Solvothermal synthesis of soluble, surface modified anatase and transition metal doped anatase hybrid nanocrystals

Titanium dioxide, or titania, is perhaps the most well-known and widely studied photocatalytic material, with myriad applications, due to a high degree of tunability achievable through the incorporation of dopants and control of phase composition and particle size. Many of the applications of titanium dioxide require particular forms, such as gels, coatings, or thin films, making the development of hybrid solution processable nanoparticles increasingly attractive. Here we report a simple solvothermal route to highly dispersible anatase phase titanium dioxide hybrid nanoparticles from amorphous titania. Solvothermal treatment of the amorphous titania in trifluoroacetic acid leads to the formation of anatase phase nanoparticles with a high degree of size control and near complete surface functionalisation. This renders the particles highly dispersible in simple organic solvents such as acetone. Dopant ions may be readily incorporated into the amorphous precursor by co-precipitation, with no adverse effect on subsequent crystallisation and surface modification.

Identifying if patient's living with heart failure retain knowledge better by gaining it through lived experience rather than through education

Funding Acknowledgements

Type of funding sources: None.

Background

Self-care is when a patient possesses a set of knowledge and skills that are used to process information to make correct health decisions. Self-care in heart failure (HF) includes monitoring symptoms for deterioration in HF and having an appropriate response time in contacting their health care provider. One of the main principles of a heart failure clinic is to provide a structured education programme for the patient regarding self-care. Patient education is the leading intervention to equip patients with the skills for symptom recognition. The education aims to ensure the patient can recall the knowledge from memory if required.

Purpose

The aim of this study was to evaluate patient knowledge, through testing memory, regarding symptom recognition in a single center HF clinic. To identify if there was a difference between attaining knowledge on symptom recognition gained through lived experience versus knowledge on symptom recognition gained through education.

Methods

50 patients were recruited for this study.

Average age was 72 years old.

38 male and 12 female.

All participants had previously experienced at least one symptom of HF.

All participants had a minimum of 2 education sessions in the HF clinic.

All patients had evidence from their weight logbook of daily weight monitoring. Question "a" tests knowledge acquired from education and question "b" tests knowledge acquired from lived experience.

All participants were asked two questions:

a) what is the amount of weight increase you are monitoring for?

b) name one symptom you are monitoring that would indicate possible deterioration in HF.

Results

single center prospective analysis

Question a: 35% answered correctly

Question b: 82% answered correctly

Conclusions

Processes of learning and the transfer of learning are central to understanding how people can achieve competency in self-care. In this study patients seem to remember information better from a lived experience rather than trying to recall taught information. It important to identify the patients’ individual factors and needs to successfully support their self-care management. Further evaluation of assessing the implementation of other supports available such as, mobile Apps and multimedia-based education, to address knowledge recall deficits is needed to determine if they aid the patient to achieve competency in self-care.

Exploring Associations Between Self-Compassion, Self-Criticism, Mental Health, and Quality of Life in Adults with Cystic Fibrosis: Informing Future Interventions

Self-compassion is increasingly recognised as an important and beneficial factor in quality of life and mental health-related research, but research within the adult cystic fibrosis (CF) population is scarce. In a cross-sectional study, 114 (56 female, 58 male) adults with CF completed and returned a series of validated questionnaires that assessed CF-related quality of life, negative emotional states (depression, anxiety and stress), self-compassion, and self-criticism. Quality of life and self-compassion were positively correlated, and each in turn were inversely correlated with negative emotional states and self-criticism. Negative emotional states correlated positively to self-criticism. Self-compassion and/or self-criticism moderated ten relationships between various sub-domains of quality of life and negative emotions. Psychological interventions that increase self-compassion may be beneficial for enhancing mental health and quality of life for adults with CF.

Use of Video Consultation in Irish General Practice:The Views of General Practitioners

Introduction Video consultation involves the live interaction between the doctor and the patient remotely. Prior to the Covid-19 pandemic, the majority of video consultations in primary care were provided by GPs who were not the individual's own GP, which presented safety and continuity issues. This study aims to determine GPs' attitudes to the use of video consultation for their own patients. Methods This was a qualitative study involving semi-structured interviews. Participants were purposively recruited through use of a GP tutor as a key informant and guided by a sampling framework to include those with and without previous video consultation experience. Braun and Clarke thematic analysis was used. Results Participants included eight GPs, half of whom had previously worked with video consultation. Four themes emerged: impact on the consultation, the potential role, and the potential threat to current practice and technology and logistics. There were optimistic and cautious observations within all themes. Conclusion With the increased use of video consultation, Irish General Practice is in a unique position to frame the future its use. The provision of this modality to one's own patients may provide benefit while mitigating some of the pitfalls but would not entirely avoid the potential dangers of video consultation.

Clinical features and presentation of cervicofacial infection: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infection (CFI) is a common presentation to the Oral and Maxillofacial (OMFS) department and accounts for significant emergency activity. The current study aims to understand the aetiology, management, and clinical features of patients hospitalised with CFI. Our study included all patients admitted for management of CFI from May to October 2017 at 25 OMFS units across 17 UK regions. Data were collected prospectively and included age, comorbidities, prior treatment received, markers of sepsis, and presenting clinical features. One thousand and two (1002) admissions were recorded; 546 (54.5%) were male. Median (range) age was 34 (1-94) years. The most common presenting complaints were trismus (46%) and dysphagia (27%). Airway compromise was present in 1.7% of cases. Odontogenic infection accounted for 822/1002 (82%) admissions. Of those with an infection of odontogenic origin, 453/822 (55.1%) had received previous treatment. Two-thirds of those who had received treatment were managed by antibiotics alone (300/453, 66.2%). Patients met criteria for sepsis in 437/1002 (43.6%) of CFI, and in 374/822 (45.5%) of odontogenic infections. This is the largest study worldwide of patients requiring inpatient management for CFI. Infection due to odontogenic origin is the most frequent reason for admission and nearly half do not seek treatment before presentation. Patients with CFI often present late in their disease and frequently meet criteria for sepsis, requiring timely and aggressive treatment to ensure optimum outcomes. Trismus is an emerging dominant feature with all the implications related to the anaesthetic management of these patients. Knowledge of these factors has implications for the referrer, triage, the emergency department, the anaesthetic team, and members of the OMFS team.

Integrating intravenous frusemide treatment into the community for heart failure patients

Background

A structured pathway was developed to allow patients to safely receive intravenous (i/v) frusemide at home.

This pathway was implemented by an integrated team consisting of primary and tertiary care.

This allowed the traditional acute hospital treatment to be now delivered in the community.

Purpose

This concept has been used on an individual case basis by a minority of acute hospitals.

Previously there was no structured pathway that would allow this treatment to become a standard part of heart failure treatment by acute hospitals.

The pathway would ensure that the treatment would be delivered safely to a cohort of patients who meet certain criteria.

Methods

A pathway was developed by a consultant cardiologist, heart failure (HF) nurses and the Community Intervention Team (CIT)/CareDoc. The Caredoc Community Intervention Team (CIT) is a nurse led professional team that provides acute nursing care to patients in the community setting.

The HF nurse would identify the suitable patient for i/v frusemide as per pathway.

A referral would be sent to the CIT team who would administer the frusemide at the patients home.

The CIT team would take a renal profile daily, check vital signs, check symptoms of HF and check daily weight on the patient while they were receiving i/v frusemide.

The bloods results would be reviewed daily by the HF nurse.

The HF nurse would liaise daily with the CIT team and patient for symptoms, daily weights and vital signs. The patient would then be reviewed in the HF clinic post treatment.

Results

Single centre retrospective analysis was undertaken of the patients who received i/v frusemide at home over a 3 year period.

83 patients meet the inclusion criteria and received the treatment. 70 male and 13 female.

Average age 78 years old.

Average length of treatment 3 days.

Treatment was given twice daily, average daily dose was 137 mg. Majority of treatment was 80mg bd or 60 mg bd.

No failure cannulating any patient as CIT had high cannulation skills due to regular cannulation as part of workload.

3 episodes of hypokalaemia, lowest potassium was 3.1 mmols, all 3 episodes were effectively treated with oral potassium supplements.

No significant acute kidney injury was noted that required change to treatment.

6 patients required heart failure associated admission to hospital, 3 had hypotension, 1 has fast A-flutter and 2 remained resistance to i/v frusemide and required inotropes.

Both patient and carers reported a high satisfaction rate with the service.

Conclusion

National length of stay for a HF patient in Ireland is 11 days.This novel structured pathway successfully selected appropriate patients who can safely receive i/v frusemide at home. 93% avoided hospital admission.This reduces the need for acute hospital admission and significant associated costs. Patients and carers rated 95% satisfaction with service.Sustainability of the project is driven by an integration team approach.

Funding Acknowledgement

Type of funding source: None

Psychiatry of learning disability – a future with mental health?

Aims and Method

A postal survey was sent to all consultants in the psychiatry of learning disability from four English regions. Their views on job satisfaction, their core roles and the management re-structuring of services were elicited.

Results

The proportion agreeing or strongly agreeing with each management option was 79% for integrated mental health–learning disability trusts, 61% for specialist learning disability trusts, 47% for care trusts, 10% for primary care trusts and 5% for social services. Only 34% felt consulted or able to influence the process of change and only 33% were satisfied with the current management changes within their trust but 67% were satisfied overall with their jobs.

Clinical Implications

Management from integrated mental health–learning disability trusts is the most preferred option for psychiatrists in learning disability. A large number of consultants, though otherwise satisfied with their jobs, feel excluded or unable to influence the current changes in management structures. A model of integrated service provision in line with the government's learning disability strategy is presented.

Risk of stillbirth, preterm delivery, and fetal growth restriction following exposure in a previous birth: systematic review and meta-analysis

BACKGROUND

Little is known about the risk of non-recurrent adverse birth outcomes.

OBJECTIVES

To evaluate the risk of stillbirth, preterm birth (PTB), and small for gestational age (SGA) as a proxy for fetal growth restriction (FGR) following exposure to one or more of these factors in a previous birth.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Maternity and Infant Care, and Global Health from inception to 30 November 2016.

SELECTION CRITERIA

Studies were included if they investigated the association between stillbirth, PTB, or SGA (as a proxy for FGR) in two subsequent births.

DATA COLLECTION AND ANALYSIS

Meta-analysis and pooled association presented as odds ratios (ORs) and adjusted odds ratios (aORs).

MAIN RESULTS

Of the 3399 studies identified, 17 met the inclusion criteria. A PTB or SGA (as a proxy for FGR) infant increased the risk of subsequent stillbirth ((pooled OR 1.70; 95% confidence interval, 95% CI, 1.34-2.16) and (pooled OR 1.98; 95% CI 1.70-2.31), respectively). A combination of exposures, such as a preterm SGA (as a proxy for FGR) birth, doubled the risk of subsequent stillbirth (pooled OR 4.47; 95% CI 2.58-7.76). The risk of stillbirth also varied with prematurity, increasing three-fold following PTB <34 weeks of gestation (pooled OR 2.98; 95% CI 2.05-4.34) and six-fold following preterm SGA (as a proxy for FGR) <34 weeks of gestation (pooled OR 6.00; 95% CI 3.43-10.49). A previous stillbirth increased the risk of PTB (pooled OR 2.82; 95% CI 2.31-3.45), and subsequent SGA (as a proxy for FGR) (pooled OR 1.39; 95% CI 1.10-1.76).

CONCLUSION

The risk of stillbirth, PTB, or SGA (as a proxy for FGR) was moderately elevated in women who previously experienced a single exposure, but increased between two- and three-fold when two prior adverse outcomes were combined. Clinical guidelines should consider the inter-relationship of stillbirth, PTB, and SGA, and that each condition is an independent risk factor for the other conditions.

TWEETABLE ABSTRACT

Risk of adverse birth outcomes in next pregnancy increases with the combined number of previous adverse events.

PLAIN LANGUAGE SUMMARY

Why and how was the study carried out? Each year, around 2.6 million babies are stillborn, 15 million are born preterm (<37 weeks of gestation), and 32 million are born small for gestational age (less than tenth percentile for weight, smaller than usually expected for the relevant pregnancy stage). Being born preterm or small for gestational age can increase the chance of long-term health problems. The effect of having a stillbirth, preterm birth, or small-for-gestational-age infant in a previous pregnancy on future pregnancy health has not been summarised. We identified 3399 studies of outcomes of previous pregnancies, and 17 were summarised by our study. What were the main findings? The outcome of the previous pregnancy influenced the risk of poor outcomes in the next pregnancy. Babies born to mothers who had a previous preterm birth or small-for-gestational-age birth were more likely to be stillborn. The smaller and the more preterm the previous baby, the higher the risk of stillbirth in the following pregnancy. The risk of stillbirth in the following pregnancy was doubled if the previous baby was born both preterm and small for gestational age. Babies born to mothers who had a previous stillbirth were more likely to be preterm or small for gestational age. What are the limitations of the work? We included a small number of studies, as there are not enough studies in this area (adverse birth outcomes followed by adverse cross outcomes in the next pregnancy). We found very few studies that compared the risk of small for gestational age after preterm birth or stillbirth. Definitions of stillbirth, preterm birth categories, and small for gestational age differed across studies. We did not know the cause of stillbirth for most studies. What are the implications for patients? Women who have a history of poor pregnancy outcomes are at greater risk of poor outcomes in following pregnancies. Health providers should be aware of this risk when treating patients with a history of poor pregnancy outcomes.

Are women in early pregnancy following the national pyramid recommendations?

Appropriate nutrition in pregnancy is fundamental for maternal and fetal health, and the long-term physiological wellbeing of the offspring. We aimed to determine whether a sample of pregnant women met the national guidelines for healthy eating during pregnancy, and to examine if compliance differs when analysed by Body Mass Index (BMI) category. Subjects completed a 24-hr dietary recall, and had their BMI calculated. The mean age was 27.8 years. The mean BMI was 25.1 kg/m2, with 32 (31.7%) subjects overweight and 14 (13.9%) obese based on BMI category. Although the majority of subjects thought that they had a healthy diet, less than half met the recommended guidelines for each individual food group with achievement of the dairy group being particularly low. Achievement of food group recommendations was not influenced by BMI category. Public health messages on healthy eating guidelines need to be clearly communicated to pregnant women.

Overcoming the barriers experienced in conducting a medication trial in adults with aggressive challenging behaviour and intellectual disabilities

BACKGROUND

Aggressive challenging behaviour in people with intellectual disability (ID) is frequently treated with antipsychotic drugs, despite a limited evidence base.

METHOD

A multi-centre randomised controlled trial was undertaken to investigate the efficacy, adverse effects and costs of two commonly prescribed antipsychotic drugs (risperidone and haloperidol) and placebo.

RESULTS

The trial faced significant problems in recruitment. The intent was to recruit 120 patients over 2 years in three centres and to use a validated aggression scale (Modified Overt Aggression Scale) score as the primary outcome. Despite doubling the period of recruitment, only 86 patients were ultimately recruited.

CONCLUSIONS

Variation in beliefs over the efficacy of drug treatment, difficulties within multidisciplinary teams and perceived ethical concerns over medication trials in this population all contributed to poor recruitment. Where appropriate to the research question cluster randomised trials represent an ethically and logistically feasible alternative to individually randomised trials.

Neuroleptics in the treatment of aggressive challenging behaviour for people with intellectual disabilities: a randomised controlled trial (NACHBID)

OBJECTIVE(S)

To assess the effects and cost-effectiveness of haloperidol, risperidone and placebo on aggressive challenging behaviour in adults with intellectual disability.

DESIGN

A double-blind randomised controlled trial of two drugs and placebo administered in flexible dosage, with full, independent assessments of aggressive and aberrant behaviour, global improvement, carer burden, quality of life and adverse drug effects at baseline, 4, 12 and 26 weeks, and comparison of total care costs in the 6 months before and after randomisation. At 12 weeks, patients were given the option of leaving the trial or continuing until 26 weeks. Assessments of observed aggression were also carried out with key workers at weekly intervals throughout the trial.

SETTING

Patients were recruited from all those being treated by intellectual disability services in eight sites in England, one in Wales and one in Queensland, Australia.

PARTICIPANTS

Patients from all severity levels of intellectual disability; recruitment was extended to include those who may have been treated with neuroleptic drugs in the past.

EXCLUSION CRITERIA

treatment with depot neuroleptics/another form of injected neuroleptic medication within the last 3 months; continuous oral neuroleptic medication within the last week; those under a section of the Mental Health Act 1983 or Queensland Mental Health Act 2000.

INTERVENTIONS

Randomisation to treatment with haloperidol (a typical neuroleptic drug), risperidone (an atypical neuroleptic drug) or placebo using a permuted blocks procedure. Dosages were: haloperidol 1.25-5.0 mg daily; risperidone 0.5-2.0 mg daily.

MAIN OUTCOME MEASURES

Primary: reduction in aggressive episodes between baseline and 4 weeks using Modified Overt Aggression Scale. Secondary: Aberrant Behaviour Checklist; Uplift/Burden Scale; 40-item Quality of Life Questionnaire; Udvalg for Kliniske Undersøgelser scale; Clinical Global Impressions scale. Economic costs recorded using a modified version of Client Service Receipt Inventory for 6 months before and after randomisation.

RESULTS

There were considerable difficulties in recruitment because of ethical and consent doubts. Twenty-two clinicians recruited a total of 86 patients. Mean daily dosages were 1.07 mg rising to 1.78 mg for risperidone and 2.54 mg rising to 2.94 mg for haloperidol. Aggression declined dramatically with all three treatments by 4 weeks, with placebo showing the greatest reduction (79%, versus 57% for combined drugs) (p = 0.06). Placebo-treated patients showed no evidence of inferior response in comparison to patients receiving neuroleptic drugs. An additional study found that clinicians who had not participated in clinical trials before were less likely to recruit. Mean total cost of accommodation, services, informal care and treatment over the 6 months of the trial was 16,336 pounds for placebo, 17,626 pounds for haloperidol and 18,954 pounds for risperidone.

CONCLUSIONS

There were no significant important benefits conferred by treatment with risperidone or haloperidol, and treatment with these drugs was not cost-effective. While neuroleptic drugs may be of value in the treatment of aggressive behaviour in some patients with intellectual disability, the underlying pathology needs to be evaluated before these are given. The specific diagnostic indications for such treatment require further investigation. Prescription of low doses of neuroleptic drugs in intellectual disability on the grounds of greater responsiveness and greater liability to adverse effects also needs to be re-examined.

Randomized controlled trial of assertive community treatment in intellectual disability: the TACTILD study

BACKGROUND

There has been a policy shift away from hospital to community in the services of all those with psychiatric disorders, including those with intellectual disability (ID), in the last 50 years. This has been accompanied recently by the growth of assertive outreach services, but these have not been evaluated in ID services.

METHOD

In a randomized controlled trial we compared assertive outreach with 'standard' community care, using global assessment of function (GAF) as the primary outcome measure, and burden and quality of life as secondary measures.

RESULTS

We recruited 30 patients, considerably less than expected; no significant differences were found between the primary and secondary outcomes in the two groups. The differences were so small that a Type II error was unlikely.

CONCLUSIONS

Reasons for this lack of specific efficacy of the assertive approach are discussed and it is suggested that there is a blurring of the differences between standard and assertive approaches in practice.

Attitude to medication of parents/primary carers of people with intellectual disability

OBJECTIVE

To investigate the influence of attitudes of carers of people with intellectual disability (ID) towards giving medication.

METHOD

Ninety-three carers of service users who are currently attending outpatients clinic (Harrow Learning Disability service) were interviewed, using the RAMS (Rating of Attitude to Medication Scale) interview schedule.

RESULTS

A significant association was found between relationship of the carer to the service user and overall positive or negative attitude towards medication, with a disproportionate number of parents expressing a negative attitude in comparison with professional carers (46% vs. 11%).

CONCLUSION

This study suggests more work needs to be done with family carers than with professional carers to improve compliance with medication. Stigma is still associated with ID and psychiatric disorders. The family carers responses may be projecting their feelings related to the impact of having a child not only with ID, but also with additional psychiatric problems. The implication of the study for psychiatrists is the identification of a number of areas that could be usefully explored before writing a prescription.

Difficulties in conducting a randomized controlled trial of health service interventions in intellectual disability: implications for evidence-based practice

BACKGROUND

In an era of evidence-based medicine, practice is constantly monitored for quality in accordance with the needs of clinical governance (Oyebode et al. 1999). This is likely to lead to a dramatic change in the treatment of those with intellectual disability (ID), in which evidence for effective intervention is limited for much that happens in ordinary practice. As Fraser (2000, p. 10) has commented, the word that best explains "the transformation of learning disability practice in the past 30 years is 'enlightenment'." This is not enough to satisfy the demands of evidence, and Fraser exhorted us to embrace more research-based practice in a subject that has previously escaped randomized controlled trials (RCTs) of treatment because of ethical concerns over capacity and consent, which constitute a denial of opportunity which "is now at last regarded as disenfranchising".

CONCLUSIONS

The present paper describes the difficulties encountered in setting up a RCT of a common intervention, i.e. assertive community treatment, and concludes that a fundamental change in attitudes to health service research in ID is needed if proper evaluation is to prosper.

Cytomegalovirus ventriculoencephalitis in a bone marrow transplant recipient receiving antiviral maintenance: clinical and molecular evidence of drug resistance

We describe a case of CMV ventriculoencephalitis in a severely immunocompromised bone marrow transplant recipient who was receiving combination therapy with ganciclovir and foscarnet for treatment of viremia and retinitis. Analysis of sequential viral isolates recovered from the patient's cerebrospinal fluid suggested that disease developed because of the presence of viral resistance and, possibly, low tissue penetration of antiviral agents.

Use of the signal-averaged electrocardiogram for predicting inducible ventricular tachycardia in patients with unexplained syncope: relation to clinical variables in a multivariate analysis

OBJECTIVES

The purpose of this study was to determine the predictors of electrically induced ventricular tachycardia in a large sample of patients with unexplained syncope and to examine the value of the signal-averaged electrocardiogram (ECG) in those patient subsets with varying pretest probability of ventricular tachycardia.

BACKGROUND

In patients with unexplained syncope, electrophysiologic study can provide important diagnostic information, such as inducibility of ventricular tachycardia. The signal-averaged ECG can predict inducible ventricular tachycardia, but its utility has not been prospectively studied in a large group of patients with unexplained syncope.

METHODS

At six hospitals, 189 consecutive patients with unexplained syncope underwent signal-averaged ECG and electrophysiologic studies.

RESULTS

Ventricular tachycardia was induced in 28 patients (15%). Univariate predictors of ventricular tachycardia included history of previous myocardial infarction, reduced left ventricular ejection fraction and abnormal signal-averaged ECG results. The signal-averaged ECG was the most sensitive test but had poor specificity. By multivariate analysis, the signal-averaged ECG and history of previous myocardial infarction were independently predictive. The risk of ventricular tachycardia increased 17-fold in patients with a previous myocardial infarction who also had an abnormal signal-averaged ECG. In patients with no history of previous myocardial infarction, no additional testing was useful in identifying those at risk for inducible ventricular tachycardia.

CONCLUSIONS

The signal-averaged ECG was the most sensitive noninvasive test available to predict sustained ventricular tachycardia at electrophysiologic study but was false positive in many patients. A history of previous myocardial infarction followed by the signal-averaged ECG was the most efficient screening process for predicting electrically induced ventricular tachycardia.

Predicting arrhythmic events after acute myocardial infarction using the signal-averaged electrocardiogram

To determine if the signal-averaged (SA) electrocardiogram (ECG) predicts the occurrence of sustained ventricular arrhythmia and sudden death after acute myocardial infarction, 182 consecutive patients underwent systematic noninvasive testing, including the SAECG. Seventy-one patients (39%) had an abnormal SAECG. The presence of an abnormal SAECG was not related to underlying left ventricular dysfunction or any other clinical or measured variable. There were 16 end points (sustained ventricular arrhythmia or sudden cardiac death) during 14-month follow-up. The SAECG was a significant predictor of these events (p less than 0.02), and an abnormal SAECG conferred a 2.7-fold increase in risk. The risk associated with an abnormal SAECG was independent of both left ventricular function and ventricular arrhythmia on Holter ECG. The SAECG had excellent negative predictive accuracy (95%), but the positive predictive accuracy was low (15%). When the results of the SAECG were combined with the results of the Holter ECG, a group of very high-risk patients was identified; at 18 months, the presence of abnormal SAECG and Holter ECG was associated with a risk of 26% compared with only 4% if both tests were normal. Furthermore, all published studies with a similar design were pooled for meta-analysis. The meta-analysis revealed a sixfold increase in risk, independent of left ventricular function, and an eightfold increase in risk, independent of Holter results when the SAECG was abnormal. The SAECG is a noninvasive test that can rapidly and easily provide potent prognostic information regarding the risk of sustained ventricular arrhythmias for patients after myocardial infarction.

Intoxicated by water. Polydipsia and water intoxication in a mental handicap hospital

A cross-sectional survey of the drinking habits of 877 mentally handicapped in-patients revealed 31 patients (prevalence 3.5%) who, in the opinion of nurses, drank five litres or more daily. Low urine specific gravity was a less useful indicator of polydipsia. Polydipsia appeared to be significantly associated with a borderline level of handicap and with a diagnosis of schizophrenia, autism or severe personality/behaviour disorder. Of five cases of water intoxication associated with polydipsia, one was fatal. In two cases excess drinking improved with increased neuroleptic medication. Lithium and demeclocycline were used in two cases to prevent hyponatraemic episodes.

Lithium in the treatment of aggression in mentally handicapped patients. A double-blind trial

In a double-blind trial lasting 4 months in 42 mentally handicapped patients, the effect of lithium on aggression was assessed in comparison with placebo. In the lithium-treated group, 73% of patients showed a reduction in aggression during treatment. There were significant differences in mean weekly aggression scores and in the frequency of aggressive episodes between the lithium and placebo groups. Side-effects were noted in 36% of the lithium group (and 20% of the placebo group), but were mainly transitory. There were no episodes of toxicity, and no patients had to be withdrawn from the trial. Lithium appears to be worth a 2-month trial in such patients, where repeated aggression has not been relieved by more appropriate placement, occupation or company.

An extrapyramidal syndrome after lithium therapy

Two patients developed an extrapyramidal syndrome after therapy with lithium carbonate. Although the clinical features of this syndrome were indistinguishable from those of drug-induced parkinsonism, it was made worse by the anti-parkinsonian drug, orphenadrine. These findings were reproduced later under laboratory conditions when extrapyramidal symptoms and physiological tremor were recorded before and after challenge doses of orphenadrine. This unwanted effect of lithium carbonate may be explained by selective blockade of dopamine receptors.