The Roles of Protocols and Protocolization in Improving Outcome From Severe Traumatic Brain Injury

BACKGROUND AND OBJECTIVES

Our Phase-I parallel-cohort study suggested that managing severe traumatic brain injury (sTBI) in the absence of intracranial pressure (ICP) monitoring using an ad hoc Imaging and Clinical Examination (ICE) treatment protocol was associated with superior outcome vs nonprotocolized management but could not differentiate the influence of protocolization from that of the specific protocol. Phase II investigates whether adopting the Consensus REVised Imaging and Clinical Examination (CREVICE) protocol improved outcome directly or indirectly via protocolization.

METHODS

We performed a Phase-II sequential parallel-cohort study examining adoption of the CREVICE protocol from no protocol vs a previous protocol in patients with sTBI older than 13 years presenting ≤24 hours after injury. Primary outcome was prespecified 6-month recovery. The study was done mostly at public South American centers managing sTBI without ICP monitoring. Fourteen Phase-I nonprotocol centers and 5 Phase-I protocol centers adopted CREVICE. Data were analyzed using generalized estimating equation regression adjusting for demographic imbalances.

RESULTS

A total of 501 patients (86% male, mean age 35.4 years) enrolled; 81% had 6 months of follow-up. Adopting CREVICE from no protocol was associated with significantly superior results for overall 6-month extended Glasgow Outcome Score (GOSE) (protocol effect = 0.53 [0.11, 0.95], P = .013), mortality (36% vs 21%, HR = 0.59 [0.46, 0.76], P < .001), and orientation (Galveston Orientation and Amnesia Test discharge protocol effect = 10.9 [6.0, 15.8], P < .001, 6-month protocol effect = 11.4 [4.1, 18.6], P < .005). Adopting CREVICE from ICE was associated with significant benefits to GOSE (protocol effect = 0.51 [0.04, 0.98], P = .033), 6-month mortality (25% vs 18%, HR = 0.55 [0.39, 0.77], P < .001), and orientation (Galveston Orientation and Amnesia Test 6-month protocol effect = 9.2 [3.6, 14.7], P = .004). Comparing both groups using CREVICE, those who had used ICE previously had significantly better GOSE (protocol effect = 1.15 [0.09, 2.20], P = .033).

CONCLUSION

Centers managing adult sTBI without ICP monitoring should strongly consider protocolization through adopting/adapting the CREVICE protocol. Protocolization is indirectly supported at sTBI centers regardless of resource availability.

Testing the Impact of Protocolized Care of Patients With Severe Traumatic Brain Injury Without Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol

BACKGROUND

Most patients with severe traumatic brain injury (sTBI) in low- or-middle-income countries and surprisingly many in high-income countries are managed without intracranial pressure (ICP) monitoring. The impact of the first published protocol (Imaging and Clinical Examination [ICE] protocol) is untested against nonprotocol management.

OBJECTIVE

To determine whether patients treated in intensive care units (ICUs) using the ICE protocol have lower mortality and better neurobehavioral functioning than those treated in ICUs using no protocol.

METHODS

This study involved nineteen mostly public South American hospitals. This is a prospective cohort study, enrolling patients older than 13 years with sTBI presenting within 24 h of injury (January 2014-July 2015) with 6-mo postinjury follow-up. Five hospitals treated all sTBI cases using the ICE protocol; 14 used no protocol. Primary outcome was prespecified composite of mortality, orientation, functional outcome, and neuropsychological measures.

RESULTS

A total of 414 patients (89% male, mean age 34.8 years) enrolled; 81% had 6 months of follow-up. All participants included in composite outcome analysis: average percentile (SD) = 46.8 (24.0) nonprotocol, 56.9 (24.5) protocol. Generalized estimating equation (GEE) used to account for center effects (confounder-adjusted difference [95% CI] = 12.2 [4.6, 19.8], P = .002). Kaplan-Meier 6-month mortality (95% CI) = 36% (30%, 43%) nonprotocol, 25% (19%, 31%) protocol (GEE and confounder-adjusted hazard ratio [95% CI] = .69 [.43, 1.10], P = .118). Six-month Extended Glasgow Outcome Scale for 332 participants: average Extended Glasgow Outcome Scale score (SD) = 3.6 (2.6) nonprotocol, 4.7 (2.8) protocol (GEE and confounder-adjusted and lost to follow-up-adjusted difference [95% CI] = 1.36 [.55, 2.17], P = .001).

CONCLUSION

ICUs managing patients with sTBI using the ICE protocol had better functional outcome than those not using a protocol. ICUs treating patients with sTBI without ICP monitoring should consider protocolization. The ICE protocol, tested here and previously, is 1 option.

Consensus-Based Management Protocol (CREVICE Protocol) for the Treatment of Severe Traumatic Brain Injury Based on Imaging and Clinical Examination for Use When Intracranial Pressure Monitoring Is Not Employed

Globally, intracranial pressure (ICP) monitoring use in severe traumatic brain injury (sTBI) is inconsistent and susceptible to resource limitations and clinical philosophies. For situations without monitoring, there is no published comprehensive management algorithm specific to identifying and treating suspected intracranial hypertension (SICH) outside of the one ad hoc Imaging and Clinical Examination (ICE) protocol in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST:TRIP) trial. As part of an ongoing National Institutes of Health (NIH)-supported project, a consensus conference involving 43 experienced Latin American Intensivists and Neurosurgeons who routinely care for sTBI patients without ICP monitoring, refined, revised, and augmented the original BEST:TRIP algorithm. Based on BEST:TRIP trial data and pre-meeting polling, 11 issues were targeted for development. We used Delphi-based methodology to codify individual statements and the final algorithm, using a group agreement threshold of 80%. The resulting CREVICE (Consensus REVised ICE) algorithm defines SICH and addresses both general management and specific treatment. SICH treatment modalities are organized into tiers to guide treatment escalation and tapering. Treatment schedules were developed to facilitate targeted management of disease severity. A decision-support model, based on the group's combined practices, is provided to guide this process. This algorithm provides the first comprehensive management algorithm for treating sTBI patients when ICP monitoring is not available. It is intended to provide a framework to guide clinical care and direct future research toward sTBI management. Because of the dearth of relevant literature, it is explicitly consensus based, and is provided solely as a resource (a "consensus-based curbside consult") to assist in treating sTBI in general intensive care units in resource-limited environments.

Endoscopic ultrasound for the evaluation of Nissen fundoplication integrity: a blinded comparison with conventional testing

BACKGROUND

For patients whose symptoms develop after Nissen fundoplication, the precise mechanism of anatomic failure can be difficult to determine. The authors have previously reported the endosonographic hallmarks defining an intact Nissen fundoplication in swine and the known causes of failure. The current clinical trial tested the hypothesis that a defined set of endosonographic criteria can be applied to determine fundoplication integrity in humans.

METHODS

The study enrolled seven symptomatic and nine asymptomatic subjects at a mean of 6 years (range, 1-30 years) after Nissen fundoplication. A validated gastroesophageal reflux disease (GERD)-specific questionnaire and medication history were completed. Before endoscopic ultrasound (EUS), all the patients underwent complete conventional testing (upper endoscopy, esophagram, manometry, 24-h pH). A diagnosis was rendered on the basis of combined test results. Then EUS was performed by an observer blinded to symptoms, medication use, and conventional testing diagnoses. Because EUS and esophagogastroduodenoscopy (EGD) are uniformly performed in combination, the EUS diagnosis was rendered on the basis of previously established criteria combined with the EGD interpretation. The diagnoses then were compared to examine the contribution of EUS in this setting.

RESULTS

The technique and defined criteria were easily applied to all subjects. All symptomatic patients had heartburn and were taking proton pump inhibitors (PPI). No asymptomatic patients were taking PPI. All diagnoses established with combined conventional testing were detected on EUS with upper endoscopy. Additionally, EUS resolved the etiology of a low lower esophageal sphincter pressure in two symptomatic patients and detected the additional diagnoses of slippage in two subjects. Among asymptomatic subjects, EUS identified additional diagnoses in two subjects considered to be normal by conventional testing methods.

CONCLUSION

According to the findings, EUS is a feasible method for evaluating post-Nissen fundoplication hiatal anatomic relationships. The combination of EUS and EGD allows the mechanism of failure to be detected in patients presenting with postoperative symptoms after Nissen fundoplication.

Cervical cytologic screening: Optimal management of atypical squamous cells of undetermined significance in young women

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Background: HPV testing is a cost-effective strategy for the management of ASC-US cytology. However, young women have a high prevalence of transient HPV infections and low incidence high grade cervical lesions which may limit the utility of HPV testing in these women. We sought to determine the utility of HPV testing for young women with ASC-US. Methods: A review of all patients with ASC-US cytology between January, 2003 and December, 2004 was performed. Reflex HPV testing using the Hybrid Capture II system was performed on all samples. Age stratified rates of HPV positivity, rates of high grade dysplasia and sensitivity and specificity were estimated. Results: A total of 1290 women with ASC-US cytology were identified. The percentage of ASC-US samples that were HPV positive was highest in the young women and decreased with advancing age: < 25 yo (55%), 26–40 (36%), 41–50 (13%), > 50 yo (12%) (p<0.0001). Among HPV positive women with ASC-US, the identification of high grade lesions (HSIL, CIN2, CIN3, cancer) was lowest in the young women and increased with age: < 25 (12%), 26–40 (24%), 41–50 (19%), > 50 yo (24%) (p=0.05). A negative HPV test more reliably excluded high disease in the young women. No high grade lesions were detected in the HPV negative women ≤ 25 compared to 3.8% of those > 50 (p=0.04). The sensitivity for detection of high grade disease was higher in women < 25 compared to those > 50 (100% vs. 50%), while specificity was lower (14% vs. 44%). Conclusions: Given the high prevalence of HPV and low occurrence of high grade lesions in young women with ASC-US, an HPV based triage strategy will result in the referral of a large number of women for colposcopy and may limit its cost effectiveness. A program of repeat cytology may be more appropriate for the follow-up of young women with ASC-US.

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Hepatitis C infection among survivors of childhood cancer

Preliminary reports have suggested that survivors of childhood cancer and aplastic anemia who are infected with the hepatitis C virus (HCV) have a low risk for progression to significant liver disease. Among our surviving patients who were transfused between 1961 and March 1992, 77 (6.6% of surviving patients tested thus far) have evidence of HCV infection, whereas 4 surviving patients who were transfused after March 1992 are HCV-infected. One patient chronically infected with HCV died of liver failure, and 2 patients died of hepatocellular carcinoma. To characterize the risk for these and other complications, 65 patients are enrolled in a longitudinal study of HCV infection, of whom 58 (89.2%) had circulating HCV RNA at the time of protocol enrollment, with genotypes 1A and 1B most commonly isolated. Most enrolled patients have few or no symptoms, carry out normal activities, and have normal liver function. To date, 35 patients have undergone liver biopsy for abnormal liver function since the diagnosis of primary malignancy; central pathology review shows 28 (80%) have chronic active hepatitis, 25 (71%) have fibrosis, and 3 (9%) have cirrhosis. These preliminary data suggest that though most survivors of childhood cancer who are infected with HCV are clinically well, some are at risk for clinically significant liver disease. Identification of other HCV-infected patients and prospective monitoring of this cohort are ongoing to determine the risk for, and to identify factors associated with the progression of, liver disease.

Effects of using recommended coping strategies on drinking outcome following a brief intervention

AIMS

To explore the unique contribution to outcome drinking of clients' use of six strategies for moderating drinking, after statistically accounting for variance explained by some client and intervention variables.

DESIGN

An exploratory hierarchical regression analysis assessed the contributions to variance in drinking outcome of pre-intervention (client characteristics, baseline drinking), assignment (level of assessment, therapist experience) and early follow-up variables. Data came from an experimental trial which evaluated the effect of adding assessment to provision of a self-help book to heavy drinkers.

SETTING

Diverse Ontario communities.

PARTICIPANTS

Heavy drinkers (99 males, 56 females) were selected from 185 media-recruited applicants who were screened by telephone to exclude cases with severe alcohol-related problems. Their mean (+/- SD) pre-admission weekly quantity of alcohol consumed was 22 +/- 15 drinks. Follow-up rates at 3 and 12 months were 92% and 88%.

MEASUREMENTS

Regressed onto weekly quantity at follow-up were: client characteristics, previous measures of weekly quantity, experimental condition and use of the menu of strategies (setting goals for drinking, keeping track of drinking, pacing drinking, planning ahead to avoid heavy drinking, developing free-time activities and coping with problems without drinking).

FINDINGS

At 3 months the variables predicting lower weekly quantity were: pre-intervention weekly quantity, developing free-time activities, setting goals for drinking and condition. Lower weekly quantity at 12 months was predicted by lower 3-month and pre-intervention weekly quantity, and regular use of: coping with problems without drinking, setting goals for drinking and keeping track of drinking.

CONCLUSIONS

This descriptive study revealed a positive association between level of use of recommended coping strategies at follow-up and drinking outcome. Controlled studies of the effects of strategy use on drinking outcome are therefore warranted.

Prevalence of asthma and respiratory symptoms in south-central Durban, South Africa

The prevalence of asthma and respiratory symptoms in south-central Durban, one of the most heavily polluted areas of South Africa, has been determined using a cross-sectional survey of 213 households in the communities of Merewent (97% Indians) and Austerville (98% coloreds). The study population consisted of 367 children (less than 17 years old) and 693 adults. About 10% of the children and 12% of adults reported doctor diagnosed asthma. The self-reported prevalence rates for wheezing (3740%) and attacks of shortness of breath with wheeze (16-28%) were much higher than that for doctor diagnosed asthma and common co-occurrence of the three symptoms is found. The prevalence rates for other respiratory symptoms include 33-35% for chronic cough, 31-32% for chronic phlegm, 44-50% for frequent blocked-runny nose, and 16-27% for sinusitis. Factors in the community that were associated with asthma, wheeze and shortness of breath with wheeze among the adult population included cigarette smoking, use of insecticides (coils and pump spray) and home ownership. An association between asthma among children and a number of household risk factors including dampness, carpet, pets or use of pesticides was not apparent in the community. Asthma prevalence was strongly correlated with missing of school by children (odds ratio (OR): 44; 95% confidence interval (CI): 13-141). The study serves to draw attention to a growing but neglected public health problem in urban areas of Africa.

Further parameters of insight and neuropsychological deficit in schizophrenia and other chronic mental disease

Evidence has begun to accumulate which suggests that lack of awareness of illness in schizophrenia is related to and possibly the result of a cognitive deficit involving prefrontal cerebral dysfunction. This study further explores this relationship along with other domains of self-awareness in chronic schizophrenics and other subjects with serious mental disorders. One hundred eight schizophrenics and 21 bipolar subjects from three separate sites in Britain, Germany, and Canada were administered the Wisconsin Card Sorting Test and three measures of self-awareness. Lack of illness awareness and other domains of self-knowledge were significantly more related to poorer neuropsychological performance in schizophrenia patients than in the other subjects. The results support the hypothesis that lack of illness awareness is related to defective frontal lobe functioning as indexed by neuropsychological measures.

Differential effect of haloperidol and clozapine on plasma homovanillic acid in elderly schizophrenic patients with or without tardive dyskinesia

BACKGROUND

Plasma homovanillic acid (HVA) changes in response to a challenge of several days with haloperidol have been found to be predictive of the therapeutic response to haloperidol over a longer period of treatment.

METHODS

Twenty-six elderly women who gave informed consent were divided into two groups, with or without tardive dyskinesia, and subjected to an 80-day washout, after which both the dyskinetic and nondyskinetic group was divided, and half of each group given haloperidol or clozapine.

CONCLUSIONS

The nondyskinetic group had a brief rise in plasma HVA, then a decline. The dyskinetic group had no change in plasma HVA. Neither group challenged with clozapine had any change in plasma HVA.

A self-help approach for high-risk drinking: effect of an initial assessment

A self-help book was offered to persons wanting to quit or cut down on their alcohol use. Study participants (99 men, 56 women) were recruited through advertisements, screened by telephone, and randomly assigned to 1 of 2 conditions. Book by mail or Assessment + Book (30-min telephone motivational interview plus book by mail). At 3-month follow-up, significantly more participants qualified as moderate drinkers in the Assessment + Book condition (65% vs. 43%), by this criterion: < or = 12 drinks/week and < or = 10% heavy drinking days (5 + drinks if male and 4 + drinks if female; 13.6 g of ethanol per drink). At 12 months there was no effect of condition, but significantly more women than men were rated as moderate drinkers (71% vs. 52%). Collateral informants corroborated the participants' reports of drinking.

A self-help approach for high-risk drinking: effect of an initial assessment

A self-help book was offered to persons wanting to quit or cut down on their alcohol use. Study participants (99 men, 56 women) were recruited through advertisements, screened by telephone, and randomly assigned to 1 of 2 conditions. Book by mail or Assessment + Book (30-min telephone motivational interview plus book by mail). At 3-month follow-up, significantly more participants qualified as moderate drinkers in the Assessment + Book condition (65% vs. 43%), by this criterion: < or = 12 drinks/week and < or = 10% heavy drinking days (5 + drinks if male and 4 + drinks if female; 13.6 g of ethanol per drink). At 12 months there was no effect of condition, but significantly more women than men were rated as moderate drinkers (71% vs. 52%). Collateral informants corroborated the participants' reports of drinking.

Cytopathology and the pathology resident. A survey of residency program directors

OBJECTIVE

To collect information on the status of cytopathology training in the United States.

DESIGN

Questionnaire survey mailed in June 1994.

SETTING

Pathology residency training programs in the United States.

PARTICIPANTS

Pathology residency directors.

MAIN OUTCOME MEASURES

Training length, numbers of cytology specimens, teaching methods and topics, and graduated responsibility.

RESULTS

Of the 196 surveys mailed, 101 (52%) programs responded. The average length of required training was 3 months. The perceived optimal training time averaged 4.5 months, however, with 80% of programs requiring less than their stated optimum. The median numbers of gynecologic, nongynecologic, and fine-needle aspiration biopsy specimens examined per resident were 1100, 500, and 200, respectively. Cytopreparatory techniques, laboratory management, computer systems, and immunocytochemistry were included in over 75% of cytopathology training programs. Teaching at the microscope was rated as the most important teaching method by 90% of respondents. The majority of senior residents performed fine-needle aspiration biopsy procedures and screened and signed out cases with direct faculty supervision, but fewer than 20% of programs allowed senior residents to independently sign out specimens.

CONCLUSIONS

Recommendations based on this review include a minimum training time of 3 months, improved training in both fine-needle aspiration biopsy techniques and gynecologic cytology, continuous exposure to cytopathologic techniques, and increased graded responsibility for senior residents.

The Occupational Health Partnership Program: a new paradigm for occupational health services

For a variety of reasons, occupational health services at Army Material Command installations became severely strained during the 1980s. The Occupational Health Partnership Program, developed to improve this support, describes control, responsibility, and cost sharing between Army Materiel Command and Army Medical Command. This innovative approach is finding new solutions to challenging problems. The authors describe the history, principles, status, and possible future of the partnership program.

The Ivemark syndrome: prenatal diagnosis of an uncommon cystic renal lesion with heterogeneous associations

Renal dysplasia has been reported in association with a number of anatomical abnormalities, including pancreatic dysgenesis and hepatic anomalies. The combination of renal, hepatic, and pancreatic dysplasia (RHPD), also known as Ivemark syndrome, is rare and uniformly fatal. We report here the gross and histological findings in 4 cases of combined RHPD, 2 of which were detected by prenatal ultrasonography. Evaluation of these 4 and the other 20 reported cases shows that combined RHPD has considerable variability in the histological findings and in organ involvement. In addition, nearly half were associated with anomalies in other organ systems, and 11 of the 24 were familial. In this study, ultrasonographic and histological abnormalities were seen as early as 18.5 weeks gestation in 1 case.

Empirically based guidelines for moderate drinking: 1-year results from three studies with problem drinkers

OBJECTIVES

The study was conducted to refine guidelines on moderate drinking for problem drinkers, persons whose alcohol use is hazardous or harmful. Information on levels of alcohol intake unlikely to cause problems is useful for health professionals, educators, and policymakers.

METHODS

Based on their reports of alcohol-related problems, participants in three studies assessing interventions to reduce heavy drinking (114 men, 91 women) were categorized as "problem-free" or "problem" drinkers at follow-up. Drinking measures were examined to identify patterns separating these outcome categories.

RESULTS

Analyses using 95% confidence intervals for means on drinking measures showed that guidelines should be sex-specific. Based on analyses of positive and negative predictive value, sensitivity, and specificity, it is recommended that men consume no more than 4 standard drinks in any day and 16 drinks in any week, and that women consume no more than 3 drinks in any day and 12 drinks in any week.

CONCLUSIONS

These guidelines are consistent with those from several official bodies and should be useful for advising problem drinkers when moderation is a valid treatment goal. Their applicability to the general population is unevaluated.

Assisting problem drinkers to change on their own: effect of specific and non-specific advice

Problem drinkers (99 males, 41 females) wishing to quit or cut down without professional help received a 60-minute session during which they were assessed and given at random one of these materials: Guidelines, a two-page pamphlet outlining specific methods for achieving abstinence or moderate drinking; Manual, a 30-page booklet describing the methods in the Guidelines; or General Information, a package about alcohol effects. At 12 months follow-up, subjects in the Guidelines and Manual conditions showed significantly greater reductions of heavy days (of 5+ drinks) than subjects in General Information (70% vs. 24%); in addition, significantly fewer subjects in the Guidelines and the Manual conditions expressed need for professional assistance with their drinking (25% vs. 46% in General Information). No main effect of condition or gender was observed on rates of moderate drinkers. At 12 months follow-up, 31% of the men and 43% of the women were rated as moderate drinkers. It was concluded that drinkers intending to cut down on their own derive greater benefit (in terms of their alcohol use) from materials containing specific instructions to develop moderate drinking than from those providing general information on alcohol effects. Clinical and research implications of the findings are discussed.

Extended iliofemoral versus triradiate approaches in management of associated acetabular fractures

From July 1988 to June 1991, 110 complex acetabular fractures were operatively treated. A triradiate approach was used in 38 patients and an extended iliofemoral approach in 21. The mean patient age was 32 years (range, 15-80 years). These 59 patients were followed for a minimum of 36 months postoperatively. The postoperative function state was evaluated according to D'Aubigne/Postel, and the results were: Excellent, 32 patients (54%); Very Good, 10 (17%); Good, 5 (8%); Fair, 4 (7%); and Poor, 8 (14%). Adequacy of acetabular reconstruction was evaluated from the anteroposterior, obturator oblique, and iliac oblique radiographs. All patients had excellent or good radiographic results (< 2 mm step off or gap). Iatrogenic sciatic nerve injury was seen in two patients with the triradiate and one with the extended iliofemoral approach. Deep infection was seen in one patient in the extended iliofemoral group and two in the triradiate group. Eight patients developed heterotopic ossification of Brooker Grade III or IV despite prophylactic treatment with indomethacin. Both approaches provided good visualization of complex acetabular fractures.

Chronic neuroleptic treatment does not suppress the dynamic characteristics of the dopaminergic receptor D2 system

1. Rats were treated with either haloperidol (0.5 mg/kg) or haloperidol plus an anticholinergic drug (0.5 and 0.15 mg/kg/day respectively) for 3 days, 7 days and 16 months. 2. Estimates made twenty hours after the last doses showed that haloperidol reduced the concentrations of the dopamine metabolites, 3,4-dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA) in the striatum and the olfactory tubercle. 3. A challenge dose of either haloperidol or haloperidol plus an anticholinergic drug was administered to rats pretreated with haloperidol or haloperidol plus an anticholinergic drug; this challenge dose reversed the reduction in dopamine metabolites caused by neuroleptic administration. 4. After sixteen months of haloperidol administration dopamine levels were reduced, but adding an anticholinergic drug to haloperidol treatment prevented this reduction in dopamine concentration.

Unawareness of illness and neuropsychological performance in chronic schizophrenia

This research attempts to explore empirically the relationship between lack of awareness of illness and neuropsychological performance in a group of chronic schizophrenic subjects. Thirty one chronic schizophrenics were administered the recently developed Scale to Assess Unawareness of Mental Disorder (SUMD) and 3 neuropsychological tests that have demonstrated ability to assess frontal lobe performance: the Wisconsin Card Sorting Test (WCST, Verbal Fluency Test and Trials A and B. The number of categories completed and the percent perseverative responses on the WCST were found to significantly correlate with lack of illness awareness as measured by the SUMD. These two WCST variables were also able to significantly discriminate between subjects of high versus low awareness. A discriminant function analysis found that a linear combination of WCST percent perseverative responses and symptom severity could successfully categorize 84% of the aware versus unaware subjects. These results are taken to support the hypothesis that at least in some of its manifestations lack of awareness among chronic schizophrenics has an organic etiology probably mediated by the frontal lobes.

Superior outcome of females over males after brief treatment for the reduction of heavy drinking: replication and report of therapist effects

The procedures and findings of a previous study were replicated. Sixty-one men and 35 women were randomized to one of three treatments: Manual: three sessions of instructions in use of a manual describing a step-by-step method for attaining abstinence or moderate drinking.

GUIDELINES

three sessions of advice using a pamphlet summarizing the contents of the manual. Therapist: application of the step-by-step method in an indefinite number of sessions. At 3-month follow-up, the number of Moderate drinkers was again significantly higher among women than men in the GUIDELINES (77% versus 24%) and Manual conditions (75% versus 33%), but not in the Therapist condition (50% versus 53%). Again, at 1-year more women than men were Moderate drinkers in all conditions (69% versus 31% overall). Changes from baseline in GGT, MCV, and the Digit Symbol Test corroborated the clients' reports of drinking. In this study the more experienced therapists had significantly lower rates of client dropout than the less experienced. Clinical and research implications of the findings are discussed.

Persistence of cyclicity of the plasma dopamine metabolite, homovanillic acid, in neuroleptic treated schizophrenic patients

The dopamine metabolite, homovanillic acid, decreases in concentration in plasma between 8:30 A.M. and 12:30 P.M. In patients with schizophrenia this cyclic change is attenuated by chronic neuroleptic treatment; however, if the 8 A.M. dose of neuroleptic is omitted, the decrease in level occurs. Presuming that neuroleptics attenuate the decline through a receptor mediated compensatory increase in dopamine release, it would appear that receptors are not fully occupied by neuroleptics even at therapeutically effective doses. The usual morning decrease in plasma cortisol levels was unaffected by neuroleptics.

Plasma homovanillic acid as a predictor of response to neuroleptics

Fourteen schizophrenic subjects were evaluated for degree of psychosis before and after treatment with the antipsychotic drug haloperidol and for plasma homovanillic acid concentration after four and 28 days of treatment. A significant correlation was found between an increase in homovanillic acid concentration on day 4 or a decrease from day 4 to day 28 and the degree of improvement after four weeks of treatment. Thus, those patients who had the greatest change in plasma homovanillic acid in response to neuroleptic blockade showed the greatest improvement. These and other observations have led us to propose that the central dopaminergic system, through adaptive changes in activity, serves as a physiologic buffer system protecting against destabilization of mental function from diverse biologic or psychologic insults.