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By N. Pranck. Seattle University.

Applications for commercial reproduction should be addressed to: NIHR Journals Library cheap levitra 10 mg line, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Examples of positive impacts by the Clinical Commissioning Groups In the pilot phase in 2014 we had been somewhat surprised to hear the response from accountable officers and chairpersons that the main achievements had been to establish the CCGs and make appointments. In other words, they focused on process aspects and institution building. So, although at that time they were relatively new bodies, they had been in existence for around 2 years in statutory and shadow form and we were expecting to see some more substantial claims about new initiatives and their progress. Therefore, by the time of the survey in 2016, we expected to hear much more about meaningful impacts and service improvements. Some respondents struggled to cite any examples of significant impacts made by their CCG. Most respondents were able to list a few impacts, albeit often the claimed initiatives were in the early stages. The claimed impacts ranged across primary, secondary and community services. Notably, there was very little reference to the use of commissioning and decommissioning as tools for bringing about change. Another notable point is that impact is often perceived in process- improvement terms – such as building positive working relationships, engaging stakeholders and stimulating discussions. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 33 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. FINDINGS FROM THE NATIONAL SURVEYS As predicted by institutional theory, there appeared to be considerable evidence of imitation. CCGs form a loose community of practice, they have learned a common language, and their ambitions are, in part at least, formed by the wider institutional field. Other comments were responses to national initiatives: use of the Better Care Fund (BCF); co-commissioning. Conversely, some referred to initiatives being stopped by NHSE. A straightforward frequency count of the most-mentioned impacts resulted in the following list of 10 in ranking order: 1. Improving Access to Psychological Therapies (IAPT) self-referral] 3. GP out of hours; federations and practice collaborations 5. Mentioned less frequently were any significant impacts on secondary care or much deployment of the power of commissioning and decommissioning. Indeed, it was also notable and curious that, given all of the talk about prime contractor arrangements and outcome-based commissioning, there was no mention of these in response to the question about the main impact of the CCG to date, or at least not directly. These forms of contracting were implicit in some of the responses about MSK and to a lesser extent in relation to changes in services for the frail elderly, but still there was no explicit mention. It might be suggested that this is because, even where arrangements had been made, it was rather too early to measure actual impact in terms of outcomes. Fortunately, we had a specific question on prime contracting and outcomes-based commissioning. Assessment of service redesign progress The preliminary pilot work had alerted us to the need to distinguish between broad plans and actual activity. However, it does seem to indicate that CCG office holders had a pretty good sense of how well their organisations were performing. There was evidence to support an optimistic view of the worth and importance of CCGs and of the role of clinical leaders, but there was also some evidence to support a more pessimistic view. Likewise, within CCGs, there were indicators of the influence exercised by GPs. They were assessed as broadly as influential as managers. Other data pointing towards an optimistic view can be found in assessments of who sets the compelling vision – a significant indicative role in the context of these bodies. Trends in communication with secondary care clinicians and with patients and the public also offered grounds for optimism. The overall assessment of the influence of clinical leadership was that they were central to nearly all service redesigns (35%) or in a significant proportion of redesigns (25%). Taken together, this suggested that around 60% of respondents claimed a key role for clinical leadership in practice. Positive assessments of CCG influence were more often made by chairpersons and accountable officers (i. In contrast, finance officers and GP board members were much less inclined to offer a positive assessment.

Altogether buy levitra 10 mg without prescription, 249 relatives (nearly 60%) were the diagnoses were combined into a single category of 'neu- directly interviewed. Although the prevalence of OCD was roticism,' the MZ correlations were significantly higher not significantly increased among relatives of OCD pro- than for the DZ twins; (0. In particular, there was an increase in the rate of 'subclini- In summary, all twin studies to date are consistent with cal' OCD among parents of OCD probands when com- the hypothesis that genetic factors are important for the pared to parents of controls. The following caveat should expression of OCD and the specific symptoms necessary be noted when interpreting these findings. Furthermore, the two most recent of psychiatric disorders, direct interviews, family history studies (94,97) suggest that some of the same genetic factors data, and medical record data are used to make 'best esti- may be important for the manifestation of some other anxi- mate' diagnoses (104). Given the secrecy of many OCD patients and their tendency to hide their Family Studies illness, it is possible that some family members denied symp- Data from the majority of family studies completed over tomatology on direct interview. As noted in the report, fam- the past 60 years suggest that OCD is familial (7); however, ily history data were collected by Black and colleagues but rates of illness among relatives vary from study to study. When Many of the studies completed prior to 1990 are difficult those family history data are included, the recurrence risk to interpret because of differences in diagnostic criteria and among first-degree relatives is 9. Some of the Using this estimate for the risk to relatives, the ranges shortcomings of this early research were addressed in six between 1. All of these studies demonstrate In 1995, Pauls and colleagues (57) reported the results that OCD and related conditions are familial. The age corrected rate of dren and adolescents and found that 17% of the parents OCD (10. In a second OCD probands when compared to controls (1. A fa- study of the families of children and adolescents, Leonard milial relationship has been reported between OCD and and co-workers (99) found that 13% of first-degree first- GTS and chronic tics (CT) (105) and it has been speculated degree relatives of OCD probands met DSM criteria for that familial OCD is that type that is related to GTS. Although this rate is cantly higher among relatives of OCD probands than somewhat lower than other studies, it nevertheless repre- among controls in this study, the patterns within the fami- sents a twofold increase over available population prevalence lies suggested that much of OCD is not related to GTS; estimates. Of note is that when probands were separated the majority of OCD individuals did not have a personal on the basis of age at onset, the morbid risk for OCD among or family history of GTS or tics; however, many did have relatives of early onset (before age 14) probands was 8. A shortcoming of these three studies is that none Finally, in the most recent and methodologically sound included a control sample. However, assessments in all of family study of OCD, Nestadt and colleagues (102) re- them were done using structured interviews that were used ported that 11. The best estimate of the popula- probands met DSM-III-R criteria for OCD compared to tion prevalence for OCD from the most recent epidemio- only 2. The methods used in this study were logic study (103) is 2. That is, the investigators directly interviewed all ington, DC). Using this estimate of prevalence, the relative available first-degree relatives and obtained family history risk ( ) (the ratio of illness among relatives to the population data for all first-degree relatives. Best estimate procedures prevalence) (103) for these two studies ranged between 4. Black and colleagues (101) studied families of 32 Nevertheless, it is remarkable that the estimates of recur- Chapter 112: The Pathophysiology and Genetics of OCD 1613 rence risk obtained in the two studies were not significantly ual, religious and somatic obsessions and related checking different. Using available population prevalence estimates behavior was 23. There was no relationship between reliable and valid, it has also become clear over the last risk to relatives and proband factor scores for the other fac- decade that there is considerable variability of symptomatol- tors. As discussed, results of complex segregation analyses ogy across individuals who have a diagnosis of OCD. Given that incorporated these factors scores suggested that there this variability, a number of investigators have begun re- were different patterns of transmission within families that search to explore the possibility that subtypes/components were related to the factor scores of the probands. Unfortu- of OCD might be distinguished on the basis of some fea- nately, the number of affected relatives for whom it was tures of the disorder. Several analyses have been completed possible to generate factor scores was too small to allow to determine whether more homogeneous groups of OCD meaningful analyses designed to determine whether the fac- patients could be identified that were also more likely to tor scores of affected relatives were correlated with the factor be familial. One way of grouping individuals that has helped scores of the probands. Analyses of age at onset of OCD disorder with different familial patterns being associated indicate that early-onset OCD is more likely to be familial with different clinical characteristics of OCD. However, there is still considerable familial heter- familial patterns, it is likely that several genes contribute to ogeneity within this group because a substantial proportion the manifestation of the disorder. It is quite plausible that of early-onset OCD cases are not familial (7). Separately examining these components of the phenotype rather than subtypes of pa- component parts of the phenotypic spectrum with regard tients is factor analysis. A number of investigators have com- to their transmission within families and the possible role pleted factor analyses on at least four independent samples of genetic factors could facilitate the identification of the of individuals with OCD (106–109). In all of these analyses genes involved in the manifestation of OCD. One factor was best characterized by aggressive, sexual, religious, and somatic Segregation Analyses obsessions and related checking behavior (in the most recent set of analyses, this factor appeared to split into two separate Together, the family and twin study data provide compel- factors).

These findings have led to the hypothesis that BI is found that parental psychopathology was a risk factor for related to a lowthreshold for arousal in the amygdala and the development of disorder only among the lower socioeco- hypothalamus (8) cheap 10mg levitra amex. This characteristic, which appears to be nomic status (STS) portion of their sample. It has been present in 10% to 15% of children, has been identified in suggested that environmental factors play a significant role children as young as 14 months, has been shown to persist in the manifestation of specific psychopathology (1). Anxi- throughout childhood (9), and is more commonly found ety in particular is believed to be related to a combination in offspring of anxious parents (8). The inhibited tempera- of negative affect, a sense of lack of control over situations ment has been associated with risk of developing an anxiety or environments, and attentional self-focus. Early experi- disorder, most commonly social phobia (10). This lack of differentiation appears to be character- istic of younger children, with increased specificity develop- Murray B. Lang: Department of Psychiatry, University ing over time (11,12). At least by middle childhood, there of California–San Diego, San Diego, California. Spence (12) conducted a confirmatory 11 to 16), but that there was a substantial amount of new factor analysis with data from children of 8 to 12 years. Their con- best model included six correlated factors—panic-agora- clusion was that the disorder may be trait-like for those who phobia, social phobia, separation anxiety, obsessive-compul- exhibit symptoms early and that the development of the sive problems, generalized anxiety, and fear of physical in- disorder in others may be triggered in adolescence. Cantwell jury (including dogs, dentists, heights, doctors)—and a and Baker (23) also found considerable stability; 25% of single higher-order factor reflecting overall anxiety. Estimates of prevalence and recovery vary widely limits the usefulness of this estimate). In contrast, Last et because of a lack of standardization of criteria, assessment al. A fewgeneral another anxiety disorder and 25% had developed a depres- conclusions can be drawn about childhood internalizing dis- sive disorder. Internalizing symptoms appear to remain fairly sta- GAD/OAD is a frequently co-occurring disorder. Among boys, internalizing symptoms those with a primary diagnosis of OAD, there is often an are not only predictive of later internalizing symptoms but additional diagnosis of separation anxiety disorder (37% to also of subsequent externalizing problems (15). Although 44%), social phobia (4% to 57%), simple phobia (9% to there may be high rates of recovery associated with a particu- 43%) or a depressive disorder (1% to 69%) (24). There are lar anxiety disorder, children who recover are at increased a number of potential reasons for the high rates of comor- risk of developing other psychiatric diagnoses, most com- bidity, including true covariation of distinct disorders, the monly other anxiety disorders or depressive disorders (16). Among young children, the disorder often and course. For children in general, compulsions alone are more common than obsessions alone (26). The most common compulsions Generalized Anxiety Disorder (GAD) include washing/cleaning, repeating/redoing, and checking, GAD is characterized by excessive anxiety or worry, which and the most common obsessions include germs/contami- is difficult to control and is accompanied by symptoms of nants and fear of harm to the self or to another (26). The GAD diagnosis symptoms change over time in 90% of children (4). Mean age of onset is approxi- about future events, personal safety, and social evaluation, mately 10 years. Information about the course of OCD is and often present with multiple somatic complaints, such variable and may be best described as chronic but fluctuat- as headaches and stomachaches (19). During the 2- to 7-year follow- was used previously. Prevalence estimates of OAD tended up period, the patients on average received two different to be quite variable, 2% to 19% (19), and often very high, modalities of treatment (medication, behavioral therapy, partially because functional impairment was not necessary other individual therapy, and family therapy), with 96% for the diagnosis (20). Recent estimates of the prevalence having had additional psychopharmacologic treatment and of GAD are in the range of 2. In spite of ongoing to be more prevalent in older children and in girls (19). Of Information about course is not yet available for the the 11% who were symptom-free, only three (of 54) patients GAD diagnosis, but some extrapolation from OAD is possi- had no symptoms and were not on current medications. Other estimates of be interpreted with caution because it is based on a single, continued OCD at follow-up (1. The Posttraumatic Stress Disorder (PTSD) most common co-occurring conditions include other anxi- To meet the criteria for a diagnosis of PTSD, a person must ety disorders (38%), tic disorders (24% to 30%), mood have been exposed to a traumatic event and as a result is disorders (26% to 29%), and specific developmental disabil- exhibiting symptoms of reexperiencing, numbing/avoid- ities (24%) (26). A recent confirmatory factor analytic history of tic disorder and current affective disorder at base- study supported the presence of these three basic clusters line were associated with poorer outcome.

In addition buy generic levitra 10mg on line, in the azotemic patient with ASO- Atheroembolism RAD, one should exclude other potential or contributing causes of renal insufficiency such as obstructive uropathy, primary glomerular disease (suggested by heavy proteinuria), drug-related renal insufficiency (eg, nonsteroidal anti-inflammatory drugs), and uncontrolled blood pressure. Renovascular Hypertension and Ischemic Nephropathy 3. Atherosclerotic renal artery disease (ASO- 11% Other RAD) has been claimed to contribute to the ESRD population. This diagram from the US Renal Data System Coordinating Center 1994 report indicates that 29% of calendar year 12% 1991 incident patients entered ESRD programs because of “hypertension (HBP). Crude estimates of the percentage of patients entering DM ESRD programs because of ASO-RAD range from 1. Precise bases for making 5% these estimates are both unclear and confounded by the high likelihood of coexisting arterio- Urology 29% lar nephrosclerosis, type II diabetic nephropathy, and atheroembolic renal disease. ASO-RAD High blood as a major contributor to the ESRD population is probably small on a percentage basis, occu- 3% pressure Cyst pying some portion of the ESRD diagnosis “hypertension (HBP). Treatment of Renovascular Hypertension and Ischemic Nephropathy FIGURE 3-39 TREATM ENT OPTIONS FOR RENOVASCULAR Treatment options for renovascular hypertension and ischemic HYPERTENSION AND ISCHEM IC NEPHROPATHY nephropathy. The main goals in the treatment of renovascular hyper- tension or ischemic nephropathy are to control the blood pressure, to prevent target organ complications, and to avoid the loss of renal Pharmacologic antihypertensive therapy function. Although the issue of renal function may be viewed as PTRA mutually exclusive from the issue of blood pressure control, uncon- trolled hypertension may hasten a decline in renal function, and Renal artery stents renal insufficiency may produce worsening hypertension. Even in the Surgical renal revascularization presence of excellent blood pressure control, progressive arterial stenosis might worsen renal ischemia and promote renal atrophy and fibrosis. Therapeutic options include pharmacologic antihypertensive therapy, percutaneous transluminal renal angioplasty (PTRA), renal artery stents, and surgical renal revascularization. Pharmacologic anti- hypertensive therapy is covered in more detail separately in this Atlas. FIGURE 3-40 INCREASING COM ORBIDITY IN PATIENTS Com orbidity in patients undergoing renovascular surgery. Patients UNDERGOING RENOVASCULAR SURGERY presenting for renovascular surgery or endovascular renal revascu- larization are at high-risk for com plications during intervention because of age, and frequently associated coronary, cerebrovascular, Comorbidity, % or peripheral vascular disease. As the population ages, the percentage of patients being considered for interventive m aneuvers on the Condition 1970–1980 1980–1993 renal artery has increased significantly. Congestive heart failure, cerebrovascular disease (eg, carotid Cerebrovascular disease 11. REVASCULARIZATION FOR ATHEROSCLEROTIC RENOVASCULAR DISEASE Severe atherosclerosis of the abdom inal aorta m ay render an aortorenal bypass or renal endarterectom y technically difficult Preoperative screening and correction of coronary and carotid artery disease and potentially hazardous to perform. Avoidance of operation on severely diseased aorta Effective alternate bypass techniques include Unilateral revascularization in patients with bilateral renovascular disease splenorenal bypass for left renal revascular- ization, hepatorenal bypass for right renal revascularization, ileorenal bypass, bench surgery with autotransplantation, and use FIGURE 3-41 of the supraceliac or lower thoracic aorta Dim inished operative m orbidity and m ortality following surgical revascularization for (usually less ravaged by atherosclerosis). O perative m orbidity and m ortality in patients under- Sim ultaneous aortic replacem ent and renal going surgical revascularization have been m inim ized by selective screening and/or correc- revascularization are associated with an tion of significant coexisting coronary and/or carotid artery disease before undertaking increased risk of operative m ortality in elective surgical renal revascularization for atherosclerotic renal artery disease. Screening com parison to renal revascularization alone. Som e surgeons advocate unilateral renal Screening tests for coronary artery disease include thallium stress testing, dipyridam ole revascularization in patients with bilateral stress testing, dobutam ine echocardiography, and coronary arteriography. FIGURE 3-42 Schem atic diagram of alternate bypass procedures. A B C D Renovascular Hypertension and Ischemic Nephropathy 3. PTRA of the renal artery has em erged as an im portant inter- A, High-grade (more than 75% ) nonostial atherosclerotic stenosis of the ventional m odality in the m anagem ent of patients with renal left main renal artery in a patient with a solitary functioning kidney (right artery stenosis. PTRA is m ost successful and should be the initial renal artery totally occluded). Note gradient of 170 mm Hg across the interventive therapeutic m aneuver for patients with the m edial stenotic lesion. B, Balloon angioplasty of the left main renal artery was fibroplasia type of fibrous renal artery disease (eg, Fig. Repeat nonostial atherosclerotic lesions of the m ain renal artery, as aortogram 3 years later demonstrated patency of the left renal artery. FIGURE 3-44 H igh-grade athero- sclerotic renal artery stenosis at the ostium of the right m ain renal artery in a 68-year-old m an with a totally occluded left m ain FIGURE 3-45 renal artery. Because percutaneous transluminal renal attem pts at balloon angioplasty (PTRA) has suboptimal long-term benefits for athero- dilatation were sclerotic ostial renal artery stenosis, endovascular stenting has gained unsuccessful. From a technical standpoint, indications oped (serum creati- for renal artery stenting include 1) as a primary procedure for ostial nine increasing from atherosclerotic renal artery disease (ASO-RAD), 2) technical difficul- 2. Renal function never It is unclear what the long-term patency and restenosis rates will be im proved and the for renal artery stenting for ostial disease. Preliminary observations patient rem ained suggest that the 1-year patency rate for stents is approximately twice on dialysis. SURGICAL REVASCULARIZATION VERSUS FOR ATHEROSCLEROTIC RENAL ARTERY DISEASE PTRA FOR FIBROUS RENAL ARTERY DISEASE Successful surgical Successful surgical Lesion Successful PTRA, % revascularization, % Lesion Successful PTRA, % revascularization, % Nonostial 80–90 90 Main 80–90 90 (20%) (50%) Ostial 25–30 90 Branch NA 90 (80%) (50%) FIGURE 3-47 Surgical revascularization vs percutaneous translum inal renal The “percent success” for PTRA and surgical revascularization angioplasty (PTRA) for renal artery disease.