Lambeth Hospital

OBJECTIVE: To evaluate the effectiveness of a service for early psychosis. DESIGN: Randomised controlled clinical trial. SETTING: Community mental health teams in one London borough. PARTICIPANTS: 144 people aged 16-40 years presenting to mental health services for the first or second time with non-organic, non-affective psychosis. INTERVENTIONS: Assertive outreach with evidence based biopsychosocial interventions (specialised care group) and standard care (control group) delivered by community mental health teams. PRIMARY OUTCOME MEASURES: Rates of relapse and readmission to hospital. RESULTS: Compared with patients in the standard care group, those in the specialised care group were less likely to relapse (odds ratio 0.46, 95% confidence interval 0.22 to 0.97), were readmitted fewer times (beta 0.39, 0.10 to 0.68), and were less likely to drop out of the study (odds ratio 0.35, 0.15 to 0.81). When rates were adjusted for sex, previous psychotic episode, and ethnicity, the difference in relapse was no longer significant (odds ratio 0.55, 0.24 to 1.26); only total number of readmissions (beta 0.36, 0.04 to 0.66) and dropout rates (beta 0.28, 0.12 to 0.73) remained significant. CONCLUSIONS: Limited evidence shows that a team delivering specialised care for patients with early psychosis is superior to standard care for maintaining contact with professionals and for reducing readmissions to hospital. No firm conclusions can, however, be drawn owing to the modest sample size.

OBJECTIVE: To describe historic markers and clinical observations of life-threatening child abuse as diagnosed using covert video surveillance (CVS). DESIGN: A descriptive, retrospective, partially controlled case study. SETTING: Two hospitals (in London and North Staffordshire, UK) receiving referrals for the investigation of apparent life-threatening events (ALTE), with the availability of CVS. PATIENTS: A total of 39 children (age range at CVS, 2 to 44 months; median, 9 months) in whom hospital CVS was used to investigate suspicions of induced illness. Thirty-six were referred for investigation of ALTE, one with suspected epilepsy, one with failure to thrive, and one with suspected strangulation. A control group consisted of 46 children with recurrent ALTE proven on physiologic recordings to be attributable to a natural medical cause (9 attributable to epileptic seizures, and 37 attributable to respiratory problems). INTERVENTION: Collection of historic details from medical, social service, and police records; interagency collaboration in planning, investigations, and management; development and use of CVS as a clinical tool in the investigation of patients in whom there was suspicion of induced illness. OUTCOME: Confirmation of attempted suffocation or other child abuse from CVS. RESULTS: CVS revealed abuse in 33 of 39 suspected cases, with documentation of intentional suffocation observed in 30 patients. Poisonings (with disinfectant or anticonvulsant), a deliberate fracture, and other emotional and physical abuse were also identified under surveillance. The first ALTE occurred at a median age corrected for the expected date of delivery of 3.6 months in the CVS patients and of 0.3 months in controls. Three CVS patients and 27 of the control children (including 20 at <32 weeks' gestation) were born prematurely. Bleeding from the nose and/or mouth was reported in 11 of the 38 patients with ALTE undergoing CVS but in none of the 46 controls. Four patients who had been subjected to recurrent suffocation before CVS had permanent neurologic deficits and/or required anticonvulsant therapy for epileptic seizures resulting from hypoxic cerebral injury. The 39 patients undergoing CVS had 41 siblings, 12 of whom had previously died suddenly and unexpectedly. Eleven of the deaths had been classified as sudden infant death syndrome but after CVS, four parents admitted to suffocating eight of these siblings. One additional sibling who had died suddenly with rotavirus gastroenteritis was reinvestigated after CVS of her sister revealed poisoning, and death was found to be caused by deliberate salt poisoning. Other signs of abuse were documented in the medical, social, and police records of an additional 15 of the siblings. In the 52 siblings of the 46 controls, 2 had died: one from hypoplastic left heart at 5 days and the other suddenly and unexpectedly (classified as sudden infant death syndrome) at 7 weeks. Twenty-three of the abusive parents were diagnosed by a psychiatrist as having personality disorders. CONCLUSIONS: Induced illness is a severe form of abuse that may cause death or permanent neurologic impairment. It may be accompanied by other severe forms of abuse, may result in behavioral disorders, and may be accompanied by immeasurable suffering. Detection of this abuse requires careful history-taking; thorough examination of the health, social, and police records; and close and focused collaboration between hospital and community child health professionals, child psychiatrists, social workers, and police officers. CVS may help investigate suspicions and ensure that children are protected from additional abuse. When parents have failed to acknowledge that they have deceived health professionals, partnership with them in seeking to protect their children may be neither safe nor effective.

BACKGROUND: In recent years there has been an upsurge of interest in the study of distinctive patterns of behavioural and psychological characteristics associated with specific, biologically determined, intellectually disabling conditions. This study investigates whether such a profile can be identified in adults with Williams syndrome. METHOD: Parents and other care-givers were interviewed about the social, emotional and behavioural characteristics of 70 adults with Williams syndrome, aged 19 years to 39 years 9 months. RESULTS: The adults were reported to have high rates of behavioural and emotional difficulties, particularly in terms of poor social relationships, over-friendliness and social disinhibition, preoccupations and obsessions, and high levels of anxiety and distractibility. CONCLUSIONS: The findings provide preliminary support for the existence of a specific pattern of behavioural and personality characteristics and associated difficulties in adults with Williams syndrome, which persist from childhood and often require intervention from mental health professionals. Implications for clinical practice are considered.

Erythromycin-resistant staphylococci can be divided into two phenotypic classes based on their pattern of cross-resistance to other macrolides, lincosamides and type B streptogramins. Strains inducibly or constitutively resistant to all MLS antibiotics possess erythromycin ribosomal methylase (erm) genes, whereas strains inducibly resistant to only 14 and 15-membered ring macrolides and type B streptogramins harbour msrA, which encodes an ATP-dependent efflux pump. Dot-blot hybridization was used to study the distribution of ermA, ermB, ermC and msrA in five epidemiologically distinct groups of staphylococci. The most widely-distributed resistance determinant was ermC, which was detected in 112 (50.6%) of 221 isolates, alone in 106 isolates and in combination with a second erythromycin resistance determinant in six strains. MsrA was detected in 73 (33%) of isolates, alone in 65 and in combination with a methylase gene in eight strains. This determinant was responsible for erythromycin resistance in over one-third (36.4%) of clinical isolates of coagulase-negative staphylococci. ErmA and ermB were present in only a minority of isolates (5.9 and 7.2% of strains, respectively). The resistance determinants present in ten strains did not hybridize to any of the four probes although, in all cases, their resistance phenotype was consistent with the possession of a methylase gene. Interestingly, ermB was found exclusively in animal isolates of Staphylococcus intermedius, Staphylococcus xylosus and Staphylococcus hyicus, but not in coagulase-negative staphylococci of human origin. This determinant has previously only been found in a small number of epidemiologically related strains of Staphylococcus aureus.

BACKGROUND: Young people with early psychosis are at particularly high risk of suicide. However, there is evidence that early intervention can reduce this risk. Despite these advances, first episode psychosis patients attending these new services still remain at risk. To address this concern, a program called LifeSPAN was established within the Early Psychosis Prevention and Intervention Centre (EPPIC). The program developed and evaluated a number of suicide prevention strategies within EPPIC and included a cognitively oriented therapy (LifeSPAN therapy) for acutely suicidal patients with psychosis. We describe the development of these interventions in this paper. METHOD: Clinical audit and surveys provided an indication of the prevalence of suicidality among first episode psychosis patients attending EPPIC. Second, staff focus groups and surveys identified gaps in service provision for suicidal young people attending the service. Third, a suicide risk monitoring system was introduced to identify those at highest risk. Finally, patients so identified were referred to and offered LifeSPAN therapy whose effectiveness was evaluated in a randomised controlled trial. RESULTS: Fifty-six suicidal patients with first episode psychosis were randomly assigned to standard clinical care or standard care plus LifeSPAN therapy. Forty-two patients completed the intervention. Clinical ratings and measures of suicidality and risk were assessed before, immediately after the intervention, and 6 months later. Benefits were noted in the treatment group on indirect measures of suicidality, e.g., hopelessness. The treatment group showed a greater average improvement (though not significant) on a measure of suicide ideation. CONCLUSIONS: Early intervention in psychosis for young people reduces the risk of suicide. Augmenting early intervention with a suicide preventative therapy may further reduce this risk.

BACKGROUND: Chronic fatigue syndrome (CFS) is an illness characterised by persistent medically unexplained fatigue. CFS is a serious health-care problem with a prevalence of up to 3%. Treatment strategies for CFS include psychological, physical and pharmacological interventions. OBJECTIVES: To investigate the relative effectiveness of exercise therapy and control treatments for CFS. SEARCH STRATEGY: CCDANCTR-Studies and CENTRAL were searched using "Chronic Fatigue" and Exercise. The Journal of Chronic Fatigue Syndrome and CFS conferences were handsearched. Experts in the field were contacted. Clinicaltrials.gov and controlled-trials.com were searched. SELECTION CRITERIA: Only Randomised Controlled Trials (RCT) including participants with a clinical diagnosis of CFS and of any age were included. DATA COLLECTION AND ANALYSIS: The full articles of studies identified were inspected by two reviewers (ME and HMG). Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals. One sensitivity analysis was undertaken to test the robustness of the results. MAIN RESULTS: Nine studies were identified for possible inclusion in this review, and five of those studies were included. At 12 weeks, those receiving exercise therapy were less fatigued than the control participants (SMD -0.77, 95% CIs -1.26 to -0.28). Physical functioning was significantly improved with exercise therapy group (SMD -0.64, CIs -0.96 to -0.33) but there were more dropouts with exercise therapy (RR 1.73, CIs 0.92 to 3.24). Depression was non-significantly improved in the exercise therapy group compared to the control group at 12 weeks (WMD -0.58, 95% CIs -2.08 to 0.92). Participants receiving exercise therapy were less fatigued than those receiving the antidepressant fluoxetine at 12 weeks (WMD -1.24, 95% CIs -5.31 to 2.83). Participants receiving the combination of the two interventions, exercise + fluoxetine, were less fatigued than those receiving exercise therapy alone at 12 weeks, although again the difference did not reach significance (WMD 3.74, 95% CIs -2.16 to 9.64). When exercise therapy was combined with patient education, those receiving the combination were less fatigued than those receiving exercise therapy alone at 12 weeks (WMD 0.70, 95% CIs -1.48 to 2.88). REVIEWERS' CONCLUSIONS: There is encouraging evidence that some patients may benefit from exercise therapy and no evidence that exercise therapy may worsen outcomes on average. However the treatment may be less acceptable to patients than other management approaches, such as rest or pacing. Patients with CFS who are similar to those in these trials should be offered exercise therapy, and their progress monitored Further high quality randomised studies are needed.

This paper reports the results of cognitive, linguistic, and academic assessments in a representative sample of 62 adults with Williams syndrome. The average age of the group was 26 years and their mean full scale IQ was 61. Differences between Verbal and Performance IQ, and between receptive and expressive language skills, were smaller than generally found in studies of children with this condition. However, an examination of subtest scores revealed an almost identical cognitive profile to that found in children. Skills in other areas, such as reading, spelling, arithmetic, and social adaptation remained at a low level, with functioning generally being around a 6-8-year age equivalent. The consistency of reports on intellectual abilities in both child and adult studies of individuals with Williams syndrome lends increased support to the notion of a syndrome specific pattern of cognitive, linguistic, and adaptive functioning.

BACKGROUND: Patient Reported Outcome Measures (PROMs) assess health status and health-related quality of life from the patient/service user perspective. Our study aimed to: i. develop a PROM for recovery from drug and alcohol dependence that has good face and content validity, acceptability and usability for people in recovery; ii. evaluate the psychometric properties and factorial structure of the new PROM ('SURE'). METHODS: Item development included Delphi groups, focus groups, and service user feedback on draft versions of the new measure. A 30-item beta version was completed by 575 service users (461 in person [IP] and 114 online [OL]). Analyses comprised rating scale evaluation, assessment of psychometric properties, factorial structure, and differential item functioning. RESULTS: The beta measure had good face and content validity. Nine items were removed due to low stability, low factor loading, low construct validity or high complexity. The remaining 21 items were re-scaled (Rasch model analyses). Exploratory and confirmatory factor analyses revealed 5 factors: substance use, material resources, outlook on life, self-care, and relationships. The MIMIC model indicated 95% metric invariance across the IP and OL samples, and 100% metric invariance for gender. Internal consistency and test-retest reliability were granted. The 5 factors correlated positively with the corresponding WHOQOL-BREF and ARC subscales and score differences between participant sub-groups confirmed discriminative validity. CONCLUSION: 'SURE' is a psychometrically valid, quick and easy-to-complete outcome measure, developed with unprecedented input from people in recovery. It can be used alongside, or instead of, existing outcome tools.

It is well known that older people are more susceptible to morbidity and mortality from infectious diseases, particularly from pulmonary diseases such as pneumococcal pneumonia where vaccines do not provide efficient protection as in younger populations. We have previously shown that the B-cell repertoire in the old is reduced and hypothesise that this may contribute to the impaired humoral responses of the elderly. Here, we investigated the repertoire and antibody responses to winter vaccination in two age groups, aged 18-49 and 65-89. We found that the serum IgM and IgA pneumococcal responses were significantly impaired in the older group, with no difference in IgG levels. IGHM spectratype analysis seems to be the most promising in terms of its predictive ability for vaccine responses. Spectratypes showed a clear change in the repertoire at day 7 after vaccination, with a return to the baseline levels at day 28. The changes at day 7 reflected expansion of IGH sequences that have smaller, more hydrophilic, CDR3 regions, and these changes were attenuated in the older group. The older group was more likely to have spectratypes indicative of a reduced diversity at day 0 and day 28. On average, the baseline repertoire in the older group was comprised of larger CDR3 regions than in the younger group. In conclusion, IgA and IgM responses are significantly impaired in the elderly pneumococcal response and are likely key mediators of protection. Hydrophilicity and/or small size of the IGH CDR3 appear to be important in these responses.

BACKGROUND: Despite the increasing development of early intervention services for psychosis, little is known about their cost-effectiveness. We assessed the cost-effectiveness of Outreach and Support in South London (OASIS), a service for people with an at-risk mental state (ARMS) for psychosis. METHOD: The costs of OASIS compared to care as usual (CAU) were entered in a decision model and examined for 12- and 24-month periods, using the duration of untreated psychosis (DUP) and rate of transition to psychosis as key parameters. The costs were calculated on the basis of services used following referral and the impact on employment. Sensitivity analysis was used to test the robustness of all the assumptions made in the model. RESULTS: Over the initial 12 months from presentation, the costs of the OASIS intervention were pound1872 higher than CAU. However, after 24 months they were pound961 less than CAU. CONCLUSIONS: This model suggests that services that permit early detection of people at high risk of psychosis may be cost saving.

Medical schools are expanding their teaching in general practices,1 2 but there are few studies on patients' responses to the presence of medical students at consultations with general practitioners. In 1974 Wright reported that up to 40% of patients in one practice preferred not to discuss personal anxieties, family problems, or sexual problems in the presence of a student.3 Seabrook and Evans discussed general practice teaching with patients and carers.4 Patients expressed concern about whether they would be given a choice about a student being present and reported bad experiences of hospital teaching. Most recently, Cooke et al concluded from a questionnaire survey that only 3% of patients had negative views about the presence of a student.5 We report patients' views about consent and confidentiality using a questionnaire developed from semistructured interviews. The questionnaire had four …

BACKGROUND: There has been an increase in the numbers of homeless young people in Britain. Little is known of the health and social welfare needs of this population. METHOD: This case-control study compares a random sample of homeless people aged under 22 years recruited from consecutive attenders at two of London's largest facilities for homeless young people with a contemporaneous sample of domiciled young people recruited through general practice registration lists. The homeless and domiciled groups were compared on measures of childhood care, education and psychiatric disorder. RESULTS: One hundred and sixty-one homeless people (88% of those approached) and 107 domiciled subjects (60% of those approached) were interviewed. Sixty-nine per cent of homeless and a third of the domiciled subjects reported a childhood lacking in affection, with indifferent and often violent carers. Psychiatric disorder was identified in 62% of homeless respondents and a quarter of the domiciled population. A fifth of homeless and 5 domiciled respondents had attempted suicide in the previous year. Multivariate analysis suggest that childhood adversity, low educational attainment and the prior presence of psychiatric disorder all independently increase the likelihood of homelessness in a youthful population. CONCLUSIONS: The evidence presented in this paper supports the hypotheses that characterize the young homeless population as experiencing higher rates of childhood adversity and psychiatric disorder than their domiciled contemporaries. A tentative model is suggested whereby childhood experiences, educational attainment and the prior presence of psychiatric disorder all independently increase the likelihood of homelessness in a youthful population.

SUMMARY The paper reports on changes in IQ scores and in reading, spelling and arithmetic skills over time in 23 young adults with Williams syndrome. They were first assessed in their early to mid‐teens and followed up 8 to 9 years later, at an average age of 21 years 9 months. Cognitive assessments indicated increases in Full Scale, Verbal and Performance IQ scores. These increases allow us to conclude that in the case of Williams syndrome (unlike some other conditions) there does not appear to be a decline in the rate of cognitive development over time. Comparisons of Reading. Spelling and Arithmetic scores attained at first and second testing periods revealed only modest increases in reading accuracy and spelling scores, a slight decline in reading comprehension scores, and little change in arithmetic test scores. Differences in the tests used at the two assessment periods do not allow for definitive conclusions to be drawn, but the findings suggest that individuals with Williams syndrome make little progress in their educational skills beyond their early teenage years. RÉSUMÉ Etude longitudinale ties capacités cognitive. et ties réalisations édttcatives dans le Syndrome de Williams L'article rclève les modifications sur les scores de QI, les capacités en lecture, orthographe et arithmétique. en fonction du temps, chez 23 jeunes adultes présentant un syndrome de Williams. lis furent évalues pour la première fois entre 10 et 15 ans et suivis ultérieurement 8 ou 9 ans. jusqu'à un âgemoyen de 21 ans et 9 mois. Les évaluations cognitives révélèrent un progrès aux scores de QI, Échellcs Globale. Vcrbale ct de Performance. Ce progrès conduit les auteurs à penser que dans le cas du syndrome de Williams (en opposition avec d'autres situations), il n'apparaît pas un déclin du développement cognitif avec le temps. Une comparaison des scores de lecture, orthographe et arithmétique entre un premier et un second examen ne montra qu'un progrès modeste dans les scores de précision de lecture et d'orthographe, un léger déclin aux scores de compréhension dc lecture et une stabilité aux scores d'arithmétique. Les différences observés entre les deux évaluations ne permettent pas de conclusions definitives, mais les données obtcnues suggèrent que les patients présentant un syndrome de Williams font peu de progrès sur le plan scolaire au dela de l'adolescence. ZUSAMMENFASSUNG Eine Langzeitstudre über kogniiive Fähigkeiten unci Aushildtingsstand beim Williams Syndrom In dieser Arbeit wird über Veränderungen der IQ Scores und der Lcse‐, Rcchtschreib‐ und Rechenfähigkeiten im Verlaufe der Zeit bei 23 Jugendlichen mit Williams Syndrom berichtet. Sie wurden erstmals im frühen bis mittleren Teen‐Alter untersucht und danach 8 bis 9 Jahre später mit einem durchschnittlichen Alter von 21 Jahren und 9 Monaten. Cognitive Beurteilungen ergaben Verbesserungen der Full Scale, Verbal und Performance IQ Scores. Aufgrund dieser Befunde kann man annehmen, daß beim Williams Syndrom (anders als bei einigen anderen Erkrankungen) keine Verschlechterung der kognitiven Entwicklung im Verlaufe der Zeit zu verzeichnen ist. Vergleiche zwischen den Lese‐, Rechtschreib‐ und Rechenscores beim ersteh und beim zweiten Test zeigten nur geringgradigc Verbesserungen der Lesegenauigkeit und der Rechtschreibscores, eine leichte Verschlechterung der Scores für das Leseverstiindnis und wenig Veränderungen bei den arithmetischen Testscores. Aufgrund von Untcrschieden in den Tests, die bei den beiden Untersuchungen verwendet wurden, können keine endgültigen Schlußfolgerungen gezogen werden, aber die Befunde weisen darauf hin, daß Patienten mit Williams Syndrom über das frühe Teen‐Alter hinaus wenig Fortschritte in ihrer Ausbildung machen. RESUMEN Estudio longitudinal de las aptitudes cognitivas y del é.xito edttcativo en el sindrome de Williams El trabajo informa sobre los cambios en los puntajes del CI y en las habilidades de icctura, deletreo y aritmética a lo largo del tiempo en 23 adultos jovenes con sfndrome de Williams. Fueron evaluados en el principio y en la mitad de su segundo decenio de vida y seguidos despucs durante 8 o 9 años a la edad promedio de 21 años y 9 meses. La evaluación cognitiva indicó aumentos en los puntajes de CI global, verbal y de realización. Estos aumentos nos permiten concluir que en el caso del sindrome de Wiliiams (al revés que en otras enfermedades) no aparece un declinar en el desarrollo cognitivo a los largo del tiempo. Las comparaciones en los puntajes de lectura, deletreo y aritmética conseguidos en los periodos primero y segundo de los exámenes, revelaron sólo aumentos modestos en la precisión en la lectura y en los puntajes de deletreo, un ligero declinar en los puntajes de comprensión de lectura y pequeños cambios en los puntajes aritméticos. Las diferencias en las pruebas usadas en los dos periodos de evaluación no permiten sacar conclusiones definitivas, pero los hallazgos sugieren que los individuos con sindrome de Williams tienen pequefios progresos en sus capacidades educativas más allá de la edad de 10 a 20 años.

WHEREAS sarcoidosis is responsible for only about 4 per cent. of cases of uveitis, eye involvement, predominantly uveitis, occurs in about one-quarter of patients with sarcoidosis.Although theocular lesion is but an incident in a generalized disease, it is the most troublesome and incapacitating.Its early recognition and treatment may prevent both protracted suffering and blindness. Patients and MethodsThe 442 patients, who have been personally studied, showed clinical or radiological features of sarcoidosis always supported by histological evidence of sarcoid tissue.Patients with clinical, radiological, and immunological features of sarcoidosis were excluded from this analysis if there was no histological confirmation.This series includes 123 (27-8 per cent.) with ophthalmic involvement.Routine clinical examination included chest radiography, ophthalmoscopy, and slit- lamp examination of the uveal tract.Mantoux tests were done in all cases, and Kveim tests were performed in 380 patients.Electrophoresis of serum proteins and estimations of serum albumin and globulin levels by the biuret method were carried out in 266 cases.Serum globulin levels above 3 5 g. per 100 ml. or an electrophoretic pattern showing a relative preponderance of a, f, or y globulin were considered abnormal.Serum calcium levels were determined in 256 and 24-hour urine calcium levels in 65 patients.Histological evidence of sarcoid tissue was obtained from various sources by biopsy and at necropsy.All histological sections were examined for acid-fast bacilli, and were scrutin- ized by polarized light for doubly-refractile material.

F. CLIFFORD ROSE, G. R. FRASER, A. I. FRIEDMANN, E. M. KOHNER; THE ASSOCIATION OF JUVENILE DIABETES MELLITUS AND OPTIC ATROPHY: CLINICAL AND GENETICAL ASPE

OBJECTIVES: Cognitive remediation therapy (CRT) may benefit people with bipolar disorder type I and II for whom cognitive impairment is a major contributor to disability. Extensive research has demonstrated CRT to improve cognition and psychosocial functioning in people with different diagnoses, but randomised trials of evidenced therapy programmes are lacking for bipolar disorders. The Cognitive Remediation in Bipolar (CRiB) study aimed to determine whether an established CRT programme is feasible and acceptable for people with bipolar disorders. METHODS: This proof-of-concept, single-blind randomised trial recruited participants aged 18-65 with bipolar disorder, not currently experiencing an episode. They were 1:1 block randomised to treatment-as-usual (TAU) with or without individual CRT for 12 weeks. The partly computerised CRT programme ("CIRCuiTS") was therapist-led and is evidence-based from trials in those with psychotic illnesses. Data were collected and analysed by investigators blinded to group allocation. The main outcomes (week 13 and 25) examined participant retention, intervention feasibility and putative effects of CRT on cognitive and psychosocial functioning via intention-to-treat analyses. TRIAL REGISTRATION: ISRCTN ID32290525. RESULTS: Sixty participants were recruited (02/2016-06/2018) and randomised to CRT (n = 29) or TAU (n = 31). Trial withdrawals were equivalent (CRT n = 2/29; TAU n = 5/31). CRT satisfaction indicated high acceptability. Intention-to-treat analyses (N = 60) demonstrated greater improvements for CRT- than TAU-randomised participants: at both week 13 and 25, CIRCuiTS participants showed larger improvements in the following domains (week 25 effect sizes reported here): IQ (SES = 0.71, 95% CI [0.29,1.13]), working memory (SES = 0.70, 95% CI [0.31,1.10]), executive function (SES = 0.93, 95% CI [0.33,1.54]), psychosocial functioning (SES = 0.49, 95% CI [0.18,0.80]) and goal attainment (SES = 2.02, 95% CI [0.89,3.14]). No serious adverse events were reported. CONCLUSIONS: CRT is feasible for individuals with bipolar disorders and may enhance cognition and functioning. The reported effect sizes from this proof-of-concept trial encourage further investigation in a definitive trial.

mother; not only is she denied the immediate joy of seeing and holding her newborn child but she has to face the next few days in doubt and uncertainty, at a time when she should be receiving the reward for months of discipline and weeks of separation from her family.Tact, sympathy, and encouragement are needed at this stage, and the obstetrician should see to it that the patient receives adequate preparation for this final period of waiting in the weeks before delivery. SummaryThe 113 pregnancies (115 foetuses) occurring in 80 diabetic patients treated in the Royal Maternity Hospital, Belfast, over the eight years 1956 to 1963 have been reviewed.The total foetal loss was 16.2% and the perinatal mortality 11.9%/.Although these results are an improvement on those of the previous years they are still too high.The management of these diabetic patients over the past eight years is discussed and those factors considered mainly responsible for the reduction in perinatal mortality are emphasized.Certain alterations in our present management have been made in the hope that our present foetal loss can be reduced still further.The most important of these are: (1) a special antenatal clinic for diabetic patients attended by both physician and obstetrician ; (2) strict antenatal supervision from the early weeks in an attempt to reduce the number of miscarriages;(3) rigorous control of the diabetes and the use of a twice-daily insulin dosage regime; (4) admission to hospital at least four weeks before the provisional date of delivery and not later than 32 weeks; (5) the maturity at which delivery should take place must be carefully selected for each individual patient-routine delivery at a particular maturity must be abandoned; (6) unless there is some contraindication, a trial medical and/or surgical induction of labour with certain reservations should be attempted in primigravid as it is in the multigravid patients.We wish to thank Professor C. H. G. Macafee and the consultants of the Royal Maternity Hospital, Belfast, for permission to study the obstetric records of these patients.We are indebted to Professor Macafee-who was responsible for the obstetric management of these patients-for his advice and encouragement in writing this paper.The assistance of the tutors and resident medical staff in the management of these patients was invaluable, and to them we are most grateful.We would also like to thank Professor F. M. B. Allen, the consultant paediatricians, and the nursing staff of the premature nursery unit of the Royal Maternity Hospital, without whose skilled care and attention many of the babies might not have survived.Our thanks are also due to Dr. J. A. Weaver and the registrars and senior house officers of the metabolic unit of the Royal Victoria Hospital, who assisted us in the diabetic management of these patients.We also wish to thank

More than 10% of the general population regularly experience paranoid thoughts. Persecutory delusions occur in one third of psychiatric patients in the United Kingdom and are associated with severe clinical and social impairment. Furthermore, individuals with elevated vulnerability to paranoia interpret ambiguous environmental information more negatively than those with low vulnerability, a cognitive phenomenon called interpretation bias. We conducted a systematic review and meta-analysis of the association between interpretation bias and paranoia. Twenty studies were included, and our meta-analysis indicated that a negative interpretation bias was associated with paranoia both in clinical (standardized mean difference, or SMD = 1.01; 95% confidence interval [CI] = [0.51, 1.52], p < .001) and nonclinical populations ( SMD = 1.06; 95% CI = [0.28, 1.85], p = .008). Our results also showed that higher negative interpretation bias was positively correlated with the severity of paranoia, and results were consistent in nonclinical ( r = .32; 95% CI = [.21, .43], p < .001) and clinical samples ( r = .38; 95% CI = [.27, .48], p < .001). These findings might orient prevention strategies and psychological interventions for paranoia.

This is a prospective longitudinal study addressing the issue of predicting violence within two weeks of admission to two psychiatric units. Predictors of violence in 100 consecutive admissions were collected at baseline and tested on an outcome of violence. Risk factors were analyzed using logistic regression models and cross-validated using jack-knifing techniques. Two separate definitions of violence were used, actual assault on another person and aggressive behavior including attempted assault, violence to property and specific threats. Thirty-two patients actually assaulted, 41 behaved aggressively and 27 were completely non-violent. Two models were developed to predict membership according to these definitions. A single model based on a three-category outcome compared unfavorably with the two-model approach. Although the presence of recent pre-admission violence had some predictive value for both models, clinical variables were most predictive. “Non-violence” and “violence” appeared to be two separate states, and did not fit neatly on to a continuum. The two models were statistically robust, but should be tested prospectively on larger samples.

This paper examines the interest and expectations of patients having access to their electronic care records. Semi-structured prospective interviews were performed with 109 patients in a community setting in London where all records are stored digitally either as coded data, free text or scanned in from the paper original. A booth had recently been set up for patients to access their electronic records in the waiting room with secure access through fingerprint recognition technology. The interviews detailed history and levels of interest in access, impact on relationship with clinician, familiarity with digital media and issues of security and accuracy. Patients were more interested in seeing their electronic than their paper record; they felt it would improve their relationship with their clinician; they generally trusted in the security of their records; they anticipated that there would be some mistakes; they were enthusiastic about the idea of adding to the record themselves, but were divided about having access over the internet. Patients are confident in and anticipate the value of having access to their electronic records.