Medical Case Note Research Articles

Agitated depression in bipolar disorder.

It has been suggested that agitated depression (AD) is a common, severe feature in bipolar disorder. We aimed to estimate the prevalence of AD and investigate whether presence of AD was associated with episodic and lifetime clinical features in a large well-characterized bipolar disorder sample. The prevalence of agitation, based on semi-structured interview and medical case-notes, in the most severe depressive episode was estimated in 2925 individuals with DSM-IV bipolar disorder recruited into the UK Bipolar Disorder Research Network. Predictors of agitation were ascertained using symptoms within the same episode and lifetime clinical features using multivariate models. 32.3% (n=946) experienced agitation during the worst depressive episode. Within the same episode, significant predictors of presence of agitation were: insomnia (OR 2.119, P<0.001), poor concentration (OR 1.966, P=0.027), decreased libido (OR 1.960, P<0.001), suicidal ideation (OR 1.861, P<0.001), slowed activity (OR 1.504, P=0.001), and poor appetite (OR 1.297, P=0.029). Over the lifetime illness course, co-morbid panic disorder (OR 2.000, P<0.001), suicide attempt (OR 1.399, P=0.007), and dysphoric mania (OR 1.354, P=0.017) were significantly associated with AD. Agitation accompanied bipolar depression in at least one-third of cases in our sample and was associated with concurrent somatic depressive symptoms, which are also common features of mixed manic states. Furthermore, AD in our sample was associated with lifetime experience of mixed mania, in addition to severe lifetime illness course including comorbid panic disorder and suicidal behavior. Our results have implications for the diagnosis and treatment of agitated features in bipolar depression.

Assessment of healthcare delivery in the early management of bacterial meningitis in UK young infants: an observational study

ObjectiveTo define early presenting features of bacterial meningitis in young infants in England and to review the adequacy of individual case management as compared with relevant national guidelines and an...

Abstract P1-06-04: Molecular characterisation, subtype concordance and prognostic group assignment between patient-matched primary breast tumours and axillary lymph node metastases

Abstract Introduction Currently the primary breast tumour is used for prognostic profiling and as a monitor of response to therapy but how often does the molecular profile of the primary cancer reflect the molecular profile of nodal metastases? No previous study has investigated in detail the genomic profile of matched primary breast cancer (P) and nodal metastases (N) and correlated these with outcome. The aim of this study was to investigate whether the mRNA profiles of matched P and N differ significantly. Methods RNA was extracted from core biopsies from primary breast tumours and paired metastatic axillary lymph node samples from both FFPE blocks and fresh frozen samples. RNA was labelled and hybridised to Illumina HT-12 BeadChips to create a dataset consisting of one primary and one or two matched nodal metastasis, totalling 68 samples from 31 patients. Data was processed and corrected for batch effects, then analysed using the statistical programming language R. Clinical data on progression free and overall survival was collected from electronic and medical case note review. Results Unsupervised hierarchical clustering of the 500 most variable genes in each sample grouped only 12 of 31 P&amp;Ns (39%) together, meaning in the majority of patients their P or N more resembled a cancer from another patient than its own paired P or N. The number of genes with greater than 2 fold change (&amp;gt;2FC) between P&amp;N was used to categorise paired samples into 'least changed' (&amp;lt;130 genes with &amp;gt;2 FC) and 'most changed' (&amp;gt;370 genes with &amp;gt;2FC) groups. Multidimensional scaling of the 500 most variable genes in the most changed group (n-=10) showed consistently that nodal metastases differed molecularly from the primary cancer. When categorised by Sorlie centroid, 12 of 31 patients (39%) had a different molecular subtype in N compared with P. N tended to be a poorer prognostic subtype than P. 50% had luminal A primaries paired with luminal B nodes. The remaining 50% changed in other non-consistent patterns. 6 patients had 2 N samples to analyse alongside P. 4 of these (67%) had the same subtype in all 3 samples, and a further 1 the same 2Ns (luminal B) which differed from P (luminal A). The final had luminal A P paired with 1 luminal A and 1 luminal B Ns. There was no evident correlation between the least changed and most changed groups and progression free and overall survival. This may however reflect the short term follow up. Discordance between P and N in expression of ESR1 was 32%; PGR 19% and ERBB2 16%. Conclusions This study of gene expression change in matched primary breast cancers and synchronous metastatic paired axillary lymph nodes shows that molecular subtype differs in 39%. 50% of nodes had a poorer prognostic subtype than their primary. Expression of ESR, PGR and ERBB2 differs in up to 32% Classifying cancer molecular phenotype and estimating prognosis based only on the primary cancer misclassifies significant numbers of patients. Classification of prognosis, and treatment based on the nodal metastasis may provide better information on which to base treatment. Citation Format: Arthur LM, Turnbull AK, Pearce DA, Renshaw L, Thomas JS, Sims AH, Dixon JM. Molecular characterisation, subtype concordance and prognostic group assignment between patient-matched primary breast tumours and axillary lymph node metastases [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-06-04.

The Melancholy Earl: Sir William Herbert in the Medical Case Notes of Dr Barker of Shrewsbury

The Melancholy Earl: Sir William Herbert in the Medical Case Notes of Dr Barker of Shrewsbury

Demographic of stroke: A comparative study between Brunei Darussalam Neuroscience, Stroke and Rehabilitation Centre and Krankenhaus Nordwest, Frankfurt, Germany

Demographic of stroke: A comparative study between Brunei Darussalam Neuroscience, Stroke and Rehabilitation Centre and Krankenhaus Nordwest, Frankfurt, Germany

Time is brain: Stroke thrombolysis in Brunei Darussalam

Time is brain: Stroke thrombolysis in Brunei Darussalam

Could Personalised Self-Inking Stamps Improve Identification Standards in Medical Records?

Doctors' handwriting has long been criticised as being difficult to read or even illegible. In more recent years research has confirmed that it is not uncommon to find medical case note entries that are deficient, illegible or unidentifiable. In Good Medical Practice the General Medical Council (GMC) asks that doctors 'keep clear, accurate, legible and contemporaneous patient records'. In addition, the GMC 'expects that all doctors will use their reference numbers widely to identify themselves to all those with whom they have professional contact'. This includes encouragement for its use in case note entries and prescribing.

P-754 - A point prevalence study of delirium in an adult acute hospital population: predictors of accurate detection

Delirium is a common neuropsychiatric syndrome associated with serious adverse healthcare outcomes. It is misdiagnosed in over 50% of cases across healthcare settings. To document the point prevalence of delirium across an acute general hospital and identify factors associated with accurate detection by medical and nursing staff, as well as patient and carer recognition. Adult in-patients in Cork University Hospital on 15.05.2010 were assessed for inattention, delirium symptoms with the Revised Delirium Rating Scale (DRS-R98) and the Confusion Assessment Method (CAM), and pre-existing cognitive impairment with the Informant Questionnaire for Cognitive Decline (IQCODE). Recognition by patients/carers and nursing staff was assessed through direct questioning, while recognition by the treating medical team was assessed through casenote review. 311 were recruited (87% of inpatients). 55(18%) had delirium. Pre-existing cognitive decline was detected in 28 delirious patients(51%). Of those with delirium, 17 (31%) were aware of their own confusion, 35(64%) were recognised by nursing staff, and 24 (44%) had delirium documented in medical casenotes. Predictors of recognition in medical casenotes were the severity of inattention, short-term memory impairment and being managed by a medical rather than surgical team. For nurse recognition, predictors were severity of delusions, affective lability, inattention and long-term memory impairment. For patient self-recognition, acuity of onset and disorientation were predictors. Delirium is present in approximately one in five hospitalised inpatients at any time. Under-detection is common. Factors linked to accurate detection can inform educational and other efforts to improve delirium recognition.

Alternative Diagnoses to Chronic Fatigue Syndrome in Referrals to a Specialist Service: Service Evaluation Survey

ObjectiveTo assess the accuracy of diagnoses made by referrers to a chronic fatigue syndrome (CFS) service.DesignRetrospective service evaluation surveys of both rejected referral letters and medical case-notes after full clinical assessment.SettingA specialist CFS clinic in London, UK.ParticipantsIn the first survey, we assessed rejected referral letters between March 2007 and September 2008. In the second survey, we ascertained the primary diagnosis made in case-notes of 250 consecutive new patients assessed between April 2007 and November 2008.Main outcome measuresReasons for rejection of referrals and primary diagnosis in those assessed.ResultsIn the first survey, 154 out of 418 referrals (37%) were rejected. Of these, 77 out of the available 127 referrals (61%) had a likely alternative diagnosis. In the second survey of clinically assessed patients, 107 (43%) had alternative medical/psychiatric diagnoses, while 137 out of 250 (54%) patients received a diagnosis of CFS. The commonest alternative medical diagnoses of those assessed were sleep disorders and the commonest alternative psychiatric diagnosis was depressive illness. Altogether 184 of 377 (49%) patients had alternative diagnoses to CFS.ConclusionsHalf of all the referred patients to a specialist CFS clinic had alternative medical and psychiatric diagnoses. Specialist medical assessment for patients with unexplained, disabling, chronic fatigue needs to incorporate both medical and psychiatric assessments.

Pathological correlates of frontotemporal lobar degeneration in the elderly

Frontotemporal lobar degeneration (FTLD) is generally recognised as a disorder with presenile onset (that is before 65years of age) with only occasional cases presenting later than this. We set out to determine what proportion of cases of FTLD had late onset of disease and whether such cases of FTLD had distinctive clinical and neuropathological features as compared to cases with presenile onset. Within a combined Manchester and Newcastle autopsy series of 117 cases with pathologically confirmed FTLD (109/117 cases also met Lund Manchester clinical criteria for FTLD), we identified 30 cases (onset age range 65-86years), comprising 25% of all FTLD cases ascertained in these two centres over a 25-year period. Neuropathologically, the 30 elderly cases presented features of several FTLD histological subgroups [FTLD-TDP (types 1, 2 and 3, 19 cases (63%)], FLTD-tau [MAPT, PiD and CBD, 10 cases (33%)] and FTLD-UPS (1 case), similar in range of phenotypes to that seen in the presenile group, though patients with MAPT, but not PGRN, mutation, or FUS pathology, were notably absent or fewer in the elderly group. Hippocampal sclerosis (HS) was present in 13/30 of the elderly FTLD cases (43%) compared with 14/79 (18%) (P=0.012) in the presenile FTLD patients. Lobar atrophy present in most of the younger patients was prominent in only 25% of the elderly subjects. Prospective and retrospective psychiatric and medical case note analysis showed that the majority of the elderly FTLD patients, like their younger counterparts, had behavioural features consistent with frontotemporal dementia. FTLD is common amongst elderly persons and all or most of the major clinical and histological subtypes present in younger individuals can be seen in the older group.

Ovarian failure following cancer treatment: current management and quality of life

There is a lack of evidence regarding current screening practices for incipient ovarian failure in young women following gonadotoxic therapy and the most appropriate form of estrogen replacement. This study examined the (i) prevalence and management of ovarian failure and (ii) quality-of-life implications of early menopause (EM). A medical case note audit for 288 women with a history of gonadotoxic therapy (aged 18-50 years) was conducted. Self-reported quality-of-life data were obtained from 178 (62%). Ovarian screening was recorded in 44% of medical case notes, and ovarian failure was documented for 35%. From the self-reported data, 89/178 (50%) women reported experiencing an EM/ovarian failure. Worse menopausal symptoms were negatively associated with both sexual activity [pleasure (r = 0.29, P < 0.01), discomfort (r = 0.50, P < 0.001) and habit (r = 0.22, P < 0.05)] and general quality of life (P = 0.01). Hormone replacement therapy is the most commonly prescribed estrogen preparation; however, 34% of women with EM/ovarian failure reported not taking any replacement therapy. Given the extent and impact of menopausal symptoms, further work is needed to establish systems for screening ovarian function and to determine appropriate and effective management of ovarian failure.

Using a self-reported functional score to assess disease progression in systemic sclerosis

This study compares the scleroderma Functional Score (FS) with the validated Disability Index of the Health Assessment Questionnaire (HAQ-DI) and other outcome measures. The aim is to determine if the FS is useful as an objective assessment tool for longitudinal evaluation of the functional impact of systemic sclerosis (SSc). A cohort of 135 patients was studied (M:F, 15:120), with a mean age of 45.7 (S.D. = 13.2) at SSc disease onset. 69 (51%) had diffuse cutaneous scleroderma (dcSSc) and 66 (49%) had limited disease (lcSSc). The mean interval between the two assessments was 1.8 yrs (S.D. = 1.2). Functional impact was determined by evaluating archived self-reported questionnaires (FS, HAQ and scleroderma-VAS). Concurrent evaluation of the disease severity score was derived from clinical data stored in the hospital database and from medical case note reviews. At baseline, the mean FS was 11.0 (S.D. = 9.0) and at reassessment 12.0 (S.D. = 9.2). The mean absolute change in FS between the two assessments was 4.1 (S.D. = 4.9). With time 49% (n = 66) showed a clinically significant change in their functional ability with regard to FS, of these 29% (n = 39) worsened and 20% (n = 27) improved. There was an excellent cross-sectional correlation between the FS and the HAQ-DI (rho = 0.90; P < 0.0001). Also, a strong correlation between longitudinal change in these two outcome measures (rho = 0.59, P < 0.0001) was observed. This is the first longitudinal study of the scleroderma FS. It demonstrates that the FS can capture bidirectional and clinically significant changes in SSc related disability over time. The concurrent validity of the FS is asserted through its strong correlation with the HAQ-DI. The FS is a disease-specific, inexpensive and practical instrument for assessing functional status in SSc. It is a promising self-administered assessment tool for use in evaluating new SSc treatments.

Defining prognostic factors in the elderly with community acquired pneumonia: a case controlled study of patients aged > or = 75 yrs.

Severity assessment in the elderly with community acquired pneumonia (CAP) may be different compared with younger patients. In particular, age per se may not be of prognostic significance in older patients. A case-control study in 158 patients aged > or = 75 yrs with CAP was conducted to determine the factors associated with in-hospital mortality. Cases were drawn from all patients aged > or = 75 yrs with CAP who died in 1997 in five hospitals in the mid-Trent region of the UK (Nottingham City Hospital, University Hospital Nottingham, Derby Royal Infirmary, Derby City General Hospital and Kings Hill Hospital). Controls were randomly selected from survivors also aged > or = 75 yrs. Factors associated with mortality were identified following a review of the medical casenotes and the contribution of these factors to mortality was determined using multivariate analysis. Absence of fever, tachycardia and chest radiograph features of bilateral involvement or an effusion were independently associated with mortality on multivariate analysis. The British Thoracic Society (BTS) severity rule was 50% sensitive and 64% specific in predicting death while the modified BTS rule displayed 67% sensitivity and 58% specificity. Age was not significantly associated with mortality in this group of patients aged > or = 75 yrs. Similarly, the clinical features employed in the British Thoracic Society rule, namely respiratory rate, diastolic blood pressure and blood urea, were not of prognostic significance and the rule itself performed poorly. The modified British Thoracic Society rule performed better.

The use of antiepileptic medication in a population-based cohort of adults with learning disability and epilepsy

The purpose of the current study was to assess the trend of antiepileptic drug use in a sample of 143 adults with learning disability and epilepsy in one health district. Information on the dose and serum level of antiepileptic drugs received by the subjects, their demographic data and the epilepsy-related data were gathered from the medical case-notes, examination of subjects and interview with the carers. Sixty (42% of the cohort) subjects received polytherapy of antiepileptic medication. The use of polytherapy was significantly associated with being female, longer duration of epilepsy, multiple-seizure type, and active epilepsy (i.e. seizure during the previous 12-month period). Of the cohort, 52% receivd sodium valproate, 38.5% received carbamazepine, 29% phenytoin, 11% lamotrigine and 11% primidone. The majority of subjects received antiepileptic drugs within the BNF-recommended range; however, 38% of the subjects receiving carbamazepine had a lower dose than that recommended in the BNF. The serum levels of most antiepileptic drugs were within the local laboratory reference range, except that in 39% of cases the phenytoin level was below the local reference range. No statistically significant difference was observed in the use of different antiepileptic drugs and the rate of mental disorder in the cohort, although the subjects receiving lamotrigine and primidone showed more behavioural problems. Similarly, no significant association was observed between the seizure types and the use of different antiepileptic medications.

Does testing for depression influence diagnosis or management by general practitioners?

This study set out to assess the effects on diagnosis and management of providing general practitioners with feedback of patients' scores on a depression screening instrument. One hundred and sixteen general practice attenders aged 16-64 with undetected depression were identified using the Beck Depression Inventory (BDI). The BDI scores of a random 45% were disclosed to the general practitioners. Subjects and medical casenotes were reviewed over 12 months. Thirty-one (27%) of subjects were later diagnosed as depressed. Rates of diagnosis were higher in the disclosed group, but only after six months. Rates of intention to treat were low, but were marginally higher for the disclosed group; they were much higher for patients diagnosed by the doctors themselves. Feedback of screening questionnaire results appears to be of limited value in enhancing general practitioners' detection or management of depression.

Non-cardiac chest pain and benign palpitations in the cardiac clinic.

To assess the characteristics of consecutive patients referred from general practice with the presenting disorder of chest pain or palpitations, and to determine the outcome at six months and three years. A single consultant teaching hospital cardiac clinic receiving new referrals from a health district. 94 consecutive referrals by general practitioners to a cardiac clinic with the presenting disorder of chest pain or palpitations were assessed at first attendance (research interview, cardiologists' ratings, systematic medical case note information), home interview six months later, and by a postal questionnaire at three years. Physical and psychological symptoms, limitation of activities, satisfaction with care, and use of health care resources. 39 patients were given a cardiac diagnosis and 51 patients were not given a cardiac or other major physical diagnosis. The non-cardiac group was more likely to be young women, and to report other physical symptoms and previous psychiatric problems. The cardiac and non-cardiac groups reported progressive improvement in presenting symptoms and disability at the six months and three year follow up, but little change in mental state. Even so, three quarters of the non-cardiac subjects described continuing limitation of activities, concern about the cause of their symptoms, and dissatisfaction with medical care. A substantial proportion of the consecutive referrals continued to describe symptoms and disability throughout the three years after clinic attendance. Outcome was poor for those who had negative investigations and were reassured that they had no cardiac disorder or other serious physical finding. These results have implications for defining the role of psychological assessment and for the formulation of cost effective clinical measures to (a) minimise disability associated with cardiac disorder; and (b) prevent and treat handicaps in those without major physical diagnoses.

Detecting depression in elderly medically ill patients: the use of the Geriatric Depression Scale compared with medical and nursing observations.

In a study of 59 elderly medically ill in-patients, 35% were found to have significant depressive symptomatology, as detected by the Geriatric Mental Status Schedule (GMSS). Of two screening methods, the Geriatric Depression Scale (GDS) performed satisfactorily but detection by nurses was poor. Acknowledgement of depression in medical casenotes was low. Training of nurses might improve detection; otherwise a mood-rating scale such as the GDS should be incorporated into routine practice.