Richmond Royal Hospital

BACKGROUND: Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterised by high levels of inattention, hyperactivity and impulsivity that are present before the age of seven years, seen in a range of situations, inconsistent with the child's developmental level and causing social or academic impairment. Parent training programmes are psychosocial interventions aimed at training parents in techniques to enable them to manage their children's challenging behaviour. OBJECTIVES: To determine whether parent training interventions are effective in reducing ADHD symptoms and associated problems in children aged between five and eigtheen years with a diagnosis of ADHD, compared to controls with no parent training intervention. SEARCH METHODS: We searched the following electronic databases (for all available years until September 2010): CENTRAL (2010, Issue 3), MEDLINE (1950 to 10 September 2010), EMBASE (1980 to 2010 Week 36), CINAHL (1937 to 13 September 2010), PsycINFO (1806 to September Week 1 2010), Dissertation Abstracts International (14 September 2010) and the metaRegister of Controlled Trials (14 September 2010). We contacted experts in the field to ask for details of unpublished or ongoing research. SELECTION CRITERIA: Randomised (including quasi-randomised) studies comparing parent training with no treatment, a waiting list or treatment as usual (adjunctive or otherwise). We included studies if ADHD was the main focus of the trial and participants were over five years old and had a clinical diagnosis of ADHD or hyperkinetic disorder that was made by a specialist using the operationalised diagnostic criteria of the DSM-III/DSM-IV or ICD-10. We only included trials that reported at least one child outcome. DATA COLLECTION AND ANALYSIS: Four authors were involved in screening abstracts and at least 2 authors looked independently at each one. We reviewed a total of 12,691 studies and assessed five as eligible for inclusion. We extracted data and assessed the risk of bias in the five included trials. Opportunities for meta-analysis were limited and most data that we have reported are based on single studies. MAIN RESULTS: We found five studies including 284 participants that met the inclusion criteria, all of which compared parent training with de facto treatment as usual (TAU). One study included a nondirective parent support group as a second control arm. Four studies targeted children's behaviour problems and one assessed changes in parenting skills. Of the four studies targeting children's behaviour, two focused on behaviour at home and two focused on behaviour at school. The two studies focusing on behaviour at home had different findings: one found no difference between parent training and treatment as usual, whilst the other reported statistically significant results for parent training versus control. The two studies of behaviour at school also had different findings: one study found no difference between groups, whilst the other reported positive results for parent training when ADHD was not comorbid with oppositional defiant disorder. In this latter study, outcomes were better for girls and for children on medication.We assessed the risk of bias in most of the studies as unclear at best and often as high. Information on randomisation and allocation concealment did not appear in any study report. Inevitably, blinding of participants or personnel was impossible for this intervention; likewise, blinding of outcome assessors (who were most often the parents who had delivered the intervention) was impossible.We were only able to conduct meta-analysis for two outcomes: child 'externalising' behaviour (a measure of rulebreaking, oppositional behaviour or aggression) and child 'internalising' behaviour (for example, withdrawal and anxiety). Meta-analysis of three studies (n = 190) providing data on externalising behaviour produced results that fell short of statistical significance (SMD -0.32; 95% CI -0.83 to 0.18, I(2) = 60%). A meta-analysis of two studies (n = 142) for internalising behaviour gave significant results in the parent training groups (SMD -0.48; 95% CI -0.84 to -0.13, I(2) = 9%). Data from a third study likely to have contributed to this outcome were missing, and we have some concerns about selective outcome reporting bias.Individual study results for child behaviour outcomes were mixed. Positive results on an inventory of child behaviour problems were reported for one small study (n = 24) with the caveat that results were only positive when parent training was delivered to individuals and not groups. In another study (n = 62), positive effects (once results were adjusted for demographic and baseline data) were reported for the intervention group on a social skills measure.The study (n = 48) that assessed parenting skill changes compared parent training with a nondirective parent support group. Statistically significant improvements were reported for the parent training group. Two studies (n = 142) provided data on parent stress indices that were suitable for combining in a meta-analysis. The results were significant for the 'child' domain (MD -10.52; 95% CI -20.55 to -0.48) but not the 'parent' domain (MD -7.54; 95% CI -24.38 to 9.30). Results for this outcome from a small study (n = 24) suggested a long-term benefit for mothers who received the intervention at an individual level; in contrast, fathers benefited from short-term group treatment. A fourth study reported change data for within group measures of parental stress and found significant benefits in only one of the two active parent training group arms (P ≤ 0.01).No study reported data for academic achievement, adverse events or parental understanding of ADHD. AUTHORS' CONCLUSIONS: Parent training may have a positive effect on the behaviour of children with ADHD. It may also reduce parental stress and enhance parental confidence. However, the poor methodological quality of the included studies increases the risk of bias in the results. Data concerning ADHD-specific behaviour are ambiguous. For many important outcomes, including school achievement and adverse effects, data are lacking.Evidence from this review is not strong enough to form a basis for clinical practice guidelines. Future research should ensure better reporting of the study procedures and results.

108 Background: In a phase 1/2 study, the combination of E, a selective oral inhibitor of the IDO1 enzyme, plus P, a PD-1 inhibitor, suggested promising antitumor activity with minimal additive toxicity. ECHO-301/KEYNOTE-252 (NCT02752074) is a phase 3, randomized, double-blind study evaluating the efficacy and safety of E + P vs placebo + P in pts with untreated unresectable or metastatic melanoma. Methods: Pts had histologically confirmed unresectable stage III or IV melanoma and were treatment naive for advanced or metastatic disease, except for pts with the BRAF V600 mutation who could have received prior BRAF/MEK therapy. Pts were stratified by PD-L1 expression and BRAF mutation status (BRAF mutant with prior BRAF-directed therapy, BRAF mutant without prior BRAF-directed therapy, and BRAF wild type) and randomized 1:1 to E 100 mg BID + P 200 mg Q3W or matched E placebo + P 200 mg Q3W. Response was assessed per RECIST v1.1 and irRECIST (both by central review). The primary endpoints were PFS per RECIST v1.1 and OS. Secondary endpoints were ORR per RECIST v1.1, duration of response, and safety. This is the final analysis for PFS and interim analysis for OS. Results: A total of 706 pts were randomized (354 to E + P and 352 to placebo + P); 72.5% of tumors were PD-L1 positive, 44.5% BRAF mutant (12.2% received prior BRAF/MEK therapy). Median follow-up was ~14 mo. E + P did not result in a significantly longer PFS vs placebo + P (median 4.7 vs 4.9 mo; HR=1.00; CI, 0.83-1.21; P=0.517). PFS rate at 12 mo was 37% in both groups. Findings were consistent across PD-L1 and BRAF subgroups. OS was not expected to reach statistical significance based on the results of this interim analysis (HR=1.13; CI, 0.86-1.49; P=0.807). The OS rate at 12 mo was 74% in both groups. ORR was 34.2% and 31.5% in the E + P and placebo + P groups, respectively. Grade ≥3 treatment-related AEs occurred in 21.8% of patients receiving E + P and 17.0% receiving placebo + P. Conclusions: The addition of E to P did not result in greater clinical benefit over P alone in pts with unresectable or metastatic melanoma. The safety profile was consistent with that observed in previously reported studies of this combination. Clinical trial information: NCT02752074.

This paper is a supplementary article on counting metamers to one presented earlier in this journal. Whereas in the previous study the basic collection of object-color stimuli contained “jagged” spectral reflectance curves, including a great many that exhibit extreme reflectance variations within small spectral ranges, the present paper makes use of basic collections which contain “smooth” spectral reflectance curves generated by frequency-limited functions. The results obtained in the present study are similar to those obtained previously, particularly when the limiting frequency of the spectral reflectance functions is set at ω = 1/50. Such a limiting frequency leads to spectral reflectance curves of typically four oscillations within the visible spectrum, making them resemble practical spectral reflectance curves.

BACKGROUND: Drugs used to treat psychotic illnesses may take weeks to be effective. In the interim, additional 'as required' doses of medication can be used to calm patients in psychiatric wards. The practice is widespread, with 20% to 50% of people on acute psychiatric wards receiving at least one 'as required' dose of psychotropic medication during their admission. OBJECTIVES: To compare the effects of 'as required' medication regimens with regular patterns of medication for the treatment of psychotic symptoms or behavioural disturbance, thought to be secondary to psychotic illness. These regimens may be given alone or in addition to any regular psychotropic medication for the long-term treatment of schizophrenia or schizophrenia-like illnesses. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Trials Register, which is based on regular searches of MEDLINE, EMBASE, PubMed, CINAHL, BIOSIS, AMED, PsycINFO and registries of clinical trials, in November 2001, March 2006, July 2012 andOctober 2013. SELECTION CRITERIA: We aimed to include all relevant randomised controlled trials involving hospital inpatients with schizophrenia or schizophrenia-like illnesses, comparing any regimen of medication administered for the short-term relief of behavioural disturbance, or psychotic symptoms, to be given at the discretion of ward staff ('as required', 'prn') with fixed non-discretionary patterns of drug administration of the same drug(s). This was in addition to regular psychotropic medication for the long-term treatment of schizophrenia or schizophrenia-like illnesses where prescribed. DATA COLLECTION AND ANALYSIS: We independently inspected abstracts and papers for inclusion. If trials had been found, we would have extracted data from the papers and quality assessed the data. For dichotomous data we would have calculated the risk ratios (RR), with the 95% confidence intervals (CI). We would have conducted analyses on an intention-to-treat basis. If data were available we would have completed a 'Summary of findings' table using GRADE. MAIN RESULTS: We have not been able to identify any randomised trials comparing 'as required' medication regimens to regular regimens of the same drug. Our main outcomes of interest were important changes in (i) mental state, (ii) behaviour, (iii) dose of medication used, (iv) adverse events, (v) satisfaction with care and (iv) cost of care. AUTHORS' CONCLUSIONS: There is currently no evidence from within randomised trials to support this common practice. Current practice is based on clinical experience and habit rather than high quality evidence.

BACKGROUND: Studies of psychological stress among substance misuse professionals rarely describe the nature of burnout and psychological morbidity. The main aim of this study was to determine the extent, pattern and predictors of psychological morbidity and burnout among substance misuse professionals. METHODS: This study was a cross-sectional mail survey of 194 clinical staff of substance misuse services in the former South Thames region of England, using the General Health Questionnaire (GHQ-12) the Maslach Burnout Inventory (MBI) as measures of psychological morbidity and burnout, respectively. RESULTS: Rates of psychological morbidity (82%: 95% CI = 76-87) and burnout (high emotional exhaustion - 33% [27-40]; high depersonalisation - 17% [12-23]; and diminished personal accomplishment - 36% [29-43]) were relatively high in the study sample. High levels of alienation and tension (job stressors) predicted emotional exhaustion and depersonalisation (burnout) but not psychological morbidity. Diminished personal accomplishment was associated with higher levels of psychological morbidity CONCLUSION: In the sample of substance misuse professionals studied, rates of psychological morbidity and burnout were high, suggesting a higher level of vulnerability than in other health professionals. Furthermore, pathways to psychological morbidity and burnout are partially related. Therefore, targeted response is required to manage stress, burnout and psychological morbidity among substance misuse professionals. Such a response should be integral to workforce development.

Attention deficit hyperactivity disorder (ADHD) generates controversy. Some believe that it does not exist, whereas others see the reluctance of clinicians to diagnose and treat it as denying effective health care to children.1 Epidemiological studies show that 3-5% of children of school age may be classified as having attention deficit hyperactivity disorder.2 No validated diagnostic test exists to confirm the clinical diagnosis. It is a complex neurodevelopmental constellation of problems rather than a single disorder. The core symptoms are inattention, hyperactivity, and impulsivity. These are also, however, normal behavioural traits present in unaffected children. The extent to which each causes disability varies and should be seen within the context of a child's developmental level. For example, an active 3 year old, impulsive and frequently interrupting of others, differs from a disruptive, unfocused 8 year old who is unable to cope educationally. Yet both may display core symptoms. Also, it is important to establish that symptoms exist …

Abstract Competition for fish oil from human nutritional supplements (nutraceuticals) is starting to threaten its supply for aquaculture feeds. World supply of fish oil is not increasing but is the main source of healthy omega-3 fats (n-3 LC-PUFA). Fish oil demand by nutraceuticals is a derived demand for such fats. Demand growth and insecure supply are causing price inflation of fish oil, helping to drive its substitution in aquaculture feeds by vegetable oils. This is reducing the content of n-3 LC-PUFA in aquaculture products, especially salmon, with potentially negative health implications. Given the scope for further substitution of fish oil, it is unlikely that future growth of global aquaculture will be constrained by reducing omega-3 content, although it will complicate consumer marketing of salmon. Nutraceuticals is paying more than aquaculture for fish oil based on omega-3 content, but novel sources of n-3 LC-PUFA will become available in the medium term. Keywords: aquaculturefish oilnutraceuticalsomega-3rapeseed oilsalmon farming ACKNOWLEDGMENTS The authors wish to thank the following for their helpful comments: Niels Alsted, Tony Bimbo, Trond Bjørndal, Adam Ismail, Bill Lands, Andrew Jackson, Ragnar Nystøyl, Ragnar Tveterås, and Peter Virley, together with the comments of two anonymous reviewers. The authors also gratefully acknowledge the willingness of certain organizations to make available statistical information, namely IFFO, GOED, Kontali Analyse, and ISTA Mielke. Notes *Assumes fish oil in salmon diet is a mix of approx. 50% Peruvian anchovy and 50% North Atlantic sources, with balance of added oil being vegetable oils, mainly rapeseed oil. **Assumes the EPA & DHA levels in the salmon fillet are the same as in the oil in the feed. Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/uaqm.

The implementation of the Care Programme Approach (CPA) in English mental health services has been slow to proceed despite general support, both in England and in other countries, of its principles of good practice. This study set out to evaluate the implementation of the CPA directly from patients' experience using the "Your Treatment and Care" assessment tool. The results of a survey of 503 patients across five NHS Trusts in England showed that many patients did not have a copy of their care plan and had not been involved in the care planning procedure. Many reported shortcomings in their experience of their key worker and their psychiatrist. However, there was substantial variation in experience across services. "Your Treatment and Care" showed good internal reliability, was acceptable to users, and appeared to be able to access actual experiences better than a traditional "satisfaction" item. It appears to be very useful as a benchmarking tool and is now being used in services across the UK, the USA and Australia.

Abstract What is often referred to as the existential approach to counselling and psychotherapy may be defined as the application of existential-phenomenological philosophy towards psychotherapeutic ends, in which individual practitioners choose how to apply their readings of the leading authors. The first of this two-part exposition introduces a form of ‘experiential’ philosophy called phenomenology, a regular experiential method that is in many ways antithetical to the conventional scientific approach. This first paper concentrates on one of the many successive definitions of phenomenology given by Husserl, the philosopher of science, in 1927, with help from his ex-student Heidegger. In the second paper, phenomenology is brought to bear on human experience, and it is Heidegger in Being and Time who added it to the writings of the earlier existentialists Kierkegaard and Nietzsche; to produce existential psychology and philosophy. Also in the second part, three forms of existential therapy are briefly mentioned. This first paper introduces a handful of key ideas for counselling psychologists, and illustrates how philosophical work is an inherent part of life, as well as the production and use of psychological knowledge.

BACKGROUND: The aim of this study was to determine the success of fasciotomy of lower limb compartments with elevated intra-compartment pressure. METHODS: The present report is a retrospective cohort study at No. 3 Combat Support Hospital involving a survey and case note review of patients who had undergone fasciotomy for compartment syndrome at least 6 months earlier (December 1997-December 2000). RESULTS: Fourteen patients met the inclusion criteria. Eleven reported success with complete resolution of symptoms and return to military fitness levels. Two reported no change and significant residual symptoms. One reported worse symptoms and one required re-operation with a successful result. CONCLUSION: Surgical decompression is the accepted treatment of compartment syndrome as proven by pressure manometry, after failure of conservative treatment.

Two reflecting surfaces which are metameric under a particular illuminant must have spectral reflectance curves that intersect. The possibility of metamerism depends on the number and the spectral positions of the intersections and on the shape of the particular spectrum locus in the chromaticity diagram which applies to a given color space. The relevant rules are derived for ordinary trichromatic vision, and the extensions necessary when metamerism rests on more than three matching conditions (e.g., metamerism for both photopic and scotopic vision) are discussed.

Abstract Aims Nitroxyl provokes vasodilatation and inotropic and lusitropic effects in animals via post‐translational modification of thiols. We aimed to compare effects of the nitroxyl donor cimlanod (BMS‐986231) with those of nitroglycerin (NTG) or placebo on cardiac function in patients with chronic heart failure with reduced ejection fraction (HFrEF). Methods and results In a randomized, multicentre, double‐blind, crossover trial, 45 patients with stable HFrEF were given a 5 h intravenous infusion of cimlanod, NTG, or placebo on separate days. Echocardiograms were done at the start and end of each infusion period and read in a core laboratory. The primary endpoint was stroke volume index derived from the left ventricular outflow tract at the end of each infusion period. Stroke volume index with placebo was 30 ± 7 mL/m 2 and was lower with cimlanod (29 ± 9 mL/m 2 ; P = 0.03) and NTG (28 ± 8 mL/m 2 ; P = 0.02). Transmitral E‐wave Doppler velocity on cimlanod or NTG was lower than on placebo and, consequently, E/e′ ( P = 0.006) and E/A ratio ( P = 0.003) were also lower. NTG had similar effects to cimlanod on these measurements. Blood pressure reduction was similar with cimlanod and NTG and greater than with placebo. Conclusion In patients with chronic HFrEF, the haemodynamic effects of cimlanod and NTG are similar. The effects of cimlanod may be explained by venodilatation and preload reduction without additional inotropic or lusitropic effects. Ongoing trials of cimlanod will further define its potential role in the treatment of heart failure.

Abstract Antimicrobial nectar secondary metabolites can support pollinator health by preventing or reducing parasite infections. To better understand the outcome of nectar metabolite–parasite interactions in pollinators, we determined whether the antiparasitic activity was altered through chemical modification by the host or resident microbiome during gut passage. We investigated this interaction with linden (Tilia spp.) and strawberry tree (Arbutus unedo) nectar compounds. Unedone from A. unedo nectar inhibited the common bumblebee gut parasite Crithidia bombi in vitro and in Bombus terrestris gynes. A compound in Tilia nectar, 1-[4-(1-hydroxy-1-methylethyl)-1,3-cyclohexadiene-1-carboxylate]-6-O-β-d-glucopyranosyl-β-d-glucopyranose (tiliaside), showed no inhibition in vitro at naturally occurring concentrations but reduced C. bombi infections of B. terrestris workers. Independent of microbiome status, tiliaside was deglycosylated during gut passage, thereby increasing its antiparasitic activity in the hindgut, the site of C. bombi infections. Conversely, unedone was first glycosylated in the midgut without influence of the microbiome to unedone-8-O-β-d-glucoside, rendering it inactive against C. bombi, but subsequently deglycosylated by the microbiome in the hindgut, restoring its activity. We therefore show that conversion of nectar metabolites by either the host or the microbiome modulates antiparasitic activity of nectar metabolites. This article is part of the theme issue ‘Natural processes influencing pollinator health: from chemistry to landscapes’.

BACKGROUND: Drugs used to treat psychotic illnesses may take weeks to be effective. In the interim, additional 'as required' doses of medication can be used to calm patients in psychiatric wards. The practice is widespread with 20% - 50% of people on acute psychiatric wards receiving at least one 'as required' dose of psychotropic medication during their admission. OBJECTIVES: To compare the effects of 'as required' medication regimens with regular regimens of medication for the treatment of psychotic symptoms or behavioural disturbance, thought to be secondary to psychotic illness. SEARCH STRATEGY: For this 2006 update, we searched The Cochrane Schizophrenia Group's register of trials (March 2006). SELECTION CRITERIA: We included all relevant randomised control trials involving hospital inpatients with schizophrenia or schizophrenia-like illnesses, comparing any regimen of medication administered for the short term relief of behavioural disturbance, or psychotic symptoms, to be given at the discretion of ward staff ('as required', 'prn') with fixed non-discretionary patterns of drug administration of the same drug(s). This was in addition to regular psychotropic medication for the long-term treatment of schizophrenia or schizophrenia-like illnesses where prescribed. DATA COLLECTION AND ANALYSIS: We independently inspected abstracts, extracted data from the papers and quality assessed the data. For dichotomous data we would have calculated the relative risks (RR), with the 95% confidence intervals (CI) and the number needed to treat statistic (NNT). Analyses would have been conducted on an intention-to-treat basis. MAIN RESULTS: We didn't identify any randomised trials comparing 'as required' medication regimens to regular regimens of the same drug. AUTHORS' CONCLUSIONS: There is no evidence from within randomised trials to support this common current practices. Current practice is based on clinical experience and habit rather than high quality evidence.

BACKGROUND: in the liver. METHODS: In this phase 1, open-label study, we administered one infusion of nex-z to patients with ATTRv-PN. Primary objectives included assessment of the safety and pharmacodynamics of nex-z. Secondary end points included changes in the familial amyloid polyneuropathy stage, polyneuropathy disability score, serum neurofilament light chain (NfL) level, modified body-mass index (modified BMI, defined as the conventional BMI [weight in kilograms divided by square of height in meters] multiplied by the albumin level in grams per liter), and modified Neuropathy Impairment Score+7 (mNIS+7; range, 0 to 304, with higher scores indicating more impairment). RESULTS: A total of 36 patients received nex-z; the mean follow-up was 27 months. The mean percent change from baseline in the serum TTR level was -90% at day 28, which was sustained through month 24 (-92%). Treatment-related adverse events included transient infusion-related reactions (in 21 patients), decreased thyroxine level without hypothyroidism or elevated thyrotropin level (in 8), and headache (in 4). One participant died from cardiac amyloidosis, and one withdrew owing to progressive decline in motor function. Serious adverse events were reported in 11 patients. At month 24, the familial amyloid polyneuropathy stage and polyneuropathy disability score remained stable in 29 and 27 patients, respectively; improved in 2 and 5, respectively; and worsened in 2 and 2, respectively. The mean change in the serum NfL level was -9.0 pg per milliliter, and the change in the modified BMI was 24.7. The mean change from baseline in the mNIS+7 was -8.5. CONCLUSIONS: A single administration of nex-z in patients with ATTRv-PN was associated with rapid, deep, and durable reductions in serum TTR levels. The results support further investigation of nex-z to treat ATTRv-PN. (Funded by Intellia Therapeutics and Regeneron Pharmaceuticals; ClinicalTrials.gov number, NCT04601051.).

Threshold summation indices were determined in a study of interrelations among Stiles π mechanisms. Test wavelengths of 630, 520, 475, and 420 nm were presented upon a 555-nm adapting field. The 630–520-nm test-stimulus combination showed very small summation indices compared to the index derived on the assumption of independence of the π4 and π5 mechanisms. We suggest that π5 is not a single or unitary mechanism, but is comprised of two components, π5r and π5g, that may inhibit or cancel each other’s effects in producing the net response of mechanism π5. The hypothesis also explains fairly well the observed small index for the combination 630–475 nm at low field luminance. The mechanisms π1, π4, and the composite π5 seem to be independent, as shown by good agreement between the calculated and experimental indices at high field luminance for the combination 630–475 nm, and over the entire range of field luminance for the combination 520–475 nm. Complete summation is observed for the combination 475–420 nm at high field luminance, with which mechanism π1 should be almost exclusively involved.

Journal Article Soviet Planning and the Price Mechanism Get access M. C. Kaser M. C. Kaser Richmond, Surrey Search for other works by this author on: Oxford Academic Google Scholar The Economic Journal, Volume 60, Issue 237, 1 March 1950, Pages 81–91, https://doi.org/10.2307/2227210 Published: 01 March 1950

Journal Article Pied Forcé or March Foot Get access Harold Dodd Harold Dodd Hon. SurgeonAssistant Surgeon King George Hospital, IlfordTo the Royal Hospital, RichmondPrincess Louise Hospital for Children, Kensington Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 21, Issue 81, July 1933, Pages 131–144, https://doi.org/10.1002/bjs.1800218113 Published: 05 December 2005

Professionals working in child and adolescent mental health services are increasingly encouraged to examine the evidence underlying their clinical practice. Embracing evidence-based practice can present difficulties, as barriers to changing practice exist. These difficulties are examined, along with the meaning of evidence-based practice in a multidisciplinary speciality, and the potential benefits that develop from it.

Stress is an important cause of impaired fulfilment and functioning at work. While instruments exist to measure stress across different occupations, this article reports the development and validation of an occupational stress scale specific to staff working with alcohol and/or drug misusers. An item analysis of 195 responses to an initial 112- item questionnaire resulted in a 25-item instrument, the addiction employees' stress scale (AESS). The AESS demonstrates adequate reliability (range of alpha coefficients, 0.88- 0.92) and construct validity across two study samples, having returned expected statistically significant correlations with five validation criteria that included the Maslach Burnout Inventory-Human Services Survey. The AESS can be used to measure stress levels, to identify sources of stress for individuals working with substance misusers and to develop appropriate work-based stress intervention programmes.