One area of overlap involves neural circuits and neuromodulatory systems in the striatum and basal ganglia, which play an established role in addiction and reward but are increasingly implicated in clinical and preclinical studies of ASDs. A second area of overlap relates to molecules like Fragile X mental retardation protein FMRP and methyl CpG-binding protein-2 MECP2, which are best known for their contribution to the pathogenesis of syndromic ASDs, but have recently been shown to regulate behavioral and neurobiological responses to addictive drug exposure.
These shared pathways and molecules point to common dimensions of behavioral dysfunction, including the repetition of behavioral patterns and aberrant reward processing. The synthesis of knowledge gained through parallel investigations of ASDs and addiction may inspire the design of new therapeutic interventions to correct common elements of striatal dysfunction.
Autism spectrum disorders ASDs and drug addiction do not share substantial comorbidity or obvious similarities in etiology or symptomatology. A second area of overlap relates to molecules like Fragile X mental retardation protein FMRP and methyl CpG-binding protein-2 MECP2 , which are best known for their contribution to the pathogenesis of syndromic ASDs, but have recently been shown to regulate behavioral and neurobiological responses to addictive drug exposure. Psychometric analysis of common mental disorders.
Although abdominal pain is a symptom of several structural gastrointestinal disorders eg, peptic ulcer disease , this comprehensive review will focus on the 4 most common nonstructural, or functional, disorders associated with abdominal pain: functional dyspepsia, constipation-predominant and diarrhea-predominant irritable bowel syndrome, and functional abdominal pain syndrome. Together, these conditions affect approximately 1 in 4 people in the United States. They are associated with comorbid conditions eg, fibromyalgia, depression , impaired quality of life, and increased health care utilization.
These disorders are defined and can generally be diagnosed by symptoms alone. Often prompted by alarm features, selected testing is useful to exclude structural disease. Identifying the specific diagnosis eg, differentiating between functional abdominal pain and irritable bowel syndrome and establishing an effective patient-physician relationship are the cornerstones of therapy.
Many patients with mild symptoms can be effectively managed with limited tests, sensible dietary modifications, and over-the-counter medications tailored to symptoms. Behavioral and psychological approaches eg, cognitive behavioral therapy can be very helpful, particularly in patients with chronic abdominal pain who require a multidisciplinary pain management program without opioids. Are male reproductive disorders a common entity? Experimental and epidemiological studies suggest that TDS is a result of disruption of embryonal programming and gonadal development during fetal life.
The recent rise in the prevalence of TDS may be causally linked to endocrine disrupters Uncommon presentation of a common disorder. Full Text Available We report about a young male who presented with generalized muscle stiffness, involving the limb, facial, and paraspinal muscles. The stiffness was severe enough to restrict all his daily activities, progressively increased with movements and also produced recurrent falls. This clinical picture resembled one of stiff person syndrome.
As he had hypertrophy of calf muscles and generalized muscle tautness he was evaluated for other disorders which can resemble stiff person syndrome. Investigations revealed severe hypothyroidism with thyroid antibodies being elevated. This case is reported to highlight the fact that myopathy as a presenting manifestation of hypothyroidism can simulate stiff person syndrome. It is essential to identify the condition early as it recovers fully with treatment. Our patient responded well to thyroid replacement therapy and was able to lead a normal life.
Prevention of recurrent sickness absence among employees with common mental disorders : design of a cluster-randomised controlled trial with cost-benefit and effectiveness evaluation. Background: Common mental disorders , such as depression, anxiety disorder , and adjustment disorder , have emerged as a major public and occupational health problem in many countries.
These disorders can have severe consequences such as absenteeism and work disability. Different interventions have. Cross-cultural patterns of the association between varying levels of alcohol consumption and the common mental disorders of depression and anxiety: secondary analysis of the WHO Collaborative Study on Psychological Problems in General Health Care.
Alcohol consumption is associated with several complications of both physical and mental health. Light or moderate alcohol consumption may have beneficial effects on physical or mental health but this effect is still controversial and research in the mental health field is relatively scarce. Our aim was to investigate the association between varying levels of alcohol consumption and the common mental disorders of depression and anxiety in a large international primary care sample.
Light to moderate alcohol consumption was associated with a lower prevalence of depression and generalized anxiety disorder compared to abstinence while excessive alcohol consumption was associated with a higher prevalence of depression. This non-linear association was not substantially affected after adjustment for a range of possible confounding variables, including the presence of chronic disease and the current physical status of participants and was evident in different drinking cultures.
Any causal interpretation of this association is difficult in the context of this cross-sectional study and further longitudinal studies are needed. They are associated with comorbid conditions eg, fibromyalgia and depression , impaired quality of life, and increased health care utilization. Behavioral and psychological approaches eg, cognitive behavioral therapy can be helpful, particularly in patients with chronic abdominal pain who require a multidisciplinary pain management program without opioids.
Published by Elsevier Inc. Post-conflict mental health in South Sudan: overview of common Post-conflict mental health in South Sudan: overview of common psychiatric disorders Part 1: Depression and post-traumatic stress disorder. Background Although the consequences of food insecurity on physical health and nutritional status of youth living have been reported, its effect on their mental health remains less investigated in developing countries. The aim of this study was to examine the pathways through which food insecurity is associated with poor mental health status among youth living in Ethiopia.
A total of 1, youth were included in the analysis. We measured food insecurity using a 5-items scale and common mental disorders using the item Self-Reporting Questionnaire SRQ Structural and generalized equation modeling using maximum likelihood estimation method was used to analyze the data. Results The prevalence of common mental disorders was Interventions that aim to improve mental health status of youth should consider strategies to improve access to sufficient, safe and nutritious food.
Half of individuals who just had passed eight weeks of continuous sickness absence had a mental disorder of which Common Mental Disorders CMD such as depression, anxiety, and somatoform disorders impose heavy burdens on individuals and on society in the form of sickness absence. CMD are frequently undetected in primary care which postpone the initiation of proper treatment. This seriously worsens return Comorbidity with somatic disorders also worsens RTW.
CMD are, controlled for lifestyle, independent causes for the development of chronic and disabling somatic disorders. Collaborative care seems to be most effective intervention with regard to RTW. In this dissertation, the intervention Update on common nutritional disorders of captive reptiles. Nutritional disorders of captive reptiles remain very common despite the increasing knowledge about reptile husbandry and nutrition.
Many nutritional disorders are diagnosed late in the disease process; often secondary complications, such as pathologic fractures in reptiles suffering from nutritional secondary hyperparathyroidism have occurred.
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Therefore, every attempt should be made to educate reptile owners and keepers about the proper care and dietary needs of reptiles under their care because all nutritional disorders seen in captive reptiles are preventable. Common mental disorders and the built environment in Santiago, Chile. There is growing research interest in the influence of the built environment on mental disorders. To estimate the variation in the prevalence of common mental disorders attributable to individuals and the built environment of geographical sectors where they live. Independently rated contextual measures of the built environment were obtained.
The Clinical Interview Schedule was used to estimate the prevalence of common mental disorders. There was a significant association between the quality of the built environment of small geographical sectors and the presence of common mental disorders among its residents. The better the quality of the built environment, the lower the scores for psychiatric symptoms; however, only a small proportion of the variation in common mental disorder existed at sector level, after adjusting for individual factors.
Findings from our study, using a contextual assessment of the quality of the built environment and multilevel modelling in the analysis, suggest these associations may be more marked in non-Western settings with more homogeneous geographical sectors. Analysis of shared heritability in common disorders of the brain.
Disorders of the brain can exhibit considerable epidemiological comorbidity and often share symptoms, provoking debate about their etiologic overlap. We quantified the genetic sharing of 25 brain disorders from genome-wide association studies of , patients and , control participants and assessed their relationship to 17 phenotypes from 1,, individuals. Psychiatric disorders share common variant risk, whereas neurological disorders appear more distinct from one another and from the psychiatric disorders.
We also identified significant sharing between disorders and a number of brain phenotypes, including cognitive measures. Further, we conducted simulations to explore how statistical power, diagnostic misclassification, and phenotypic heterogeneity affect genetic correlations. These results highlight the importance of common genetic variation as a risk factor for brain disorders and the value of heritability-based methods in understanding their etiology.
No claim to original U. Government Works. Despite the increase in the incidence and prevalence rates of children and adolescents' mental disorders , there are few works performed with large and representative samples of children and adolescents with psychopathological symptoms.
The present work analyses participants referred by first care pediatricians to a specialized unit for children and adolescents' mental health. As a result of the study, a statistically significant relation was found between age and diagnosis: a larger incidence of behavioral disorders , communication disorders , elimination disorders , pervasive developmental disorders , impulse-control disorders from 0 to 5 years; behavioral disorders and attention deficit hyperactivity disorder ADHD were more common from 6 to 11 years, behavioral and anxiety disorders were more likely at 12 to 15 years; and, lastly, behavioral disorders were more prevalent from 16 to 18 years.
With respect to gender, there was a significant relationship with diagnosis: boys had more behavioral disorders , whereas girl had more anxiety disorders. To conclude, a relationship between mental disorders and developmental achievements could be indicated in the younger group. Additionally, externalizing disorders in boys and internalizing ones n girls were more prevalent across all ages.
The aim of this study was to assess the prevalence of common mental disorders and the association with self-esteem and other factors in pregnant women. A nested cross-sectional study was performed in a cohort of pregnant women treated in the public health system in Pelotas, Rio Grande do Sul State, Brazil. Mean self-esteem was 9. Lower self-esteem was associated with higher odds of common mental disorders p low self-esteem. Full Text Available Although the consequences of food insecurity on physical health and nutritional status of youth living have been reported, its effect on their mental health remains less investigated in developing countries.
Food insecurity is directly associated with common mental disorders among youth in Ethiopia. Disorders of compulsivity: a common bias towards learning habits. Why do we repeat choices that we know are bad for us? Decision making is characterized by the parallel engagement of two distinct systems, goal-directed and habitual, thought to arise from two computational learning mechanisms, model-based and model-free. The habitual system is a candidate source of pathological fixedness. Using a decision task that measures the contribution to learning of either mechanism, we show a bias towards model-free habit acquisition in disorders involving both natural binge eating and artificial methamphetamine rewards, and obsessive-compulsive disorder.
This favoring of model-free learning may underlie the repetitive behaviors that ultimately dominate in these disorders. Further, we show that the habit formation bias is associated with lower gray matter volumes in caudate and medial orbitofrontal cortex. Our findings suggest that the dysfunction in a common neurocomputational mechanism may underlie diverse disorders involving compulsion. Workplace bullying and common mental disorders : a follow-up study. Workplace bullying has been associated with mental health , but longitudinal studies confirming the association are lacking.
This study examined the associations of workplace bullying with subsequent common mental disorders years later, taking account of baseline common mental disorders and several covariates. The final data amounted to respondents. Workplace bullying was measured at baseline using an instructed question about being bullied currently, previously or never.
Common mental disorders were measured at baseline and at follow-up using the item version of the General Health Questionnaire. Those scoring were classified as having common mental disorders. Covariates included bullying in childhood, occupational and employment position, work stress, obesity and limiting longstanding illness.
Logistic regression analysis was used. After adjusting for age, being currently bullied at baseline was associated with common mental disorders at follow-up among women OR 2. The association for the previously bullied was weaker. Adjusting for baseline common mental disorders , the association attenuated but remained. Adjusting for further covariates did not substantially alter the studied association. Measures against bullying are needed at workplaces to prevent mental disorders. Vulvovaginitis and other common vulvar disorders in children. Vulvovaginitis, labial adhesions, and other vulvar disorders occur commonly in children and can provoke high anxiety in both the parent and child.
Performed correctly, the pediatric gynecologic examination can diagnose and treat, educate and reassure both parent and child. This examination requires patience, sensitivity, direct communication with the child as well as with the parent, and an open manner that inspires trust in both parties to manage a potentially anxiety-provoking situation.
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This chapter will review common vulvar disorders , including vulvovaginitis, lichen sclerosis et atrophicus, bubble bath vaginitis, labial adhesions, urethral prolapse, and other common problems. A discussion of childhood sexual abuse is beyond the scope of this chapter, with appropriate references available elsewhere. Karger AG, Basel. Burden of common mental disorders in patients with Functional Dyspepsia.
Objective: To assess the frequency of common mental disorders among diagnosed functional dyspepsia patients. Methods: A case-control study with cases of functional dyspepsia FD and healthy controls were recruited from Gastroenterology Clinic at the Aga Khan University Hospital Karachi from 1, March through 31, August Data was entered and analyzed by SPSS version Result: There was significant difference in CMD i. Conclusion: There is high prevalence of Common mental disorders among patients with functional dyspepsia and this needs to be addressed while treating patients.
The effect of social networks and social support on common mental disorders following specific life events. This study examined the association between life events and common mental disorders while accounting for social networks and social supports. Participants included adults in the Baltimore Epidemiologic Catchment Area Cohort who were interviewed in , of whom were re-interviewed in Generalized estimating equations were used to analyze the data. Social support from friends, spouse or relatives was associated with significantly reduced odds of panic disorder and psychological distress, after experiencing specific life events.
Social networks or social support had no significant stress-buffering effect. Social networks and social support had almost no direct or buffering effect on major depressive disorder , and no effect on generalized anxiety disorder and alcohol abuse or dependence disorder. The significant association between social support and psychological distress, rather than diagnosable mental disorders , highlights the importance of social support, especially when the severity of a mental health related problem is low.
Undetected common mental disorders in long-term sickness absence. Undetected Common Mental Disorders CMDs amongst people on sick leave complicate rehabilitation and return to work because appropriate treatments are not initiated. In this respect, Phase 1 included individuals, who were screened for mental disorders. In Phase 2, following the screening of Phase 1, individuals were thoroughly examined by a psychiatrist applying Present State Examination.
The analyses of the study were carried out based on the individuals from Phase 2 and, subsequently, weighted to be representative of the individuals in Phase 1. The frequencies of undetected mental disorders among all sick-listed individuals were for any psychiatric In addition, rehabilitation professionals should provide individualized and active support and ensure Purpose The aim was to aggregate knowledge about the opportunities, challenges and need for support employees with common mental disorders experience in relation to work participation in order to develop recommendations for practice.
Methods A meta-synthesis was conducted using a meta One synthesized finding indicates that a strong work identity and negative perceptions regarding mental disorders can impede work participation, creating an essential need for a supportive work environment. The other reveals that the diffuse nature of the symptoms of mental disorders causes Disgust and fear: common emotions between eating and phobic disorders. Eating disorders ED are prevalent mental illnesses composed mainly of anorexia nervosa, bulimia nervosa and binge eating disorders.
Anxiety disorders are another set of mental illnesses, with phobic disorder PD being the most prevalent disorder. ED and PD are highly comorbid. The aim of this study is to assess, in individuals attending an outpatient clinic for different health issues, the level of fear related to situations generating avoidance such as in social anxiety and specific phobias according to the fear questionnaire FQ , the level of disgust according to the disgust scale DS-R and the vulnerability towards ED according to the SCOFF scale to demonstrate that high levels of both fear and disgust increase the vulnerability towards ED.
Accordingly, fear and disgust are negative emotions that seem to be clinically associated which better explains the comorbidity of ED with PD. Level III. Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. Prospective association of common eating disorders and adverse outcomes. Anorexia nervosa and bulimia nervosa BN are rare, but eating disorders not otherwise specified EDNOS are relatively common among female participants. This study comprised a prospective analysis of female participants from the ongoing Growing Up Today Study.
Questionnaires were sent annually from through , then biennially through and Participants who were 9 to 15 years of age in and completed at least 2 consecutive questionnaires between and were included in the analyses. Girls with BED were almost twice as likely as their nondisordered peers to become overweight or obese odds ratio [OR]: 1. Female participants with PD had a significantly increased risk of starting to use drugs OR: 1.
PD and BED are common and predict a range of adverse outcomes. Primary care clinicians should be made aware of these disorders , which may be underrepresented in eating disorder clinic samples. Efforts to prevent eating disorders should focus on cases of subthreshold severity. What every gastroenterologist needs to know about common anorectal disorders. Anorectal complaints are very common and are caused by a variety of mostly benign anorectal disorders.
Many anorectal conditions may be successfully treated by primary care physicians in the outpatient setting,but patients tend not to seek medical attention due to embarrassment or fear of cancer. As a result,patients frequently present with advanced disease after experiencing significant decreases in quality of life.
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A number of patients with anorectal complaints are referred to gastroenterologists. However,gastroenterologists' knowledge and experience in approaching these conditions may not be sufficient. This article can serve as a guide to gastroenterologists to recognize, evaluate, and manage medically or nonsurgically common benign anorectal disorders , and to identify when surgical referrals are most prudent.
A review of the current literature is performed to evaluate comprehensive clinical pearls and management guidelines for each topic. Topics reviewed include hemorrhoids, anal fissures, anorectal fistulas and abscesses, and pruritus ani. Social support and common mental disorder among medical students. Different kinds of psychological distress have been identified for students in the health field, especially in the medical school.
To estimate the prevalence of mental suffering among medical students in the Southeastern Brazil and asses its association with social support. It is a cross-sectional study. Background: There is a paucity of evidence on working hours and their psychological correlates in police officers of the federated ranks in England. Common mental disorders , neighbourhood income inequality and income deprivation: small-area multilevel analysis. Background Common mental disorders are more prevalent in areas of high neighbourhood socioeconomic deprivation but whether the prevalence varies with neighbourhood income inequality is not known.
Aims To investigate the hypothesis that the interaction between small-area income deprivation and income inequality was associated with individual mental health. A total of 88 respondents aged 18—74 years were nested within 50 households within lower super output areas neighbourhoods and 22 unitary authorities regions , linked to the Gini coefficient income inequality and the per cent of households living in poverty income deprivation.
Income inequality at regional level was significantly associated with poorer mental health parameter estimate Conclusions The associations between common mental disorders , income inequality and income deprivation are complex.
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Income inequality at neighbourhood level is less important than income deprivation as a risk factor for common mental disorders. The adverse effect of income inequality starts to operate at the larger regional level. Common mental disorders are more prevalent in areas of high neighbourhood socioeconomic deprivation but whether the prevalence varies with neighbourhood income inequality is not known. To investigate the hypothesis that the interaction between small-area income deprivation and income inequality was associated with individual mental health.
A total of 88, respondents aged years were nested within 50, households within lower super output areas neighbourhoods and 22 unitary authorities regions , linked to the Gini coefficient income inequality and the per cent of households living in poverty income deprivation.
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Mental health was measured using the Mental Health Inventory MHI-5 as a discrete variable and as a 'case' of common mental disorder. The associations between common mental disorders , income inequality and income deprivation are complex. The role of job strain in understanding midlife common mental disorder : a national birth cohort study. Long-standing concerns exist about reverse causation and residual confounding in the prospective association between job strain and risk of future common mental disorders.
We aimed to address these concerns through analysis of data collected in the UK National Child Development Study, a large British cohort study. Population attributable fractions were calculated to estimate the public health effect of job strain on midlife mental health. High job strain appears to independently affect the risk of future common mental disorders in midlife.
These findings suggest that modifiable work-related risk factors might be an important target in efforts to reduce the prevalence of common mental disorders. Many colleges also have a counseling center which students should go to for mental health concerns.
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How can I get seen at the The staff at your student health center will know Common management issues in pediatric patients with mild bleeding disorders. Type 1 von Willebrand disease and mild platelet function defects are among the most common disorders seen by pediatric hematologists. The management and prevention of bleeding in these patients can be challenging, as there are limited published data to guide clinical practice, and a complete lack of randomized clinical trials.
Desmopressin DDAVP and antifibrinolytics are the mainstays of treatment in these patients, yet the optimal dosing and timing of these agents to prevent or resolve bleeding, while minimizing adverse side effects, is sometimes unclear. DDAVP-induced hyponatremia is a particularly under-recognized complication in children with bleeding disorders who undergo surgery. Clinicians need to be aware of local measures that are equally important in treating problems such as epistaxis and surgical bleeding. This review will discuss the published literature and provide practical suggestions regarding four common management issues in the care of children and adolescents with mild bleeding disorders : epistaxis, heavy menstrual bleeding, dental extractions, and tonsillectomy.
Mental disorders among health workers in Brazil. In total, professionals participated in the study. The ratio of CMDs between the two groups of professionals was statistically different p health problems arising from work and with a lower prevalence of mental disorders compared to CHA. Discrimination and common mental disorders of undergraduate students of the Universidade Federal de Santa Catarina. The pathogenic and consistent effect of discrimination on mental health has been largely documented in the literature.
However, there are few studies measuring multiple types of discrimination, evaluating the existence of a dose-response relationship or investigating possible effect modifiers of such an association. To investigate the association between experiences of discrimination attributed to multiple reasons and common mental disorders , including the adjustment for potential confounders, assessment of dose-response relations, and examination of effect modifiers in undergraduate students from southern Brazil.
In the first semester of , 1, students from the Universidade Federal de Santa Catarina answered a self-administered questionnaire on socio-demographic characteristics, undergraduate course, experiences of discrimination and common mental disorders. The study results showed that students reporting discrimination at high frequency and intensity were 4.
However, the relationship between discrimination and common mental disorders was protective among Electrical Engineering students, when compared to Accounting Sciences students who did not report discrimination. The findings suggest that the dose-response relationship between experiences of discrimination and common mental disorders reinforces the hypothetical causal nature of this association. Nevertheless, the modification of effect caused by the undergraduate course should be considered in future studies for a better understanding and measurement of both phenomena.
The aim of the study was to determine the prevalence of symptoms of common mental disorders among professional rugby players across countries. A cross-sectional analysis of the baseline questionnaires from an ongoing prospective cohort study was conducted. Nine national players' associations and three rugby unions distributed questionnaires based on validated scales for assessing symptoms of common mental disorders. These findings support the prevalence rates of symptoms of common mental disorders found in previous studies among professional i.
Awareness of the prevalence of symptoms of common mental disorders should be improved in international rugby, and an interdisciplinary approach including psychological attention should be fostered in the medical care of professional rugby players. Adequate supportive measures to enhance awareness and psychological resilience would lead not only to improved health and quality of life among rugby players but arguably to enhanced performance in rugby. Common mental disorders in public transportation drivers in Lima, Peru. Traffic related injuries are leading contributors to burden of disease worldwide.
In developing countries a high proportion of them can be attributed to public transportation vehicles. Several mental disorders including alcohol and drug abuse, psychotic disorders , mental stress, productivity pressure, and low monetary income were found predictors of high rates of traffic related injuries in public transportation drivers. The goal of this study was to estimate the prevalence of common mental disorders in the population of public transportation drivers of buses and rickshaws in Lima, Peru. Cross sectional study. A sample of bus and rickshaw drivers was systematically selected from formal public transportation companies using a snowball approach.
Participants completed self-administered questionnaires for assessing major depressive episode, anxiety symptoms, alcohol abuse, and burnout syndrome. Socio demographic information was also collected. A total of bus and rickshaw drivers out of 25 companies agreed to participate in the study. The estimated prevalence of each variable was The estimated prevalence of alcohol abuse was Common mental disorders such as alcohol abuse, major depressive episode, anxiety symptoms and burnout syndrome presented higher rates in public transportation drivers than general population.
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Management of common behaviour and mental health problems. Behavioural problems are usually influenced by both biological and environmental factors. Disruptive behavioural problems such temper tantrums or attention deficit hyperactivity disorder are displayed during the first years of childhood. Breath-holding attacks are relatively common and are an important problem. Although the attacks are not serious and the prognosis is usually good, parents often fear that their child may die during an attack.
Parents therefore require explanation and reassurance from health professionals. Conduct disorders often referred to as antisocial behaviours , such as aggression to others or theft, are more serious as they tend to be repetitive and persistent behaviours where the basic rights of others are violated. Emotional problems, such as anxiety, depression and post-traumatic stress disorder tend to occur in later childhood, and are often unrecognised because young children often find it difficult to express their emotions, or it may go unnoticed by the child's parents.
This article briefly discusses the most common behavioural problems, including autism, that affect children of all ages. Psychotic experiences and suicide attempt risk in common mental disorders and borderline personality disorder. Subha ,. Sarita Chaudhary ,. Ramu ,. Apurvakumar Pandya ,. Siddhi Pandya. Vimala ,. Gunjan Garg ,. Daleep Parimoo. Debarun Chakraborty ,. Monu Lal Sharma ,.
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Barua , Hitesh Gupta Editor it was amazing 5. Urhekar , Asha T. Kore , Hitesh Gupta Editor 0. Research Methodology by Hitesh Gupta , S. Gupta 0. Coli by Anahita V. Hodiwala , Y. To determine the degree of met and unmet needs of registers, local experts, societies, sales force registers substitution patients. This list originally contained over 3, names Part II longitudinal component and addresses. All these names were linked within one register and cross-checked by phone, letter, question- 1.
The 2. A comprehensive description of this pre- 3. To test whether the extent to which psychological liminary register work has been described in a separate and social interventions have been provided influ- publication Wittchen et al. To examine whether patients treated with methadone or buprenorphine differ in month Initial sampling considerations follow-up health outcomes. For this goal a wider The goal of the COBRA study is to provide a represen- range of criteria will be considered natural course tative picture of substitution doctors as well as their and outcome, quality of care, reduction of medical patients.
We assumed that the main study should Building on a nationwide sample of substitution doc- include a random sample of approximately doctors tors in Germany in , we adopted a complex to reflect sufficiently the variety of substitution set- sequential design with five steps and components tings in Germany, ranging from small primary care Figure 1 : settings with few patients to large specialized centres with hundreds of patients per day, as well as the 1.
Preliminary work to establish a register. This number 2. Figure 1. The main study differ considerable and systematically with regard to was originally designed as a target day assessment, and structural characteristics for example, personal and we estimated that doctors could be expected to enrol social interventions as well as the predominant and and document on average 10 to 12 consecutive preferred treatments applied.
For example, in small patients into the study. This fairly low number was due provider settings mostly primary care type, with a few to a quite demanding assessment procedure requesting patients per day only , the proportion of patients the doctors to spend at least 20 minutes face to face treated with buprenorphine to those treated with with each patient to complete the standardized clini- methadone is In contrast, in large substitution cal appraisal in addition to the informed consent, centres, the proportion is Similar marked differ- urine screening and the time for each patient to fill out ences are apparent with regard to the breadth and the questionnaire.
Based on these considerations — scope of additional intervention components social supported by initial power calculations to detect differ- and psychological interventions within the setting. Evidence becoming available from the preparatory We thus stratified the providers into a small settings register work soon revealed two significant, interre- with less than 10 opioid addicted patients a day, b lated complications that required us to adopt a medium-size providers with 10—40 and c large modified, complex sampling strategy for both the sam- settings with more than 40 patients a day.
Table 1 column D agree to participate in both the main and the follow- shows the final distribution by type of setting in this up component — by filling out a contract and main study sample. For each patient enrolled and docu- mented in the main study, the doctors received Final sampling of patients Trained study monitors performed the enrolment of Further evidence from the preparatory work revealed the doctors.
Therefore, study, constituting a response rate of The settings were requested to list all time restrictions of other type Because tution drugs, before an equal number of at least five funding did not allow us to enrol all settings into methadone and five buprenorphine patients were the main study, we randomly selected from these approached for participation by a prefixed algorithm.
Furthermore, it allowed us to estimate roughly tings column A; for details, see Wittchen et al. Distribution of substitution doctors in Germany estimated , the prestudy and the main study sample A. Germany B. Prestudy doctor sample C. Main study sample D. It should be noted that the absolute drug sampling scheme for patients in the participating number of buprenorphine cases was quite low for large settings. Table 2 shows the total number of patients listed by Patients: recruitment and in-and exclusion criteria type of setting and drug and the response rate along During the assessment period from February to April with information about patients refusing participation.
The list was stratified by type of substitution small settings were not required to use the listing proce- drug, and it showed the distinction between patients dure at all. The middle part B shows the rates for all with new onset up to 4 weeks ongoing and those with settings with a valid recruitment procedure. Each As can be seen in the row of total patients listed C doctor was requested to sample at least 12 patients total , a considerably higher number of patients treated according to a prefixed random designation sheet. This burden- the inclusion criteria. The most frequent reason for some recruitment list procedure was chosen to avoid ineligibility was that a sufficient number of patients systematic selection of special patients and to allow for for the respective condition had already been enrolled the estimation of the prevalence of buprenorphine- and successfully strata full.
Other relatively frequent rea- methadone-treated patients in each setting. Each eligible patient should be asked to participate by explaining the study rationale, handing over the Representativeness of the prestudy and main study sample study information and signing the informed consent To examine whether our doctors sample could be form. This procedure was chosen to avoid systematic regarded as roughly representative for all substitution selection of special patients.
As we conducted a non- settings in terms of their geographical distribution, we interventional naturalistic study, inclusion and compared the nationwide distribution of our prestudy exclusion criteria were minimal. All consecutive and the final main study sample with the official BfArM patients 16 years or older with a past or current opioid nationwide regional distribution by Laender. Using addiction problem were eligible. Exclusion criteria the official, yet confidential, federal data for as the applied for patients with acute emergencies, those who standard, in Table 3, we present overall relatively similar were cognitively so impaired that they could not fill out distributions in each of the COBRA sampling stages.
Disregarding the few cases receiving derive the appropriate weighting scheme. Overall scale settings as found in the BfArM data register.
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Total number of patients listed by type of setting and drug, non-eligible and eligible patients and response rate Type of setting small medium large total Meth. Table 3. Cross-tabulation of the proportions of small vs. This card should also reduce changes from avoidable loss and attrition and allow intermediate interviews to be planned and con- to increase their awareness that particular patients ducted with those patients who stop treatment with were part of the follow-up study. In the month their doctors in the follow-up interval.
Furthermore, a interval, it is likely that relying on retrospective infor- dropout interview for all patients stopping substitution mation only will result in a considerable loss of data. The month follow-up patterns; practice characteristics in terms of staff, ser- interviews are scheduled to take place between vices, attitude to guidelines and indication, allocation February and May , approximately 12 months and withdrawal decisions of substitution therapy.
As after the main study. Patient questionnaire Urine screens Upon signing the informed consent form, the patients In addition, from all patients, a standardized urine were asked to complete a page patient question- screening supervised by a nurse was obtained to con- naire. Test-retest reliability HIV ; findings are currently being analysed Wittchen et al. The doctors received the final tions — was assessed and evaluated by the doctor using study material at least 2 weeks before the start of the a standardized appraisal form.
This seven-page main study, had to complete at least two practice appraisal covers the following domains see Table 3 : assessments up-front and had the opportunity to con- tact the study telephone hotline to clarify issues. The fact that our we adjusted for non-response in each strata. The statis- COBRA proportions of small versus large settings are tical analyses for the cross-sectional study will largely almost identical to those in the Federal Register, as are be descriptive.
We will approach. First, For the follow-up primary outcome criteria, discrete some centres evidently were not properly sampling the time survival modelling will be applied for selected patients for the study randomly. With regard to the comparisons between treated patients. Second, the patient sample does not treatments, the study is powered to detect differences reflect the total of all patients treated in the participat- even when provider strata are considered.