Dancing with the patient: a qualitative study of general practitioners' experiences of managing patients with multimorbidity and common mental health problems.

BACKGROUND: Patients with multimorbidity, having two or more chronic diseases, suffer frequently from undiagnosed common mental health problems and are an increasing challenge in primary care. There is a call to improve care delivery to address all these patients' needs at the same time. The aim of this study was to identify general practitioners' experiences of managing patients with multimorbidity and common mental health problems in primary care. METHODS: We conducted five focus group interviews with 28 physicians (3-8 participants in each group) in 5 primary care practices in and outside of Stockholm, Sweden. We used a semi-structured interview guide, and we analysed the data using reflexive thematic analysis. The methodological orientation of the study was inductive, latent constructivism. RESULTS: We generated two themes from the data: Unmet patient needs and fragmented care send patients and physicians off balance and Dancing with the patient individually and together with others leads to confident and satisfied patients and physicians. The two themes are related as general practitioners expressed a need to shift from disease-specific fragmentation to relational continuity, teamwork, and flexibility to meet the needs of patients with multimorbidity and common mental health problems. CONCLUSIONS: These findings can provide guidance in developing future interventions for patients with multimorbidity and common mental health problems in primary care in general, and in Sweden in particular.

Age is associated with increased mortality in the RETTS-A triage scale.

BACKGROUND: Triage is widely used in the emergency department (ED) in order to identify the patient's level of urgency and often based on the patient's chief complaint and vital signs. Age has been shown to be independently associated with short term mortality following an ED visit. However, the most commonly used ED triage tools do not include age as an independent core variable. The aim of this study was to investigate the relationship between age and 7- and 30-day mortality across the triage priority level groups according to Rapid Emergency Triage and Treatment System - Adult (RETTS-A), the most widely used triage tool in Sweden. METHODS: In this cohort, we included all adult patients visiting the ED at the Karolinska University Hospital, Sweden, from 1/1/2010 to 1/1/2015, n = 639,387. All patients were triaged according to the RETTS-A and subsequently separated into three age strata: 18-59, 60-79 and ≥ 80 years. Descriptive analyses and logistic regression was used. The primary outcome measures were 7- and 30-day mortality. RESULTS: We observed that age was associated with both 7 and 30-day mortality in each triage priority level group. Mortality was higher in older patients across all triage priority levels but the association with age was stronger in the lowest triage group (p-value for interaction = < 0.001). Comparing patients ≥80 years with patients 18-59 years, older patients had a 16 and 7 fold higher risk for 7 day mortality in the lowest and highest triage priority groups, respectively. The corresponding numbers for 30-d mortality were a 21- and 8-foldincreased risk, respectively. CONCLUSION: Compared to younger patients, patients above 60 years have an increased short term mortality across the RETTS-A triage priority level groups and this was most pronounced in the lowest triage level. The reason for our findings are unclear and data suggest a validation of RETTS-A in aged patients.

Lane formation in a driven attractive fluid.

We investigate nonequilibrium lane formation in a generic model of a fluid with attractive interactions, that is, a two-dimensional Lennard-Jones fluid composed of two particle species driven in opposite directions. Performing Brownian dynamics simulations for a wide range of parameters, supplemented by a stability analysis based on dynamical density functional theory, we identify generic features of lane formation in the presence of attraction, including structural properties. In fact, we find a variety of states (as compared to purely repulsive systems), as well as a close relation between laning and long-wavelength instabilities of the homogeneous phase such as demixing and condensation.

[Psychotherapy of depression in old age]. / Psychotherapie der Altersdepression.

Depression in old age is common and also dangerous due to somatic comorbidity and suicide; however, it is often not recognized and not adequately treated. Psychotherapy is almost never offered to the elderly. However, clinical experience, single-case studies and some controlled trials show effectiveness--at least to the age of 75. The psychotherapist must be aware of unusual transference and countertransference between a younger therapist and elderly patient. Psychotherapy in old age requires some modifications, especially concerning special interest in biography and history, strong empathy, "container function", and focusing. In the future, psychotherapy for the elderly should be both investigated and educated more. In addition, it is hoped that psychotherapists offer to treat elderly people with depression and that more older patients accept this professional help.

Combined medical-psychiatric inpatient units: evaluation of the Centre for the Elderly.

Considering the large number of elderly patients in acute hospitals who receive medical as well as psychiatric treatment because of relevant comorbidity, adequate interdisciplinary treatment models have to be developed and applied. The Centre for Elderly, a cooperation project between the departments of geriatric and psychogeriatric medicine in a community hospital in Germany, was founded in 2000. In addition to traditionally structured units, the centre consists of interdisciplinary units. Patient-, staff- and hospital-related characteristics influenced by the reformation of both departments were evaluated by comparing hospital-based registry data records containing age, gender, main and minor diagnoses, length of stay and patient transferrals within the centre. Experts working at the centre were asked to take a stand on the development of the treatment quality, allocation of patients, diagnostic procedures, consultation services and information transmission. The number of admissions to the Centre for the Elderly increased within one year. The distribution of the main diagnose groups remained unchanged, with an overlap between the geriatric and psychogeriatric department consisting of the main diagnoses dementia and depression. The length of stay and the number of transferrals decreased significantly in both departments. The majority of the interviewed employees stated that the treatment quality and the allocation of patients were improved. We conclude that interdisciplinary treatment between the departments of psychiatry and geriatric medicine may contribute to the medical needs of subgroups of elderly inpatients suffering from medical-psychiatric comorbidity.

Escherichia coli P fimbriae utilize the Toll-like receptor 4 pathway for cell activation.

Fimbriae mediate bacterial attachment to host cells and provide a mechanism for tissue attack. They activate a host response by delivery of microbial products such as lipopolysaccharide (LPS) or through direct fimbriae-dependent signalling mechanisms. By coupling to glycosphingolipid (GSL) receptors, P fimbriae trigger cytokine responses in CD14 negative host cells. Here we show that P fimbriae utilize the Toll-like receptor 4 (TLR4)-dependent pathway to trigger mucosal inflammation. Escherichia coli strains expressing P fimbriae as their only virulence factor stimulated chemokine and neutrophil responses in the urinary tract of TLR4 proficient mice, but TLR4 defective mice failed to respond to infection. Mucosal cells were CD14 negative but expressed several TLR species including TLR4, and TLR4 protein was detected. Infection with P fimbriated bacteria stimulated an increase in TLR4 mRNA levels. The activation signal did not involve the LPS-CD14 pathway and was independent of lipid A myristoylation, as shown by mutational inactivation of the msbB gene. Co-staining experiments revealed that TLR4 and the GSL receptors for P fimbriae co-localized in the cell membrane. The results demonstrate that P fimbriae activate epithelial cells by means of a TLR4-dependent signalling pathway, and suggest that GSL receptors for P fimbriae can recruit TLR4 as co-receptors.

Type 1 fimbriae deliver an LPS- and TLR4-dependent activation signal to CD14-negative cells.

Fimbriae target bacteria to different mucosal surfaces and enhance the inflammatory response at these sites. Inflammation may be triggered by the fimbriae themselves or by fimbriae-dependent delivery of other host activating molecules such as lipopolysaccharide (LPS). Although LPS activates systemic inflammation through the CD14 and Toll-like receptor 4 (TLR4) pathways, mechanisms of epithelial cell activation by LPS are not well understood. These cells lack CD14 receptors and are unresponsive to pure LPS, but fimbriated Escherichia coli overcome this refractoriness and trigger epithelial cytokine responses. We now show that type 1 fimbriae can present an LPS- and TLR4-dependent signal to the CD14-negative epithelial cells. Human uroepithelial cells were shown to express TLR4, and type 1 fimbriated E. coli strains triggered an LPS-dependent response in those cells. A similar LPS- and fimbriae-dependent response was observed in the urinary tract of TLR4-proficient mice, but not in TLR4-defective mice. The moderate inflammatory response in the TLR4-defective mice was fimbriae dependent but LPS independent. The results demonstrate that type 1 fimbriae present LPS to CD14-negative cells and that the TLR4 genotype determines this response despite the absence of CD14 on the target cells. The results illustrate how the host "sees" LPS and other microbial products not as purified molecules but as complexes, and that fimbriae determine the molecular context in which LPS is presented to host cells.

P fimbriae-dependent, lipopolysaccharide-independent activation of epithelial cytokine responses.

Cells in the mucosal barrier are equipped to sense and respond to microbes in the lumen and translate this molecular information into signals that can reach local or distant sites. The interaction of P-fimbriated Escherichia coli with human uroepithelial cells is a model to study the molecular mechanism of epithelial cell activation by mucosal pathogens. Here, we examine the role of lipopolysaccharide (LPS) as a co-stimulatory molecule in epithelial cell activation by P-fimbriated E. coli. P-fimbriated clinical isolates or recombinant strains were shown to trigger a fimbriae-dependent epithelial cell cytokine response. Mutational inactivation of the msbB sequences that control lipid A myristoylation drastically impaired monocyte stimulation but not epithelial responses to P-fimbriated bacteria. Polymyxin B or bactericidal/permeability increasing factor (BPI) neutralized the effects of lipid A in the monocyte assay, but did not reduce epithelial responses. Finally, isolated LPS of the smooth, rough and deep rough chemotypes were poor epithelial cell activators. The cells were shown to lack surface CD14 or CD14 mRNA as well as the CD14 co-receptor function and were also very poor LPS responders in the presence of human serum. These results demonstrate that epithelial cell responses to P-fimbriated E. coli are CD14 and LPS independent, and suggest that attaching pathogens can overcome the LPS unresponsiveness of epithelial cells by fimbriae-dependent activation mechanisms.

[The gerontopsychiatric team in the specialized department]. / Das gerontopsychiatrische Team in der Fachabteilung.

People 65 years and older constitute a group with high risk for psychiatric disease, and their numbers are increasing. At the same time familial networks and financial resources are weakening. In order to improve psycho-geriatric therapy, we developed teamwork within our department. In the present work we describe the psycho-geriatric ward and the special functions of team members. It seems to be important that there are enough staff members who are well trained and motivated; it should be guaranteed that members regularly meet in conferences and have regular supervision; work hours should be favorable. Team process is described as consisting of imaging a comprehensive idea of the personality and the problems of the patient; agreeing on a therapeutic proceeding and-as a result-translating into action. Finally, it focuses on the necessity for further development and research.

[15 years of geriatric day care clinics in Germany]. / 15 Jahre gerontopsychiatrische Tageskliniken in der Bundesrepublik Deutschland.

Day hospital treatment for psycho-geriatric patients in the Federal Republic of Germany started in 1976. At present (October 1991) 13 psychogeriatric day hospitals are established. The day hospitals offer a wide range of diagnostic and therapeutic strategies. Though they are expected to be of great importance especially for the elderly, day hospitals don't play a significant part within the care system for psycho-geriatric patients in Germany. It seems to be recommendable, to establish more psycho-geriatric day hospitals, especially together with an out-patient department and an information centre ("Geronto-psychiatrisches Zentrum"). In addition the care system should be supplied with day centres, in particular for those patients suffering from chronic paranoid psychosis or dementia; the medical care of out-patients should be improved. Besides that the efficacy of day hospital treatment for psycho-geriatric patients should be evaluated.

Classification of parasuicide by cluster analysis. Types of suicidal behaviour, therapeutic and prognostic implications.

A classification of suicidal behaviour was derived by cluster analysis from descriptive data on parasuicide patients. The grouping was meaningful in terms of clinical interpretation and had both therapeutic and prognostic implications. The sample was broken down into three groups, identified as repeated, serious and non-serious attempts. The repeated attempters had the worst prognosis at 1-year follow-up. When the sample was classified into five groups according to seriousness of the attempts, the repeater and non-serious groups were retained, while the serious attempts were split into three subtypes, which differed on nosological characteristics, treatment disposal and outcome. An excessively high successful suicide rate was found in a small group of elderly attempters.

[Description of sociodemographic and psychiatric data of 295 patients following attempted suicide by poisoning--inpatient treatment within the scope of a psychiatric liaison service at an internal medicine clinic of a large municipal hospital]. / Beschreibung soziodemographischer und psychiatrischer Daten von 295 Patienten nach einem Suizidversuch durch Intoxikation--Stationäre Betreuung im Rahmen eines psychiatrischen Liaison-Dienstes an einer internistischen Klinik eines grossen Stadtkrankenhauses.

295 attempted suicides with intoxication are described by sociodemographic, biographic, and psychiatric characteristics. The patients were hospitalized for detoxification, and after clearing up interviewed by a psychiatrist working in the hospital as a liaison-psychiatrist. The patients did not differ essentially from patients treated in the emergency unit of another general hospital of the city in terms of basic social data. The patients--65% women, 35% men--are young (up to 40 years), 39% had already attempted suicide before the index-time. 41% came from "broken homes", 40% had one or more psychiatric disease(s) in their families. 56% were diagnosed as "psychiatrically ill", second diagnosis was in 33.5% abuse of alcohol/drugs. The referal offer to the patients for the time after discharge from emergency unit is described in detail. Just 12% of the patients were treated in a psychiatric hospital, after-care in an ambulatory setting seemed to be sufficient for most of the other patients. 20% were not offered any after-care. Patients with addiction and psychosis were sent to institutions specialized for these diagnoses.

[Treatment of patients following attempted suicide within the scope of a liaison service]. / Die Behandlung von Patienten nach einem Suizidversuch im Rahmen eines Liaisondienstes.

Only few patients after suicide attempt are examined by a psychiatrist. In order to intensify the primary psychiatric care of suicide attempters, a psychiatric liaison scheme was established at an intensive care unit of the Technical University, Munich. The main advantages are: A psychiatrist talks with every suicide attempter; the psychiatrist and the medical staff are better informed about the suicidal act and the personality of the suicide attempter because of close cooperation; there is more time for diagnostic and psychotherapeutic activities; suicide risk diminishes while staying on the medical ward. If a psychiatric liaison scheme cannot be established it should be tried to change ward atmosphere by advising the medical staff and offering emotional support.

[Suicidal behavior of the elderly]. / Die Suizidalität älterer Menschen.

Age extensively influences suicidal behaviour. Compared with younger persons, the elderly show higher suicide rates. Suicide attempts more often show characteristics of "unsuccessful suicides". Somewhat more frequent then in younger persons the suicide attempts are caused by depressive or schizophrenic psychosis. Nevertheless with the elderly the most frequent diagnoses are neurosis and depressive reaction. The elderly react depressive more often in relation to life events as conflicts with or loss of relatives or contracting a severe physical disease. Conclusions are drawn for a more adequate treatment of elderly suicidal patients with regard to their specific needs concerning psychological, physical and social problems. In many respects the G.P. seems to be the most suitable person for this task.

[On the problem of the "Seriousness" of suicide attempts]. / Zum Problem der "Ernsthaftigkeit" von Suizidversuchen.

In 15.3% of 295 hospitalized suicide attempters (94% with intoxication) severe intoxication that would have had a lethal outcome without medical treatment was significantly associated with previously described factors characterizing persons who committed suicide. A strong death wish (47.3%), as judged by physicians, was highly associated with almost the same factors. A high degree of physical harm and a firm intention to die correlated significantly with the intensity of care during hospitalization and after discharge from the emergency unit.