliation(s)
- K Armon
- Academic Division of Child Health, Nottingham, UK.
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Abstract
Obesity is associated with considerable morbidity and decreased life expectancy. Weight gain is a commonly encountered problem associated with antipsychotic treatment. We reviewed the literature regarding the mechanisms of weight gain in response to these agents and eight substances implicated as potential obesity prevention or treatment: orlistat, sibutramine, fluoxetine, topiramate, amantadine, nizatidine and cimetidine, and metformin. Weight gain in response to antipsychotic treatment may be mediated through serotonergic, dopaminergic, adrenergic, cholinergic, histaminergic and glutaminergic receptors. Sex hormone dysregulation and altered insulin sensitivity have also been implicated. Two compounds, orlistat and sibutramine, have been shown to help prevent weight gain following a hypocaloric diet, but orlistat requires compliance with a fat-reduced diet, and sibutramine is unsuitable for patients taking serotonergic agents. The weight reducing effect of fluoxetine, even in conjunction with a hypocaloric diet, is only transient. Topiramate, amantadine and metformin may have adverse side-effects potentially outweighing the weight reducing potential. The effectiveness of cimetidine and nizatedine remains unclear. The hazards of these agents in a psychiatric population are discussed. It is concluded that the current evidence does not support the general use of pharmacological interventions for overweight patients treated with antipsychotic medication, although individually selected patients may benefit.
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Affiliation(s)
- U Werneke
- Pharmacy Department, Maudsley Hospital, London, UK
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Abstract
BACKGROUND Routine hospital statistics for England appear to overestimate use of children's wards and include numbers of well newborn babies staying with their mothers after delivery ("well babies"). AIM To review trends in use of children's wards excluding data on newborn babies. METHODS We reviewed routine, published, and age stratified data requested from the Department of Health to identify separately "well babies" and babies receiving neonatal specialist care from admissions (surgical and paediatric) to children's wards. RESULTS Routine reports for paediatric activity contain large numbers of "well babies", (almost half the total) as well as babies receiving specialist neonatal care. After excluding these, paediatric admissions represent 9.9% of the child population aged under 5 years each year (an additional 2.5% are admitted for surgical care). Between 1989 and 1997 paediatric admissions rose by 19% and surgical admissions fell by 25% with a plateau reached in overall child admissions. There are now fewer beds in which children stay for a shorter time and there is more day case surgery. Neonatal specialist care work has risen despite a fall in births. CONCLUSION Categories should be established for reporting paediatric episodes on children's wards separately from those on neonatal units, with better identification of "well babies". When monitoring use of children's inpatient facilities or planning new units, care must be taken to separate paediatric data on neonatal units from work on children's wards. Children's surgical episodes should also be taken into account.
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Affiliation(s)
- R MacFaul
- Paediatric Department, Pinderfields Hospital, Wakefield WF1 4DG, UK.
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Abstract
The herbal remedy St John's wort is widely used as an antidepressant but its efficacy has not been systematically investigated. Meta-analyses and systematic reviews of published trials strongly suggest St John's wort is more effective than placebo although comparative efficacy to standard antidepressants is less clearly established. We updated and expanded previous meta-analyses of St John's wort, scrutinised the validity of published reports and examined possible mechanisms of action. Twenty-two randomised controlled trials were identified. Meta-analysis showed St John's wort to be significantly more effective than placebo (relative risk (RR) 1.98 (95% CI 1.49-2.62)) but not significantly different in efficacy from active antidepressants (RR 1.0 (0.90-1.11)). A sub-analysis of six placebo-controlled trials and four active comparator trials satisfying stricter methodological criteria also suggested that St John's wort was more effective than placebo (RR 1.77 (1.16-2.70)) and of similar effectiveness to standard antidepressants (RR 1.04 (0.94-1.15)). There was no evidence of publication bias. Adverse effects occurred more frequently with standard antidepressants than with St John's wort. The mechanism of action of St John's wort remains unknown. Future research should include large scale, appropriately powered comparisons of St John's wort and standard antidepressants.
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Affiliation(s)
- E Whiskey
- Pharmacy Department, Maudsley Hospital, London, UK
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Abstract
OBJECTIVE To develop an evidence and consensus based guideline for the management of the child who presents to hospital with diarrhoea (with or without vomiting), a common problem representing 16% of all paediatric medical attenders at an accident and emergency department. Clinical assessment, investigations (biochemistry and stool culture in particular), admission, and treatment are addressed. The guideline aims to aid junior doctors in recognising children who need admission for observation and treatment and those who may safely go home. EVIDENCE A systematic review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendation were generated. CONSENSUS An anonymous, postal Delphi consensus process was used. A panel of 39 selected medical and nursing staff were asked to grade their agreement with the generated statements. They were sent the papers, appraisals, and literature review. On the second and third rounds they were asked to re-grade their agreement in the light of other panelists' responses. Consensus was predefined as 83% of panelists agreeing with the statement. RECOMMENDATIONS Clinical signs useful in assessment of level of dehydration were agreed. Admission to a paediatric facility is advised for children who show signs of dehydration. For those with mild to moderate dehydration, estimated deficit is replaced over four hours with oral rehydration solution (glucose based, 200-250 mOsm/l) given "little and often". A nasogastric tube should be used if fluid is refused and normal feeds started following rehydration. Children at high risk of dehydration should be observed to ensure at least maintenance fluid is tolerated. Management of more severe dehydration is detailed. Antidiarrhoeal medication is not indicated. VALIDATION The guideline has been successfully implemented and evaluated in a paediatric accident and emergency department.
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Affiliation(s)
- K Armon
- Academic Division of Child Health, School of Human Development, University of Nottingham, Nottingham NG7 2UH, UK.
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Armon K, Stephenson T, Gabriel V, MacFaul R, Eccleston P, Werneke U, Smith S. Determining the common medical presenting problems to an accident and emergency department. Arch Dis Child 2001; 84:390-2. [PMID: 11316679 PMCID: PMC1718762 DOI: 10.1136/adc.84.5.390] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [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: 11/03/2022]
Abstract
All accident and emergency (A&E) attendances over a one year period were prospectively studied in order to determine common medical presenting problems. Data were collected on children (0-15 years) attending a paediatric A&E department in Nottingham between February 1997 and February 1998. A total of 38 982 children were seen. The diagnoses of 26 756 (69%) were classified as trauma or surgical, and 10 369 (27%) as medical; 1857 (4%) could not be classified. The commonest presenting problems reported for "medical" children were breathing difficulty (31%), febrile illness (20%), diarrhoea with or without vomiting (16%), abdominal pain (6%), seizure (5%), and rash (5%). The most senior doctor seeing these patients in A&E was a senior house officer (intern or junior resident) in 78% of cases, paediatric registrar (senior resident) in 19%, consultant (attending physician) in 1.4%, and "other" in 2.6%. Guidelines developed for A&E should target the commonest presenting problem categories, six of which account for 83% of all medical attendances, and be directed towards senior house officers.
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Affiliation(s)
- K Armon
- Academic Division of Child Health, School of Human Development, Medical Faculty, University of Nottingham, Nottingham NG7 2UH, UK.
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Eccleston P, Werneke U, Armon K, Stephenson T, MacFaul R. Accounting for overlap? An application of Mezzich's kappa statistic to test interrater reliability of interview data on parental accident and emergency attendance. J Adv Nurs 2001; 33:784-90. [PMID: 11298216 DOI: 10.1046/j.1365-2648.2001.01718.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [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: 11/20/2022]
Abstract
STUDY RATIONALE The number of interview studies with service users is rising because of growth in health services research. The level of agreement between multiple interview data coders requires statistical calculation to support results. Basic kappa statistics are often used but this depends on having mutually exclusive data. Researchers should be aware that this is not valid when an interview word or paragraph can be coded into more than one category. The 'proportional overlap' kappa extension by Mezzich et al. (1981, Journal of Psychiatric Research 16, 29-39) has been investigated as an original solution. OBJECTIVES To assess the level of agreement beyond chance between several raters of interview data by applying the 'proportional overlap' kappa statistic by Mezzich et al. to verbal interview data. The clinical area investigated was child attendance at an Accident and Emergency Department, where parental attendance experiences have been under-explored. METHODS Two researchers using a coding schedule coded a random sample of interview transcripts. These data were applied to Mezzich's procedure; coder 1 notes that a paragraph refers to category A and B but coder 2 notes A, B and C. The total agreement overlap in this case was 0.66 because two actual agreements out of three possible agreements were made. This was repeated for each paragraph and divided by the number of coding pairs. All agreement values were summed then subsequently divided by the total number of paragraphs to get Po (total number of observed agreements) and by the total number of coding pairs to get Pe (total number of agreements by chance alone). Po and Pe were used in the basic kappa formula to assess interview coding reliability. RESULTS The overall mean Po was 0.61, the mean Pe was 0.32, with a kappa score of 0.43; a moderate level of agreement which was statistically significant (t=4.8, P < 0.001, d.f.=23). CONCLUSION Mezzich's procedure may be applied to interview data to calculate agreement levels between several coders.
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Affiliation(s)
- P Eccleston
- Academic Division of Child Health, School of Human Development, University of Nottingham, Nottingham, UK.
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Abstract
AIMS To estimate the nature and quantity of clinical experience available for trainees in paediatrics or general practice in acute general hospitals of differing sizes in the UK. To discuss implications for training and service configuration taking account of current Royal College recommendations (a minimum of 1,800 acute contacts each year and ideally covering a population of 450,000 to 500,000 people). METHODS Observed frequencies of diagnoses in Pinderfields Hospital, Wakefield were compared with those in five other hospitals in Yorkshire and four in the South of England, and with expected frequencies from a review of selected marker conditions using national routine and epidemiological data. Based on the Pinderfields data, we modelled expected frequencies of a wider range of diagnoses for different sized hospitals. RESULTS Small units (1,800 or less acute referrals a year) provide adequate exposure to common conditions such as gastroenteritis (157 per annum) and asthma (171 per annum) but encounter serious or unusual disease rarely. When modelled for units serving larger populations, numbers of such disorders remain small. For example, about 0.5% of admissions require intensive care to the level of ventilatory support. Medium size units offer a wide range of experience but differ little from those serving the population of 500,000 proposed as being optimal for training. This standard is not justified by the evidence in this review. Closing or amalgamating units on the scale necessary to achieve this ideal would be impractical as only five hospitals in England have a paediatric workload equivalent to this population; it would also raise issues of access and equity.
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Affiliation(s)
- R MacFaul
- Paediatric Department, Pinderfields Hospital, Pinderfields and Pontefract NHS Trust, Wakefield WF14 DG, UK.
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Abstract
BACKGROUND Different versions of the General Health Questionnaire (GHQ), including the GHQ-12 and GHQ-28 have been subjected to factor analysis in a variety of countries. The World Health Organization study of psychological disorders in general health care offered the opportunity to investigate the factor structure of both GHQ versions in 15 different centres. METHODS The factor structures of the GHQ-12 and GHQ-28 extracted by principal component analysis were compared in participating centres. The GHQ-12 was completed by 26,120 patients and 5,273 patients completed the GHQ-28. The factor structure of the GHQ-28 found in Manchester in this study was compared with that found in the earlier study in 1979. RESULTS For the GHQ-12, substantial factor variation between centres was found. After rotation, two factors expressing depression and social dysfunction could be identified. For the GHQ-28, factor variance was less. In general, the original C (social dysfunction) and D (depression) scales of the GHQ-28 were more stable than the A (somatic symptoms) and B (anxiety) scales. Multiple cross-loadings occurred in both versions of the GHQ suggesting correlation of the extracted factors. In Manchester, the factor structure of the GHQ had changed since its development. Validity as a case detector was not affected by factor variance. CONCLUSIONS These findings confirm that despite factor variation for the GHQ-12, two domains, depression and social dysfunction, appear across the 15 centres. In the scaled GHQ-28, two of the scales were remarkably robust between the centres. The cross-correlation between the other two subscales, probably reflects the strength of the relationship between anxiety and somatic symptoms existing in different locations.
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Affiliation(s)
- U Werneke
- Maudsley Hospital and Institute of Psychiatry, London
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Stewart M, Werneke U, MacFaul R, Taylor-Meek J, Smith HE, Smith IJ. Medical and social factors associated with the admission and discharge of acutely ill children. Arch Dis Child 1998; 79:219-24. [PMID: 9875016 DOI: 10.1136/adc.79.3.219] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [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: 11/03/2022]
Abstract
AIM To examine medical and sociodemographic factors involved in acute paediatric admission. To compare outcome of admission with factors present at time of admission. METHODS Prospective questionnaire based study of 887 consecutive emergency general paediatric admissions to five Yorkshire hospitals during two separate three week periods in summer and winter. MAIN OUTCOME MEASURES Discharge diagnosis, length of stay. RESULTS Most admissions (53%) occurred "out of hours" with a peak during the evening. Two thirds (64%) of patients were under 3 years of age and clinical problems varied with age. Self referral via an accident and emergency department occurred in one third and was more likely after a fit in older children and in more socioeconomically deprived children. The most frequent presenting problems were breathing difficulty (24%), fit (16%), and feverish illness (15%). One quarter (24%) were discharged within 24 hours and 61% spent, at most, one night in hospital. Length of stay was shorter for night admissions and longer for children with a discharge diagnosis of asthma. Although most children had mild, self limiting illnesses, serious illness was subsequently found in 13% and could not be predicted from the presenting problems. CONCLUSIONS Current demand on emergency paediatric admission is mainly from young children with mild self limiting illnesses who spend one night or less in hospital. Changes in delivery of care to acutely ill children must take account of the pattern and nature of presenting problems and be rigorously audited to ensure that improvements in the health of children continue.
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Affiliation(s)
- M Stewart
- Nuffield Department of Child Health, Queen's University of Belfast, UK
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MacFaul R, Stewart M, Werneke U, Taylor-Meek J, Smith HE, Smith IJ. Parental and professional perception of need for emergency admission to hospital: prospective questionnaire based study. Arch Dis Child 1998; 79:213-8. [PMID: 9875015 PMCID: PMC1717678 DOI: 10.1136/adc.79.3.213] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [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: 11/04/2022]
Abstract
AIM To compare views of parents, consultants, and general practitioners on severity of acute illness and need for admission, and to explore views on alternative services. METHOD Prospective questionnaire based study of 887 consecutive emergency paediatric admissions over two separate three week periods in summer and winter of five Yorkshire hospitals, combined with a further questionnaire on a subsample. OUTCOME MEASURES Parental scores of need for admission and parent and consultant illness severity scores out of 10. Consultant judgment of need for admission. Alternatives to admission considered by consultants and, for a subsample, by parents and family GP. RESULTS Ninety nine per cent of parents thought admission was needed. Parents scored need for admission more highly than severity of illness with no association observed between severity and presenting problem or diagnosis. High parental need score was associated with a fit, past illness, and length of stay. Consultant illness severity scores were skewed to the lower range. Consultants considered admission necessary in 71%, especially for children aged over 1 year, presentation with breathing difficulty or fit, and after a longer stay. More admissions in the evening were considered unnecessary as were admissions after longer preadmission illness, gastroenteritis, or upper respiratory tract infection. Of a subsample of parents, 81% preferred admission during the acute stage of illness even if home nursing had been available. Similar responses were obtained from GPs. Alternative services could have avoided admission for 19% of children, saving 15.6% of bed days used. CONCLUSIONS Medical professionals and parents differ in their views about admission for acute illnesses. More information is needed on children not admitted. Alternative services should take account of patterns of illness and should be acceptable to parents and professionals; cost savings may be marginal.
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Affiliation(s)
- R MacFaul
- Health Services Committee, Royal College of Paediatrics and Child Health, London, UK
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Werneke U, McPherson K. Extending the benefits of breast cancer screening. Still hard to know how large the benefits will really be. BMJ 1998; 317:360-1. [PMID: 9694746 PMCID: PMC1113666 DOI: 10.1136/bmj.317.7155.360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Werneke U. Quantitative estimates of sensitivity and specificity in mammographic screening. J Epidemiol Community Health 1997; 51:731. [PMID: 9519141 PMCID: PMC1060575 DOI: 10.1136/jech.51.6.731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
The reliability and validity of the North American paediatric appropriateness evaluation protocol (PAEP) for use in paediatric practice in Britain was tested. The protocol was applied to 418 case records of consecutive emergency admissions to three Yorkshire district general hospitals. The PAEP ratings were then compared with a clinical consensus opinion obtained from two expert panels. Altogether 32% of the admissions were rated inappropriate by the PAEP and 36% by the panels. Validity of the PAEP, as measured by agreement beyond chance with the expert panel rating, was only moderate with a kappa of 0.29 (95% confidence interval 0.11 to 0.47). The PAEP has limited validity for evaluating British paediatric practice. Utilisation review instruments developed in differing clinical cultures should be used with caution until shown to be valid for the practice setting under review.
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Affiliation(s)
- U Werneke
- London Health Economics Consortium, London School of Hygiene and Tropical Medicine
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Gagliardino JJ, Werneke U, Olivera EM, Assad D, Regueiro F, Diaz R, Pollola J, Paolasso E. Characteristics, clinical course, and in-hospital mortality of non-insulin-dependent diabetic and nondiabetic patients with acute myocardial infarction in Argentina. J Diabetes Complications 1997; 11:163-71. [PMID: 9174897 DOI: 10.1016/s1056-8727(96)00002-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [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: 02/04/2023]
Abstract
The characteristics and clinical course of 1040 cases of acute myocardial infarction (AMI) among non-insulin-dependent diabetics (146) and nondiabetics (894) were compared. Patients with non-insulin-dependent diabetes mellitus (NIDDM) historically showed a greater percentage of AMI, angina, and risk factors than nondiabetic patients. Although the degree of left-ventricular function upon admission (according to the Killip and Kimball scores) was similar in both the diabetic and nondiabetic groups, the prevalence of hypertension and hypercholesterolemia was significantly higher in the NIDDM patients. All told, NIDDM cases were 1.73 [relative risk (RR)] times more likely to die of AMI than nondiabetic patients. The age factor and the presence of shock of any type also significantly increased the case-fatality rate. Diabetic patients showed signs of successful reperfusion less often than control subjects, an event that was closely associated with their case-fatality rate. In the NIDDM group, both the age and gender factor as well as a history of either casual or in-hospital clinical events such as cardiogenic shock, reinfarction, unsuccessful reperfusion, and incidence of anterior AMI along with either pain or previous angina were clear prognosticators of poor outcome from AMI. In the nondiabetic group, cardiogenic shock and hypertension were indicators of poor prognosis. These results would suggest that an improvement in the incidence of successful reperfusion in NIDDM patients, particularly in the face of clinical indicators of poor AMI prognosis, could decrease the high AMI mortality currently observed in these patients.
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Affiliation(s)
- J J Gagliardino
- CENEXA, Centro de Endocrinología Experimental y Aplicada (UNLP-CONICET), Latinoamérica
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Edwards N, Werneke U. Emergency admissions. In the fast lane. Health Serv J 1994; 104:30-2. [PMID: 10141227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- N Edwards
- London School of Hygiene and Tropical Medicine
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Werneke U, Mühlhauser I, Berger M. [Knowledge about technics of blood pressure determination of medical students in their internship year at the University of Düsseldorf]. Schweiz Rundsch Med Prax 1988; 77:1167-70. [PMID: 3238239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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