CLEAR - clozapine in early psychosis: study protocol for a multi-centre, randomised controlled trial of clozapine vs other antipsychotics for young people with treatment resistant schizophrenia in real world settings

BACKGROUND

Clozapine is an antipsychotic drug with unique efficacy, and it is the only recommended treatment for treatment-resistant schizophrenia (TRS: failure to respond to at least two different antipsychotics). However, clozapine is also associated with a range of adverse effects which restrict its use, including blood dyscrasias, for which haematological monitoring is required. As treatment resistance is recognised earlier in the illness, the question of whether clozapine should be prescribed in children and young people is increasingly important. However, most research to date has been in older, chronic patients, and evidence regarding the efficacy and safety of clozapine in people under age 25 is lacking. The CLEAR (CLozapine in EARly psychosis) trial will assess whether clozapine is more effective than treatment as usual (TAU), at the level of clinical symptoms, patient rated outcomes, quality of life and cost-effectiveness in people below 25 years of age. Additionally, a nested biomarker study will investigate the mechanisms of action of clozapine compared to TAU.

METHODS AND DESIGN

This is the protocol of a multi-centre, open label, blind-rated, randomised controlled effectiveness trial of clozapine vs TAU (any other oral antipsychotic monotherapy licenced in the British National Formulary) for 12 weeks in 260 children and young people with TRS (12-24 years old).

AIM AND OBJECTIVES

The primary outcome is the change in blind-rated Positive and Negative Syndrome Scale scores at 12 weeks from baseline. Secondary outcomes include blind-rated Clinical Global Impression, patient-rated outcomes, quality of life, adverse effects, and treatment adherence. Patients will be followed up for 12 months and will be invited to give consent for longer term follow-up using clinical records and potential re-contact for further research. For mechanism of action, change in brain magnetic resonance imaging (MRI) biomarkers and peripheral inflammatory markers will be measured over 12 weeks.

DISCUSSION

The CLEAR trial will contribute knowledge on clozapine effectiveness, safety and cost-effectiveness compared to standard antipsychotics in young people with TRS, and the results may guide future clinical treatment recommendation for early psychosis.

TRIAL REGISTRATION

ISRCTN Number: 37176025, IRAS Number: 1004947.

TRIAL STATUS

In set-up. Protocol version 4.0 01/08/23. Current up to date protocol available here: https://fundingawards.nihr.ac.uk/award/NIHR131175# /.

SP4.2.2 Recovery after Emergency Laparotomy – what do patients want?

Aim

Recent focus on Emergency Laparotomy outcomes has improved mortality, but little attention has been given to recovery. The aim of this qualitative study was to explore recovery after EmLap.

Method

A focus group was established of ten EmLap patients. Inclusion criteria: EmLap<5 years ago, non-palliative. Patients were selected to provide balance of age, sex and pathology. Thematic qualitative analysis was performed by two researchers.

Results

Several key themes were highlighted;

Lack of communication on diagnosis/expectations after surgery. Little continuity of care. Long delays in seeing doctors after surgery and no way to contact them and GPs unable to help.

Financial consequences are significant, with no guidance. Took longer to recover than expected, difficult to explain to employer. Led to early retirement or change of hours/role.

Hernias; Some patients aware of hernia risk but given conflicting advice, e.g avoid lifting and rest for 6 weeks, others told to exercise regularly. Difficult to access support garments.

Diet – Conflicting advice on what they could/couldn't eat, especially fibre. Felt more by patients who had stoma or bowel resection. Poor quality food in hospital and lack of options for diet (e.g. vegan, coeliac).

Poor mental health after surgery with anxiety, depression and loss of confidence all having large impact, especially on relationships and intimacy. Key issues lack of access to services and waiting times. Too ‘complex’ for primary care.

Conclusions

The impact of emergency surgery on patients is significant, particularly mental health and financial impact. Recommend standardised information (leaflets/website/signposting) and key support worker.

747 YouTube And Neurosurgery: Better Content, More Views

Introduction

YouTube is the world’s largest open-access media sharing platform and contains much content on Neurosurgery. Inserting an External Ventricular Drain is a common procedure, often performed by neurosurgical trainees to treat emergency hydrocephalus. We set out to evaluate the content on EVD insertion posted on YouTube and its usefulness for trainees in learning the procedure

Method

A YouTube keyword search was conducted to identify videos on EVD insertion. Inclusion criteria was used to find videos specifically aimed to EVD insertion. We devised a scoring sheet to give each video an educational score (0-20), which two independent reviewers used to analyse the included videos.

Results

A total of 12/556 videos met the inclusion criteria. Dates posted ranged from 01/07/2012 to 24/04/2019, with views ranging from 359 – 166,388 (mean 30531, SD 49, 570). The mean educational score was 6.91 (SD 3.86), with only four videos scoring 10 or greater. There was a strong correlation between viewership and educational score (R .085 p <.001).

Conclusions

The majority of YouTube content relating to EVD insertion is not useful to trainees, but useful content can attract a greater viewership. There is an opportunity for Neurosurgeons and Institutions to gain exposure on YouTube with high-quality open-access educational content.

Psychological sequelae of colonic resections

AIM

The prevalence of anxiety, depression and post-traumatic stress disorder (PTSD) in the general population has been estimated to be 5.9%, 3.3% and 4.4% respectively. The aim of this study was to determine whether psychological problems are more prevalent following colorectal surgery.

METHOD

Patients who had undergone colorectal resection in a 2-year period across four centres were asked to complete validated screening questionnaires for anxiety, depression and PTSD (GAD-7, PHQ-9, PCL-5) 12-48 months after surgery. Risk factors were identified using multiple linear regression analysis.

RESULTS

After excluding those who had died or received palliative diagnoses, questionnaires were sent to 1150 patients. 371 responded (32.3% response rate); median age 67 (20-99) years; 51% were men. 58% of patients underwent surgery for cancer; 23% had emergency surgery. 28% of patients screened positive for at least one psychological condition, with 20% screening positive for anxiety, 22% for depression and 14% for PTSD. Patients who were younger, women, had surgery as an emergency, for benign conditions, had stomas and had critical care stay were more likely to have poorer psychological outcomes. Multiple linear regression found that only younger age (P = 0.000) and female gender (P = 0.048) were significant risk factors.

CONCLUSION

The prevalence of anxiety, depression and PTSD appears to be high in patients who have undergone colorectal surgery. Younger patients and women are particularly at risk. Further work is needed to determine how best to prevent, detect and treat people with adverse psychological outcomes following colorectal surgery.

Largest GWAS of PTSD (N=20 070) yields genetic overlap with schizophrenia and sex differences in heritability

The Psychiatric Genomics Consortium-Posttraumatic Stress Disorder group (PGC-PTSD) combined genome-wide case-control molecular genetic data across 11 multiethnic studies to quantify PTSD heritability, to examine potential shared genetic risk with schizophrenia, bipolar disorder, and major depressive disorder and to identify risk loci for PTSD. Examining 20 730 individuals, we report a molecular genetics-based heritability estimate (h2SNP) for European-American females of 29% that is similar to h2SNP for schizophrenia and is substantially higher than h2SNP in European-American males (estimate not distinguishable from zero). We found strong evidence of overlapping genetic risk between PTSD and schizophrenia along with more modest evidence of overlap with bipolar and major depressive disorder. No single-nucleotide polymorphisms (SNPs) exceeded genome-wide significance in the transethnic (overall) meta-analysis and we do not replicate previously reported associations. Still, SNP-level summary statistics made available here afford the best-available molecular genetic index of PTSD-for both European- and African-American individuals-and can be used in polygenic risk prediction and genetic correlation studies of diverse phenotypes. Publication of summary statistics for ∼10 000 African Americans contributes to the broader goal of increased ancestral diversity in genomic data resources. In sum, the results demonstrate genetic influences on the development of PTSD, identify shared genetic risk between PTSD and other psychiatric disorders and highlight the importance of multiethnic/racial samples. As has been the case with schizophrenia and other complex genetic disorders, larger sample sizes are needed to identify specific risk loci.

A comparison of DSM-5 and ICD-11 PTSD prevalence, comorbidity and disability: an analysis of the Ukrainian Internally Displaced Person's Mental Health Survey

OBJECTIVE

Recently, the American Psychiatric Association (DSM-5) and the World Health Organization (ICD-11) have both revised their formulation of post-traumatic stress disorder (PTSD). The primary aim of this study was to compare DSM-5 and ICD-11 PTSD prevalence and comorbidity rates, as well as the level of disability associated with each diagnosis.

METHOD

This study was based on a representative sample of adult Ukrainian internally displaced persons (IDPs: N = 2203). Post-traumatic stress disorder prevalence was assessed using the PTSD Checklist for DSM-5 and the International Trauma Questionnaire (ICD-11). Anxiety and depression were measured using the Generalized Anxiety Disorder Scale and the Patient Health Questionnaire-Depression. Disability was measured using the WHO Disability Assessment Schedule 2.0.

RESULTS

The prevalence of DSM-5 PTSD (27.4%) was significantly higher than ICD-11 PTSD (21.0%), and PTSD rates for females were significantly higher using both criteria. ICD-11 PTSD was associated with significantly higher levels of disability and comorbidity.

CONCLUSION

The ICD-11 diagnosis of PTSD appears to be particularly well suited to identifying those with clinically relevant levels of disability.

A dedicated district poisons treatment unit: response to the College guidance on the management of deliberate self-harm

Aims and method

An examination of the activities of a district-wide dedicated admission unit for poisoned patients in Cardiff, Wales, between 1987 and 1997. Number of admission episodes, gender, drugs taken. intent, psychiatric diagnosis and disposal were recorded.

Results

Although the number of admission episodes almost doubled over the 10–year period, the median length of stay fell by almost half.

Clinical implications

The results suggest that a dedicated unit is a cost-effective model for the management of poisoned patients.

Coping strategies and mental health outcomes of conflict-affected persons in the Republic of Georgia

AIMS

Adults who experienced the 1992 and 2008 armed conflicts in the Republic of Georgia were exposed to multiple traumatic events and stressors over many years. The aim was to investigate what coping strategies are used by conflict-affected persons in Georgia and their association with mental disorders.

METHOD

A cross-sectional survey was conducted with 3600 adults, representing internally displaced persons (IDPs) from conflicts in the 1990s (n = 1200) and 2008 (n = 1200) and former IDPs who returned to their homes after the 2008 conflict (n = 1200). Post-traumatic stress disorder, depression, anxiety and coping strategies were measured using the Trauma Screening Questionnaire, Patient Health Questionnaire-9, Generalised Anxiety and adapted version of the Brief Coping Inventory, respectively. Descriptive and multivariate regression analyses were used.

RESULTS

Coping strategies such as use of humour, emotional support, active coping, acceptance and religion were significantly associated with better mental health outcomes. Coping strategies of behavioural and mental disengagement, denial, venting emotions, substance abuse and gambling were significantly associated with poorer mental health outcomes. The reported use of coping strategies varied significantly between men and women for 8 of the 15 strategies addressed.

CONCLUSIONS

Many conflict-affected persons in Georgia are still suffering mental health problems years after the conflicts. A number of specific coping strategies appear to be associated with better mental health and should be encouraged and supported where possible.

Retrospective analysis of self-reporting pain scores and pain management during head and neck IMRT radiotherapy: A single institution experience

AIMS

Head and neck carcinomas are relatively rare in the United Kingdom with an estimated 9000 cases diagnosed annually. However, pain associated with disease and treatment side effects such as oral mucositis present a major issue for therapy radiographers in providing effective care and maintaining radiotherapy treatment compliance, all factors that can compromise patient outcome if not managed appropriately.

METHOD

This retrospective analysis of self-reporting pain scores collected during a course of radiotherapy aims to assess the perceived pain intensity scores in 30 patients. Data was collected during radiographer review sessions held weekly to determine if any variables to perceived pain scores occurred during a course of radiotherapy.

RESULTS

As treatment progressed, the self-reporting pain scores within the cohort increased, in week one the total cohort pain score was 35, this increased to 114 in week 3 and in the final week had totalled 151. An escalation in pain was observed in week 3 of treatment possibly as a result of radiation induced inflammation alongside cytotoxic chemotherapy.

CONCLUSIONS

The findings of this study provide further evidence to an individualised approach to patient pain relief and providing regular on treatment reviews, thus maintaining patient comfort and ensuring continued treatment compliance.

Psychological treatment of post-traumatic stress disorder (PTSD)

BACKGROUND

Psychological interventions are widely used in the treatment of post-traumatic stress disorder (PTSD).

OBJECTIVES

To perform a systematic review of randomised controlled trials of all psychological treatments following the guidelines of The Cochrane Collaboration.

SEARCH STRATEGY

Systematic searches of computerised databases, hand search of the Journal of Traumatic Stress, searches of reference lists, known websites and discussion fora, and personal communication with key workers.

SELECTION CRITERIA

Types of studies - Any randomised controlled trial of a psychological treatment. Types of participants - Adults suffering from traumatic stress symptoms for three months or more. Types of interventions - Trauma-focused cognitive behavioural therapy/exposure therapy (TFCBT); stress management (SM); other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and hypnotherapy); group cognitive behavioural therapy (group CBT); eye movement desensitisation and reprocessing (EMDR). Types of outcomes - Severity of clinician rated traumatic stress symptoms. Secondary measures included self-reported traumatic stress symptoms, depressive symptoms, anxiety symptoms, adverse effects and dropouts.

DATA COLLECTION AND ANALYSIS

Data were entered using Review Manager software. Quality assessments were performed. Data were analysed for summary effects using Review Manager 4.2.

MAIN RESULTS

Thirty-three studies were included in the review. With regards to reduction of clinician assessed PTSD symptoms measured immediately after treatment TFCBT did significantly better than waitlist/usual care (standardised mean difference (SMD) = -1.40; 95% CI, -1.89 to -0.91; 14 studies; n = 649). There was no significant difference between TFCBT and SM (SMD = -0.27; 95% CI, -0.71 to 0.16; 6 studies; n = 239). TFCBT did significantly better than other therapies (SMD = -0.81; 95% CI, -1.19 to -0.42; 3 studies; n = 120). Stress management did significantly better than waitlist/usual care (SMD = -1.14; 95% CI, -1.62 to -0.67; 3 studies; n = 86) and than other therapies (SMD = -1.22; 95% CI, -2.09 to -0.35; 1 study; n = 25). There was no significant difference between other therapies and waitlist/usual care control (SMD = -0.43; 95% CI, -0.90 to 0.04; 2 studies; n = 72). Group TFCBT was significantly better than waitlist/usual care (SMD = -0.72; 95% CI, -1.14 to -0.31). EMDR did significantly better than waitlist/usual care (SMD = -1.51; 95% CI, -1.87 to -1.15; 5 studies; n = 162). There was no significant difference between EMDR and TFCBT (SMD = 0.02; 95% CI, -0.28 to 0.31; 6 studies; n = 187). There was no significant difference between EMDR and SM (SMD = -0.35; 95% CI, -0.90 to 0.19; 2 studies; n = 53). EMDR did significantly better than other therapies (self-report) (SMD = -0.84; 95% CI, -1.21 to -0.47; 2 studies; n = 124).

AUTHORS' CONCLUSIONS

There was evidence individual TFCBT, EMDR, stress management and group TFCBT are effective in the treatment of PTSD. Other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly. There was some evidence that individual TFCBT and EMDR are superior to stress management in the treatment of PTSD at between 2 and 5 months following treatment, and also that TFCBT, EMDR and stress management were more effective than other therapies. There was insufficient evidence to determine whether psychological treatment is harmful. There was some evidence of greater drop-out in active treatment groups. The considerable unexplained heterogeneity observed in these comparisons, and the potential impact of publication bias on these data, suggest the need for caution in interpreting the results of this review.

Psychological treatment of post-traumatic stress disorder (PTSD)

BACKGROUND

Psychological interventions are widely used in the treatment of post-traumatic stress disorder (PTSD).

OBJECTIVES

To perform a systematic review of randomised controlled trials of all psychological treatments except eye movement desensitisation and reprocessing following the guidelines of the Cochrane Collaboration.

SEARCH STRATEGY

Systematic searches of computerised databases, hand search of the Journal of Traumatic Stress, searches of reference lists, known websites and discussion fora, and personal communication with key workers.

SELECTION CRITERIA

Types of studies - Any randomised controlled trial of a psychological treatment. Types of participants - Adults suffering from traumatic stress symptoms for three months or more. Types of interventions - Trauma-focused cognitive behavioural therapy/exposure therapy (TFCBT); stress management (SM); other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and hypnotherapy); group cognitive behavioural therapy (group CBT). Types of outcomes - Severity of clinician rated traumatic stress symptoms. Secondary measures included self-reported traumatic stress symptoms, depressive symptoms, anxiety symptoms, adverse effects and dropouts.

DATA COLLECTION AND ANALYSIS

Data was entered using the Review Management software. Quality assessments were performed. The data were analysed for summary effects using the RevMan 4.2 programme.

MAIN RESULTS

Twenty-nine studies were included in the review. With regards to reduction of clinician assessed PTSD symptoms TFCBT did significantly better than waitlist/usual care (standardised mean difference (SMD) = -1.36; 95% CI, -1.88 to -0.84; 13 studies; n = 609). There was no significant difference between TFCBT and SM (SMD = -0.27; 95% CI, -0.71 to 0.16; 6 studies; n = 239). TFCBT did significantly better than other therapies (SMD = -0.81; 95% CI, -1.19 to -0.42; 3 studies; n = 120). Stress management did significantly better than waitlist/usual care (SMD = -1.14; 95% CI, -1.62 to -0.67; 3 studies; n = 86) and than other therapies (SMD = -1.22; 95% CI, -2.09 to -0.35; 1 study; n = 25). There was no significant difference between other therapies and waitlist/usual care control (SMD = -0.43; 95% CI, -0.90 to 0.04; 2 studies; n = 72). Group TFCBT was significantly better than waitlist/usual care (SMD = -0.72; 95% CI, -1.14 to -0.31).

AUTHORS' CONCLUSIONS

There was evidence that individual TFCBT, stress management and group TFCBT are effective in the treatment of PTSD. Other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly. There was some evidence that individual TFCBT is superior to stress management in the treatment of PTSD at between 2 and 5 months following treatment, and also that TFCBT was also more effective than other therapies. There was insufficient evidence to determine whether psychological treatment is harmful. There was some evidence of greater drop-out in active treatment groups.

Diode-pumped mode-locked Yb3+:Y2O3 ceramic laser

A diode-pumped femtosecond ytterbium laser with a host material of Y2O3 ceramics is reported. Passive mode locking by a semiconductor saturable-absorber mirror generates 98-MHz, 615-fs pulses at a center wavelength of 1076.5 nm. The average power is 420 mW and the pulse energy is 4.3 nJ with a 2.6-W absorbed pump power. To our knowledge, this is the first continuous-wave mode-locked ceramic laser.

Longitudinal effects of an early family intervention programme on the adaptation of parents of children with a disability

This study assesses the longitudinal effects of an original early intervention programme on the adaptation of parents of children with a disability (Down syndrome and cleft lip/palate, i.e. DS and CLP). Variations in the effects of the programme according to the time of measurement, the type of disability and parent's gender are also examined. Globally, the results show a better adaptation among parents who participated in the intervention programme compared to those who did not participated in the programme. These parents had lower levels of parental stress, they had more positive perceptions and attitudes concerning their child's disability and their parental situation, they were more confident in their own resources and the help they could receive from others, they had lower levels of emotional distress, anxiety and depression and they perceived more emotional support from their spouse. In general, these gains were maintained throughout the year when the children were between six and 18 months of age, they were relatively similar for parents of children with DS and parents of children with CLP, as well as for mothers and fathers.

Adaptation of parents in relation to their 6-month-old infant's type of disability

The adaptation of parents to a disabled infant was studied in relation to the type of disability presented by the baby. Participants were divided according to three types of disability and one control group: patents of infants with (1) Down's syndrome (DS), (2) congenital heart disease (CHD), (3) a cleft lip and/or palate (CLP), and (4) no disability (ND). The data were collected using a self-administered questionnaire given to each parent 6 months after the birth of their baby. The measures included parenting stress, stress appraisal, and psychological distress. Overall, the results indicate that parents of infants with DS and parents of infants with CHD report greater levels of parenting stress and psychological distress than parents of babies with CLP or non-disabled infants. Mothers were found to report greater levels of stress and distress overall, but differences across diagnostic groups were similar for mothers and fathers. The implications of the findings for theory and clinical intervention are discussed.

The validity of the CAGE scale to screen for heavy drinking and drinking problems in a general population survey

BACKGROUND

The CAGE scale is a short test developed in the 1970s to screen for alcoholism or covert drinking problems. The reliability and validity of the scale has been demonstrated in the majority of studies conducted in clinical settings, but the validity of the scale in general population surveys has not yet been shown conclusively.

AIMS

The goal of this study was to assess the criterion validity of the CAGE scale in a general population survey.

METHOD

Data from a large general health survey conducted in 1992 in the province of Quebec (Canada) (N = 23,564) were used to define various measures of heavy drinking and drinking problems and to calculate, for male and female drinkers separately, standard measures of sensitivity, specificity and positive predictive value at different cutoff scores on the CAGE.

FINDINGS

With respect to both male and female drinkers, with all operational definitions of heavy drinking and useful cutoff scores on the CAGE, the scale was shown to be unable to discriminate between heavy drinkers and non-heavy drinkers. Prevalence of drinking problems among CAGE positive drinkers was also very low.

CONCLUSION

These results do not support the use of the CAGE as a screening tool for heavy drinking and drinking problems in a general population survey or as a tool to estimate the prevalence of drinking problems in the population.

Wives' convergence with their husbands' alcohol use: social conditions as mediators

OBJECTIVE

This study examines, in a general population, how the association of wives' alcohol use with their husbands' is mediated by social conditions such as working and child-rearing roles, age, marital happiness and socioeconomic levels.

METHOD

Data come from the Québec Health and Social Survey 1992-93. The sample comprised 6,582 couples; 3,872 couples after weighting. Regression analyses assessed the contribution of husbands' drinking to wives' drinking, independently, as well as in interaction with social conditions. Frequency of drinking in general and frequency of five or more drinks per occasion (5+) were analyzed.

RESULTS

Wives' drinking is positively related to their husbands' drinking, both in terms of frequency of drinking and, to a lesser degree, of frequency of 5+. The drinking frequency association is not modified by working or child-rearing roles, nor by age, but is more marked for couples of higher socioeconomic levels and for wives happy with marital life. The frequency of 5+ association is not modified by marital happiness or by wives' working roles, but is more marked for couples of higher socioeconomic levels, for couples with a child at home and for younger women.

CONCLUSIONS

This study highlights the contribution of social factors to the association of wives' drinking with their husbands' and suggests that these social factors operate through structuring marital drinking interactions. Further research is needed to clarify the complex social processes that mediate the spousal drinking association.

[Systematic family nursing intervention applied to the birth of a disabled child: effects on the parents' adaptation]

This quasi-experimental study evaluated the effectiveness of a new systemic family nursing intervention to facilitate the adaptation of parents with a handicapped child, as well as variations in effectiveness according to the gender of the parent, family income, and type of handicap. Conducted over a 6-month period, the intervention began immediately after birth and included the participation of 198 mothers and fathers of 6-month-old babies with Down syndrome or a cleft lip and/or palate. Half of the group received the intervention, while the other half, constituting the control group, received regular services. Emotional distress was measured, as were various aspects of parental stress. The results confirm the program's effectiveness. Almost all parental stress indicators showed less stress among parents who received the intervention. For some indicators, the effect of the intervention varied with the parent's gender. No significant correlation was found to exist between the program's effectiveness and family income or type of handicap. These results are discussed in light of the goals of the intervention, various aspects of parental adaptation, and a number of factors that may be linked to the effectiveness of the intervention.

Brief early psychological interventions following trauma: a systematic review of the literature

A systematic literature search/review was undertaken of brief early psychological interventions following trauma. Only six randomized controlled trials were found, and none of these included group interventions. Of the six trials, two studies associated the intervention with a positive outcome, two demonstrated no difference on outcome between intervention and non-intervention groups, and two showed some negative outcomes in the intervention group. This review suggests that early optimism for brief early psychological interventions including debriefing was misplaced and that there is an urgent need for randomized controlled trials of group debriefing and other early interventions.

[Neuroleptic medication and the risk of tardive dyskinesia: a survey of psychiatrists and general practitioners in Quebec]

The incidence of tardive dyskinesia (TD) during the first five years of neuroleptic treatment of adult schizophrenic patients, may rise to 35%. Yet, the prevention of this iatrogenic effect remains a secondary objective for clinicians. This study explored how medication decisions might vary depending on patient characteristics and medical specialty, and to identify correlates of prescribing aimed at the prevention of TD.

METHOD

Simulated medication decisions were elicited from 352 psychiatrists and 279 general practitioners in response to 12 brief written descriptions of a male schizophrenic outpatient treated for 5 years with 20 mg/day of haloperidol. Patient age, psychotic symptoms, signs of dyskinesia, and effectiveness of past treatment varied systematically in the descriptions.

RESULTS

Every variable except patient age affected decisions. Most physicians reduced doses for stable patients. In cases of active psychosis, decisions were affected by presence of dyskinesia and treatment effectiveness. Psychiatrists were more likely to increase or reduce doses, general practitioners to change medication. Very few physicians opted to cease medication. Younger psychiatrists made the most prudent decisions.

CONCLUSIONS

From a tardive dyskinesia prevention perspective, similar prescriptions to older and younger patients are worrying. We need to understand why physicians might believe that older patients require just as aggressive medication regimen as younger patients. Respondents within and between specialties tend make similar simulated decisions, but these do not necessarily reflect recommendations from controlled research on chronic neuroleptic treatment.

When anthropology meets epidemiology: using social representations to predict drinking patterns

Based on a sample of 2,015 adult drinkers from the Montreal metropolitan area (Quebec, Canada), this study investigates the relationship between eight social representations of drinking (i.e., compensatory, convivial, relaxing, disinhibitory, harmful, sexually enhancing, conventional, socially enabling) and drinking measures (QF Index, drinking frequency, and maximum number of drinks on one occasion) according to age and sex. The representations explain up to 34% of the variance in drinking measures. Representations differed in the strength of their relation to drinking measures and in population prevalence. Strength of relation to drinking and prevalence rates were relatively independent. Representations were generally more strongly endorsed by men than women, although they were related in the same way to drinking behaviors. Representations were also more strongly endorsed by younger than by older respondents, and they related differently to drinking in each age group. The implications of these results for prevention are discussed.

Is selective abortion for a genetic disease an issue for the medical profession? A comparative study of Quebec and France

This article discusses the results of a study of the stand and attitudes of physicians from the Picardie, Nord-Pas-de-Calais region in France and the province of Quebec (Canada) regarding abortion following the diagnosis of a fetal anomaly by ultrasound, amniocentesis, or chorionic villus sampling. The study examined the degree of acceptability of abortion for several specific conditions as well as the physicians' perceptions of their role in the women's decision to abort. The study shows a consensus (over 75 per cent of the physicians surveyed) for aborting a fetus with trisomy 21. There is a similar consensus, except among Francophones in Quebec, for muscular dystrophy, cystic fibrosis, and Huntington disease. Conversely, there is no consensus (below 60 per cent) for several anomalies. In these cases, Quebec Anglophone physicians find abortion more acceptable than Quebec Francophone or French physicians. Concerning the role of the practitioners in the decision to abort, physicians in France tend to be much more directive than their overseas colleagues. Several hypotheses are suggested to explain the difference between the three groups surveyed.

Urolithiasis from stapler anastomosis

The simplicity of operation and versatility and speed of automatic stapling devices in the creation of ileal loops have been amply documented. Three cases of stone formation in the ileal loop, secondary to encrustation about the staples, are reported herein, and the modification to the surgical technic which would obviate this problem is presented.