Horton General Hospital

A rating scale for drug-induced akathisia has been derived that incorporates diagnostic criteria for pseudoakathisia, and mild, moderate, and severe akathisia. It comprises items for rating the observable, restless movements which characterise the condition, the subjective awareness of restlessness, and any distress associated with the akathisia. In addition, there is an item for rating global severity. A standard examination procedure is recommended. The inter-rater reliability for the scale items (Cohen's kappa) ranged from 0.738 to 0.955. Akathisia was found in eight of 42 schizophrenic in-patients, and nine had pseudoakathisia, where the typical sense of inner restlessness was not reported.

OBJECTIVE: To describe the average primary care physician consultation length in economically developed and low-income/middle-income countries, and to examine the relationship between consultation length and organisational-level economic, and health outcomes. DESIGN AND OUTCOME MEASURES: This is a systematic review of published and grey literature in English, Chinese, Japanese, Spanish, Portuguese and Russian languages from 1946 to 2016, for articles reporting on primary care physician consultation lengths. Data were extracted and analysed for quality, and linear regression models were constructed to examine the relationship between consultation length and health service outcomes. RESULTS: One hundred and seventy nine studies were identified from 111 publications covering 28 570 712 consultations in 67 countries. Average consultation length differed across the world, ranging from 48 s in Bangladesh to 22.5 min in Sweden. We found that 18 countries representing about 50% of the global population spend 5 min or less with their primary care physicians. We also found significant associations between consultation length and healthcare spending per capita, admissions to hospital with ambulatory sensitive conditions such as diabetes, primary care physician density, physician efficiency and physician satisfaction. CONCLUSION: There are international variations in consultation length, and it is concerning that a large proportion of the global population have only a few minutes with their primary care physicians. Such a short consultation length is likely to adversely affect patient healthcare and physician workload and stress.

OBJECTIVES: To provide evidence of underdiagnosis of coeliac disease and to describe the main presenting symptoms of coeliac disease in primary care. DESIGN: Case finding in a primary care setting by testing for coeliac disease by using the endomysial antibody test. SETTING: Nine surgeries in and around a market town in central England, serving a population of 70 000. PARTICIPANTS: First 1000 patients screened from October 1996 to October 1997. OUTCOME MEASURES: Determination of endomysial antibody titre of patients fulfilling the study criteria, followed by small intestine biopsy of those with positive results. RESULTS: The 30 patients (out of 1000 samples) with positive results on the endomysial antibody test all had histological confirmation on small intestine biopsy. The commonest mode of presentation (15/30) was anaemia of varying severity. Most patients (25/30) presented with non-gastrointestinal symptoms. Specificity of the endomysial antibody test was 30/30. CONCLUSIONS: Underdiagnosis and misdiagnosis of coeliac disease are common in general practice and often result in protracted and unnecessary morbidity. Serological screening in primary care will uncover a large proportion of patients with this condition and should be made widely available and publicised. Coeliac disease should be considered in patients who have anaemia or are tired all the time, especially when there is a family history of the disease.

OBJECTIVES: To determine the respective efficacy of quetiapine and rivastigmine for agitation in people with dementia in institutional care and to evaluate these treatments with respect to change in cognitive performance. DESIGN: Randomised double blind (clinician, patient, outcomes assessor) placebo controlled trial. SETTING: Care facilities in the north east of England. PARTICIPANTS: 93 patients with Alzheimer's disease, dementia, and clinically significant agitation. INTERVENTION: Atypical antipsychotic (quetiapine), cholinesterase inhibitor (rivastigmine), or placebo (double dummy). MAIN OUTCOME MEASURES: Agitation (Cohen-Mansfield agitation inventory) and cognition (severe impairment battery) at baseline and at six weeks and 26 weeks. The primary outcome was agitation inventory at six weeks. RESULTS: 31 patients were randomised to each group, and 80 (86%) started treatment (25 rivastigmine, 26 quetiapine, 29 placebo), of whom 71 (89%) tolerated the maximum protocol dose (22 rivastigmine, 23 quetiapine, 26 placebo). Compared with placebo, neither group showed significant differences in improvement on the agitation inventory either at six weeks or 26 weeks. Fifty six patients scored > 10 on the severe impairment battery at baseline, 46 (82%) of whom were included in the analysis at six week follow up (14 rivastigmine, 14 quetiapine, 18 placebo). For quetiapine the change in severe impairment battery score from baseline was estimated as an average of -14.6 points (95% confidence interval -25.3 to -4.0) lower (that is, worse) than in the placebo group at six weeks (P = 0.009) and -15.4 points (-27.0 to -3.8) lower at 26 weeks (P = 0.01). The corresponding changes with rivastigmine were -3.5 points (-13.1 to 6.2) lower at six weeks (P = 0.5) and -7.5 points (-21.0 to 6.0) lower at 26 weeks (P = 0.3). CONCLUSIONS: Neither quetiapine nor rivastigmine are effective in the treatment of agitation in people with dementia in institutional care. Compared with placebo, quetiapine is associated with significantly greater cognitive decline.

Confirmation is reported of an earlier finding that the symptoms of patients with chronic schizophrenia segregate into three syndromes: psychomotor poverty (poverty of speech, flatness of affect, decreased spontaneous movement); disorganisation (disorders of the form of thought, inappropriate affect); and reality distortion (delusions and hallucinations).

Eighty-two schizophrenic outpatients receiving maintenance antipsychotic medication were assessed for akathisia and tardive dyskinesia. Thirty-nine (48%) manifested patterns of nondyskinetic, restless movement characteristic of akathisia. On the basis of their clinical features, these patients were divided into three groups: "acute" akathisia (recent onset, related to an increase in antipsychotic drug dose); "pseudoakathisia" (motor signs but no subjective symptoms); and "chronic" akathisia (a mixed category including persistent acute akathisia and "tardive" akathisia with the pharmacologic characteristics of tardive dyskinesia). Coarse, jerky foot tremor was observed as an invariable accompaniment of acute akathisia. A significant association was found between choreoathetoid limb dyskinesias, orofacial dyskinesias, and the presence of chronic akathisia. Also, the findings suggested a possible relationship between pseudoakathisia, orofacial and limb dyskinesia, and the severity of negative schizophrenic symptoms.

Cytogenetic classification of 350 adults with acute lymphoblastic leukaemia on MRC UKALL XA trial showed the following statistically significant associations: t(9;22) (11%) increased with increasing age and leucocyte counts (WBC) and most had a C/pre-B immunophenotype. t(4;11) (3%) was associated with higher WBCs, increasing age and null immunophenotype. Other abnormalities of 11q (abn11q) (4%) were associated with male sex and T-cell ALL. High hyperdiploidy (7%) and abn9p (5%) decreased with increasing WBC. High hyperdiploid patients were younger and tended to have C/pre-B ALL. Triploidy/tetraploidy (3%) decreased and pseudodiploidy (11%) increased with increasing WBC. Cytogenetic classification was prognostically important (chi-square for heterogeneity of classification = 53.56; P < 0.0001) and added significance to age, sex and WBC. A poor prognosis for patients classed as t(9;22) (13% disease-free survival at 3 years), as t(4;11) 24% at 3 years) and hypodiploid (11% at 3 years), and good prognosis for abn12p (4% of subjects) and high hyperdiploidy (74% and 59% at 3 years respectively) were statistically significant, but the 54% 3-year disease-free survival for patients with t(1;19) was not. The prognosis of patients classed as t(9;22) was independent of other single variables. Abn12p, abnormalities of 11q (including t(4;11) cases) and hypodiploidy added prognostic significance to all other variables combined.

The efficacy of the Historical, Clinical, and Risk Management Scales (HCR-20; C. D. Webster, D. Eaves, K. S. Douglas, & A. Wintrup, 1995), Psychopathy Checklist-Revised (PCL-R; R. D. Hare, 1991), Beck Hopelessness Scale (BHS; A. T. Beck, A. Weissman, D. Lester, & L. Trexler, 1974), and Brief Psychiatric Rating Scale (BPRS) to predict violence and self-harm in 34 institutionalized mentally disordered offenders was assessed. Both the HCR-20 and BPRS were strong predictors of violence whereas the PCL-R had moderate predictive ability. BHS was the only variable predictive of self-harm. Although risk assessment measures were successful at predicting in-patient violence, a clinical measure of mental state was at least as effective in these mentally disordered offenders.

OBJECTIVES: Elevated serum immunoglobulin G4 (IgG4) levels have been associated with autoimmune pancreatitis and IgG4-related disease (IgG4-RD) for over a decade. However, an elevated serum IgG4 is not specific for the disease. There have been inconsistent reports of its use in diagnosis, as a marker of disease relapse, and its relationship to organ involvement in retrospective cohorts. The aims of this study were to ascertain conditions that are associated with an elevated serum IgG4 and to investigate the role of IgG4 in diagnosis, relapse, and organ involvement in a prospective cohort of patients with IgG4-RD. METHODS: We evaluated serum IgG4 measurements in the Oxford Immunology Laboratory over 6 years. Patients in whom serum IgG4 was requested to differentiate IgG4-RD from other diseases were recruited into a longitudinal follow-up study to determine final diagnosis. In a prospective cohort of IgG4-RD patients, organ involvement, response to therapy, and disease relapse were determined. RESULTS: Two thousand and sixty-seven samples from 1,510 patients had serum IgG4 measured. Of these, IgG4 was elevated (≥1.4 g l(-1)) in 243 (16.1%) patients. The main indication (85.6%) was to distinguish between IgG4-RD and non-IgG4-RD conditions. Only 5.1% of patients who had serum IgG4 measured for this purpose had a final diagnosis of IgG4-RD. Of those with an elevated serum IgG4, 22.4% met IgG4-RD diagnostic criteria. Serum IgG4 was elevated in 48 (82.8%) of IgG4-RD patients. An IgG4 cutoff of 1.4 g l(-1) gave a sensitivity of 82.8% and specificity of 84.7% to diagnose IgG4-RD. Increasing this to 2.8 g l(-1) increased specificity to 96.2% and negative predictive value to 97.7%, with a lower sensitivity of 56.9% and positive predictive value of 44.5%. Serum IgG4 levels fell with corticosteroid therapy, but this was not disease-specific. A serum IgG4 of ≥2.8 g l(-1) at diagnosis was associated with multi-organ involvement and risk of relapse. CONCLUSIONS: Serum IgG4 levels are elevated in multiple non-IgG4-RD inflammatory and malignant conditions, with less than one-quarter of those with an elevated IgG4 meeting IgG4-RD diagnostic criteria. A serum IgG4 of ≥2.8 g l(-1) is useful in distinguishing between IgG4-RD and non-IgG4-RD diagnoses, predicting multiple-organ involvement and risk of relapse in IgG4-RD.

Out of 194 chronic schizophrenic in-patients, depressed mood (item 23 of the PSE) was present in 25 (13%). When compared with 25 matched controls, the patients with depressed mood had significantly higher scores on the MADRS and the Beck Depression Inventory. Serious suicidal ideas and auditory hallucinations were significantly more common in the depressed group. However, there were no significant differences between the matched groups in terms of negative symptoms, Parkinsonism, tardive dyskinesia, anticholinergic medication, or current dose of antipsychotic drug, which suggests that the depression identified was not related to drug treatment, nor was it a direct manifestation or misinterpretation of negative symptoms. Over three-month follow-up, the MADRS and Beck scores covaried closely with the presence or absence of depressed mood. This depressive syndrome persisted over the three months in the majority of patients originally depressed.

Fourteen cases of philadelphia chromosome (Ph1) positive chronic myeloid leukaemia in blast transformation have been investigated using cell surface markers. Morphologically eight cases were lymphoid and the remainder myeloid in appearance. All cases were negative with surface markers for thymocytes and T and B lymphocytes. Five of the lymphoid cases reacted with an antiserum specific for acute lymphoid leukaemia )ALL) of non-T non-B type and were also weakly reactive with a lymphocyte reactive antiserum. A sixth patient, whose blast cells were anti-ALL negative (ALL-) at presentation, subsequently developed central nervous system leukaemia with anti-ALL positive (ALL+) blast cells in the CSF. In all cases the leukaemic blast cells showed greatly diminished expression of cholera toxin receptors when compared to granulocytic cells from the chronic phase of CML. This parallels weak or negligible expression of the cholera toxin receptor in ALL and AML. These results suggest that the blastic phase of CML may involve different cellular derivatives of a pluripotential stem cell in which the primary malignant/genetic changes reside. The blast crisis of CML can therefore be heterogeneous with respect to cellular expression and in a significant proportion of patients involves a cell which is by membrane markers and morphological criteria indistinguishable from that seen in the common form of ALL. In these cases the Philadelphia chromosome may be the only distinguishing cellular characteristic.

BACKGROUND: We set out to determine whether and to what degree life events independent of illness increase the risk of relapse in schizophrenia following withdrawal from medication in the previous 6 months, either by triggering a relapse in the following 4 weeks or by acting cumulatively over time. METHOD: Seventy-one patients fulfilling DSM-III-R criteria for schizophrenia with chronic illness were followed for 48 weeks and assessed on the LEDS scale. Half were treated with regular neuroleptic medication and half had been recently withdrawn from medication. A subgroup was randomised double-blind to treatment or placebo. RESULTS: A proportional hazards regression model showed that life events made a significant cumulative contribution over time (P < 0.05) to the risks of relapse and that ceasing medication made an independent contribution. The risk of relapse increased in proportion to the number of life events but no interaction between medication status and events could be detected, i.e. life events were not more closely associated with relapse on medication than off medication. For those of the sample exposed to the mean rate of life events during the study period, it was estimated that 23% of the relapse risk could be attributed to life events, and for those with twice the mean rate of events, 41%. In contrast, patients who continued on regular medication had 80% less risk of relapse than those who had been withdrawn from medication either by choice or under double-blind controlled conditions. CONCLUSIONS: A contribution of life events to the risk of relapse in schizophrenia was confirmed by this study but the hypothesis that life events trigger relapse was not supported, nor was the hypothesis that life events are more relevant to relapse in patients on maintenance medication than in patients off medication.

A syndrome of subcortical dementia has been described in conditions predominantly affecting the basal ganglia or thalamus, structures that have also been implicated in the pathogenesis of schizophrenia. There are similarities between subcortical dementia and the type II syndrome of schizophrenia, in terms of clinical features, pattern of neuropsychological deficits, pathology, biochemistry and data from brain-imaging studies. These similarities raise the possibility that certain schizophrenic symptoms, particularly negative symptoms and disturbance of movement, may reflect subcortical pathology. Neuropsychological deficits of presumed frontal lobe origin have been reported in some schizophrenic subjects. The occurrence of such deficits in a condition in which frontal lobe pathology has not been clearly demonstrated may be explicable in terms of a subcortical deafferentation of the pre-frontal cortex.

Chronic schizophrenic patients in a long stay hospital were found to have low levels of intelligence (mean IQ of 80), which was attributed to the effects of substantial intellectual deterioration on below average pre-morbid levels of functioning. Patients with the lowest IQ scores had the least severe positive symptoms but symptomatology was not related to age or extent of intellectual decline. Speed of functioning was relatively more impaired than level of intellectual functioning, with cognitive speed being more affected than motor speed. The severity of negative but not positive symptoms was significantly related to the severity of bradyphrenia (cognitive slowing), a result which would be consistent with the notion of a subcortical pathology in patients with Type II schizophrenia.

OBJECTIVE: To examine changes in the rate of seeing patients between 1990 and 2004 and to see whether performance might be related to patient age, using data held on the patient administration system. METHOD: Data collected in 1990 were compared with those collected in 2004. Age related data were examined for the following parameters: the number of patients arriving by ambulance; the time taken to process the attendance; the number of investigations; the number of emergency admissions; and the length of inpatient stay. RESULTS: Emergency department (ED) performance has fallen markedly since 1990. Between 1990 and 2004, there was a 54% increase in total patients with a disproportionate 198% increase in patients aged more than 70 years, including a 671% increase in those aged more than 90 years. The time taken to manage patients increased with age. In 2004, there was a marked rise in investigation rates, and the probability of having investigations increased with age. In 2004, older patients (aged more than 70 years) were 4.9 times more likely to require admission to hospital than younger patients (aged 30 years or less). Their average length of stay was 6.9 times longer. Younger patients were 3.3 times more numerous than older patients but older patients occupied 9.8 times more emergency bed days. CONCLUSIONS: Pressure on emergency care is associated with a disproportionate increase in the number of elderly patients and with an increased tendency to investigate them. Population ageing is of central importance in planning health services.

BACKGROUND AND PURPOSE: A comprehensive study of both fatigue and excessive daytime sleepiness (EDS) in association with Parkinson's disease (PD)-related symptoms and treatment has not been performed yet. To assess the frequency and severity of fatigue and EDS in patients with idiopathic PD and to study their relation to motor and non-motor symptoms and dopaminergic treatment. METHODS: We prospectively assessed Fatigue Severity Scale (FSS) scores, Epworth Sleepiness Scale (ESS) scores, Beck Depression Inventory (BDI) scores, severity (Unified PD Rating Scale, UPDRS, part III; Hoehn & Yahr staging) and duration of the disease, and the current dopaminergic treatment in 88 consecutive patients with idiopathic PD. RESULTS: Fatigue was found in 52 (59%), EDS in 42 (48%), and both complaints in 31 (35%) patients. Fatigued patients had higher UPDRS III scores (23.5 ± 11.1 vs. 18.6 ± 7.6, P = 0.03), higher Hoehn & Yahr staging (2.4 ± 0.9 vs. 2.1 ± 0.7, P = 0.03), and higher BDI scores (13.4 ± 7.1 vs. 9.1 ± 5.8, P = 0.004) than non-fatigued patients. In contrast, UPDRS III, Hoehn & Yahr, and BDI scores did not differ between patients with or without EDS. However, the type of dopaminergic treatment (levodopa monotherapy versus combination of levodopa/dopamine agonists) was associated with significant differences in ESS (8.5 ± 5.2 vs. 10.8 ± 4.3, P = 0.04), but not FSS scores (4.1 ± 1.5 vs. 4.3 ± 1.5, P = 0.55). Disease duration correlated with ESS scores (r = 0.32, P = 0.003), but not with FSS scores (r = -0.02, P = 0.82). CONCLUSIONS: In PD, there is a significant overlap of fatigue and EDS, but the two symptoms are differently correlated with the severity of motor symptoms, disease duration, depression, and dopaminergic treatment.

Research on massage therapy for maternal pain and anxiety in labour is currently limited to four small trials. Each used different massage techniques, at different frequencies and durations, and relaxation techniques were included in three trials. Given the need to investigate massage interventions that complement maternal neurophysiological adaptations to labour and birth pain(s), we designed a pilot randomised controlled trial (RCT) to test the effects of a massage programme practised during physiological changes in pain threshold, from late pregnancy to birth, on women's reported pain, measured by a visual analogue scale (VAS) at 90 min following birth. To control for the potential bias of the possible effects of support offered within preparation for the intervention group, the study included 3 arms--intervention (massage programme with relaxation techniques), placebo (music with relaxation techniques) and control (usual care). The placebo offered a non-pharmacological coping strategy, to ensure that use of massage was the only difference between intervention and placebo groups. There was a trend towards slightly lower mean pain scores in the intervention group but these differences were not statistically significant. No differences were found in use of pharmacological analgesia, need for augmentation or mode of delivery. There was a trend towards more positive views of labour preparedness and sense of control in the intervention and placebo groups, compared with the control group. These findings suggest that regular massage with relaxation techniques from late pregnancy to birth is an acceptable coping strategy that merits a large trial with sufficient power to detect differences in reported pain as a primary outcome measure.

BACKGROUND: Weight gain is common for people with schizophrenia and this has serious implications for a patient's health and well being. Switching strategies have been recommended as a management option. OBJECTIVES: To determine the effects of antipsychotic medication switching as a strategy for reducing or preventing weight gain and metabolic problems in people with schizophrenia. SEARCH STRATEGY: We searched key databases and the Cochrane Schizophrenia Group's trials register (January 2005 and June 2007), reference sections within relevant papers and contacted the first author of each relevant study and other experts to collect further information. SELECTION CRITERIA: All clinical randomised controlled trials comparing switching of antipsychotic medication as an intervention for antipsychotic induced weight gain and metabolic problems with continuation of medication and/or other weight loss treatments (pharmacological and non pharmacological) in people with schizophrenia or schizophrenia-like illnesses. DATA COLLECTION AND ANALYSIS: Studies were reliably selected, quality assessed and data extracted. For dichotomous data we calculated risk ratio (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed-effect model. The primary outcome measures were weight loss, metabolic syndrome, relapse and general mental state. MAIN RESULTS: We included four studies for the review with a total of 636 participants. All except one study had a duration of 26 weeks or less. There was a mean weight loss of 1.94 kg (2 RCT, n = 287, CI -3.9 to 0.08) when switched to aripiprazole or quetiapine from olanzapine. BMI also decreased when switched to quetiapine (1 RCT, n = 129, MD -0.52 CI -1.26 to 0.22) and aripiprazole (1 RCT, n = 173, RR 0.28 CI 0.13 to 0.57) from olanzapine.Fasting blood glucose showed a significant decrease when switched to aripiprazole or quetiapine from olanzapine. (2 RCT, MD -2.53 n = 280 CI -2.94 to -2.11). One RCT also showed a favourable lipid profile when switched to aripiprazole but these measures were reported as percentage changes, rather than means with standard deviation.People are less likely to leave the study early if they remain on olanzapine compared to switching to quetiapine or aripiprazole.There was no significant difference in outcomes of mental state, global state, and adverse events between groups which switched medications and those that remained on previous medication. Three different switching strategies were compared and no strategy was found to be superior to the others for outcomes of weight gain, mental state and global state. AUTHORS' CONCLUSIONS: Evidence from this review suggests that switching antipsychotic medication to one with lesser potential for causing weight gain or metabolic problems could be an effective way to manage these side effects, but the data were weak due to the limited number of trials in this area and small sample sizes. Poor reporting of data also hindered using some trials and outcomes. There was no difference in mental state, global state and other treatment related adverse events between switching to another medication and continuing on the previous one. When the three switching strategies were compared none of them had an advantage over the others in their effects on the primary outcomes considered in this review. Better designed trials with adequate power would provide more convincing evidence for using medication switching as an intervention strategy.

Seven patients presenting as an acute leukaemia caused difficulty in diagnosis. The lymphoid appearance of the balst cells either initially or during treatment suggested acute lymphoid leukaemia (ALL). In each case the Philadelphia chromosome was shown to be present thus suggesting that these cases were examples of chronic myeloid leukaemia (CML) presenting in blast crisis without a detectable chronic phase. The implications of these findings are discussed and the difficulty in achieving a precise diagnosis in the acute leukaemias is emphasised. Cytogenetic analysis should be carried out whenever the type of acute leukaemia present is of critical importance.

In recent years, exploration of the distinction between positive and negative symptoms of schizophrenia has provided a fruitful basis for attempts to relate the clinical features of schizophrenia to the accumulating evidence of brain abnormalities in schizophrenic patients. By 1982, there was an extensive body of evidence supporting the hypothesis that negative schizophrenic symptoms, such as poverty of speech and flatness of affect, were associated with substantial brain abnormalities, such as increased ventricular to brain ratio, and extensive cognitive impairment (Crow, 1980; Andreasen &amp; Olsen, 1982). However, at that stage there were several fundamental unanswered questions about the nature of negative symptoms, and their relationship to indices of brain abnormality. This paper presents some findings of a series of studies initiated in 1982 to seek answers to some of these questions.