Impact of superior hypogastric nerve block during uterine fibroid embolisation on pain scores, opioid requirements, and same-day discharge: a case-control study.

AIM: To assess the safety and efficacy of superior hypogastric nerve block (SHNB) in managing periprocedural pain associated with uterine fibroid embolisation (UFE) and in facilitating same-day discharge. MATERIALS AND METHODS: Prospectively enrolled case-control study with retrospective analysis comprising 119 eligible patients who underwent UFE for symptomatic fibroids was undertaken at a UK teaching hospital between January 2016 and September 2022. SHNB was administered to 62 participants in addition to systemic analgesia; 57 participants received systemic analgesia alone. SHNB was performed mid-UFE using 20 ml of 0.25% levobupivacaine. Pain scores were assessed using an 11-point (0-10) verbal numerical rating scale (NRS). The study received research and ethics committee approval. Statistical analysis was performed using the chi-square and independent t-test or Mann-Whitney U-test. A p-value of <0.05 defined significance. RESULTS: Participants who received SHNB experienced significantly less pain during the first 6 h post-procedure (averaged median pain score 2.6 versus 3.8, p=0.031). SHNB reduced the proportion of participants requiring post-procedural anti-emetics (45% versus 63%, p<0.05). For participants entered on the day-case pathway (SHNB = 34, no-SHNB = 16), those who received SHNB had a higher rate of successful same-day discharge (62% versus 31%, p=0.044). This SHNB group required significantly less opioids for periprocedural pain relief (median oral morphine equivalents; 44 mg versus 80 mg, p=0.020). No SHNB-related adverse events occurred. CONCLUSION: SHNB is safe and effective in reducing perioperative pain, opioid requirements, and anti-emetic use in patients undergoing UFE for symptomatic fibroids. SHNB, as an adjunct to analgesic optimisation, facilitates same-day discharge, which is often limited by severe post-embolisation pain.

The distribution of gamma-hydroxybutyrate-induced Fos expression in rat brain: comparison with baclofen.

gamma-Hydroxybutyrate (GHB) is a euphoric, prosocial and sleep inducing drug that binds with high affinity to its own GHB receptor site and also more weakly to GABA(B) receptors. GHB is efficacious in the treatment of narcolepsy and alcoholism, but heavy use can lead to dependence and withdrawal. Many effects of GHB (sedation, hypothermia, catalepsy) are mimicked by GABA(B) receptor agonists (e.g. baclofen). However other effects (euphoric and prosocial effects and a therapeutic effect in narcolepsy) are not. The present study used Fos immunohistochemistry to assess the neural activation produced in rat brain by medium to high doses of GHB (250, 500 and 1000 mg/kg) and a high dose of baclofen (10 mg/kg) that produced similar sedation to 500 mg/kg GHB. Results showed many common regions of activation with these two drugs including the supraoptic, paraventricular, median preoptic and ventral premammillary nuclei of the hypothalamus, the central nucleus of the amygdala, Edinger-Westphal nucleus, lateral parabrachial nucleus, locus coeruleus, and nucleus of the solitary tract. GHB (500 mg/kg), but not baclofen (10 mg/kg), induced significant Fos expression in the median raphe nucleus and lateral habenula, while a higher dose of GHB (1000 mg/kg) induced additional Fos expression in the islands of Calleja, dentate gyrus (polymorphic layer) and arcuate nucleus, and in various regions implicated in rapid and non-rapid eye movement sleep (laterodorsal tegmental nucleus, tuberomammillary nucleus and the ventrolateral and anterodorsal preoptic nuclei). Surprisingly, Fos immunoreactivity was not observed with either GHB or baclofen in reward-relevant regions such as the nucleus accumbens, striatum and ventral tegmental area. Overall these results indicate a distinctive signature of brain activation with GHB that may be only partly due to GABA(B) receptor effects. This confirms a unique neuropharmacological profile for GHB and indicates key neural substrates that may underlie its characteristic influence on sleep, body temperature, sociability and endocrine function.

The galilean satellites and jupiter: voyager 2 imaging science results.

Voyager 2, during its encounter with the Jupiter system, provided images that both complement and supplement in important ways the Voyager 1 images. While many changes have been observed in Jupiter's visual appearance, few, yet significant, changes have been detected in the principal atmospheric currents. Jupiter's ring system is strongly forward scattering at visual wavelengths and consists of a narrow annulus of highest particle density, within which is a broader region in which the density is lower. On Io, changes are observed in eruptive activity, plume structure, and surface albedo patterns. Europa's surface retains little or no record of intense meteorite bombardment, but does reveal a complex and, as yet, little-understood system of overlapping bright and dark linear features. Ganymede is found to have at least one unit of heavily cratered terrain on a surface that otherwise suggests widespread tectonism. Except for two large ringed basins, Callisto's entire surface is heavily cratered.

A new look at the saturn system: the voyager 2 images.

Voyager 2 photography has complemented that of Voyager I in revealing many additional characteristics of Saturn and its satellites and rings. Saturn's atmosphere contains persistent oval cloud features reminiscent of features on Jupiter. Smaller irregular features track out a pattern of zonal winds that is symmetric about Saturn's equator and appears to extend to great depth. Winds are predominantly eastward and reach 500 meters per second at the equator. Titan has several haze layers with significantly varying optical properties and a northern polar "collar" that is dark at short wavelengths. Several satellites have been photographed at substantially improved resolution. Enceladus' surface ranges from old, densely cratered terrain to relatively young, uncratered plains crossed by grooves and faults. Tethys has a crater 400 kilometers in diameter whose floor has domed to match Tethys' surface curvature and a deep trench that extends at least 270 degrees around Tethys' circumference. Hyperion is cratered and irregular in shape. Iapetus' bright, trailing hemisphere includes several dark-floored craters, and Phoebe has a very low albedo and rotates in the direction opposite to that of its orbital revolution with a period of 9 hours. Within Saturn's rings, the "birth" of a spoke has been observed, and surprising azimuthal and time variability is found in the ringlet structure of the outer B ring. These observations lead to speculations about Saturn's internal structure and about the collisional and thermal history of the rings and satellites.

Encounter with saturn: voyager 1 imaging science results.

As Voyager 1 flew through the Saturn system it returned photographs revealing many new and surprising characteristics of this complicated community of bodies. Saturn's atmosphere has numerous, low-contrast, discrete cloud features and a pattern of circulation significantly different from that of Jupiter. Titan is shrouded in a haze layer that varies in thickness and appearance. Among the icy satellites there is considerable variety in density, albedo, and surface morphology and substantial evidence for endogenic surface modification. Trends in density and crater characteristics are quite unlike those of the Galilean satellites. Small inner satellites, three of which were discovered in Voyager images, interact gravitationally with one another and with the ring particles in ways not observed elsewhere in the solar system. Saturn's broad A, B, and C rings contain hundreds of "ringlets," and in the densest portion of the B ring there are numerous nonaxisymmetric features. The narrow F ring has three components which, in at least one instance, are kinked and crisscrossed. Two rings are observed beyond the F ring, and material is seen between the C ring and the planet.

The jupiter system through the eyes of voyager 1.

The cameras aboard Voyager 1 have provided a closeup view of the Jupiter system, revealing heretofore unknown characteristics and phenomena associated with the planet's atmosphere and the surfaces of its five major satellites. On Jupiter itself, atmospheric motions-the interaction of cloud systems-display complex vorticity. On its dark side, lightning and auroras are observed. A ring was discovered surrounding Jupiter. The satellite surfaces display dramatic differences including extensive active volcanismn on Io, complex tectonism on Ganymnede and possibly Europa, and flattened remnants of enormous impact features on Callisto.

Voyager 2 in the uranian system: imaging science results.

Voyager 2 images of the southern hemisphere of Uranus indicate that submicrometersize haze particles and particles of a methane condensation cloud produce faint patterns in the atmosphere. The alignment of the cloud bands is similar to that of bands on Jupiter and Saturn, but the zonal winds are nearly opposite. At mid-latitudes (-70 degrees to -27 degrees ), where winds were measured, the atmosphere rotates faster than the magnetic field; however, the rotation rate of the atmosphere decreases toward the equator, so that the two probably corotate at about -20 degrees . Voyager images confirm the extremely low albedo of the ring particles. High phase angle images reveal on the order of 10(2) new ringlike features of very low optical depth and relatively high dust abundance interspersed within the main rings, as well as a broad, diffuse, low optical depth ring just inside the main rings system. Nine of the newly discovered small satellites (40 to 165 kilometers in diameter) orbit between the rings and Miranda; the tenth is within the ring system. Two of these small objects may gravitationally confine the e ring. Oberon and Umbriel have heavily cratered surfaces resembling the ancient cratered highlands of Earth's moon, although Umbriel is almost completely covered with uniform dark material, which perhaps indicates some ongoing process. Titania and Ariel show crater populations different from those on Oberon and Umbriel; these were probably generated by collisions with debris confined to their orbits. Titania and Ariel also show many extensional fault systems; Ariel shows strong evidence for the presence of extrusive material. About halfof Miranda's surface is relatively bland, old, cratered terrain. The remainder comprises three large regions of younger terrain, each rectangular to ovoid in plan, that display complex sets of parallel and intersecting scarps and ridges as well as numerous outcrops of bright and dark materials, perhaps suggesting some exotic composition.

Voyager 2 at neptune: imaging science results.

Voyager 2 images of Neptune reveal a windy planet characterized by bright clouds of methane ice suspended in an exceptionally clear atmosphere above a lower deck of hydrogen sulfide or ammonia ices. Neptune's atmosphere is dominated by a large anticyclonic storm system that has been named the Great Dark Spot (GDS). About the same size as Earth in extent, the GDS bears both many similarities and some differences to the Great Red Spot of Jupiter. Neptune's zonal wind profile is remarkably similar to that of Uranus. Neptune has three major rings at radii of 42,000, 53,000, and 63,000 kilometers. The outer ring contains three higher density arc-like segments that were apparently responsible for most of the ground-based occultation events observed during the current decade. Like the rings of Uranus, the Neptune rings are composed of very dark material; unlike that of Uranus, the Neptune system is very dusty. Six new regular satellites were found, with dark surfaces and radii ranging from 200 to 25 kilometers. All lie inside the orbit of Triton and the inner four are located within the ring system. Triton is seen to be a differentiated body, with a radius of 1350 kilometers and a density of 2.1 grams per cubic centimeter; it exhibits clear evidence of early episodes of surface melting. A now rigid crust of what is probably water ice is overlain with a brilliant coating of nitrogen frost, slightly darkened and reddened with organic polymer material. Streaks of organic polymer suggest seasonal winds strong enough to move particles of micrometer size or larger, once they become airborne. At least two active plumes were seen, carrying dark material 8 kilometers above the surface before being transported downstream by high level winds. The plumes may be driven by solar heating and the subsequent violent vaporization of subsurface nitrogen.

Weekly gamma-hydroxybutyrate exposure sensitizes locomotor hyperactivity to low-dose 3,4-methylenedioxymethamphetamine in rats.

Users of the popular party drug 3,4-methylenedioxymethamphetamine (MDMA) sometimes report combining MDMA with gamma-hydroxybutyrate (GHB) to enhance the pleasurable effects of both drugs. However, very few studies have examined the influences of this drug combination. The present study investigated the development of locomotor sensitization in laboratory rats given 7 once-weekly exposures to either MDMA, GHB or their combination (MDMA/GHB). The drugs were administered at a high ambient temperature (28 degrees C) to mimic nightclub conditions. MDMA (5 mg/kg), given once weekly, produced a progressively greater locomotor and hyperthermic response over time. In contrast, GHB (500 mg/kg) administered weekly produced consistent low levels of locomotor activity and few changes in body temperature. Rats receiving the mixture of MDMA (5 mg/kg) and GHB (500 mg/kg) showed asymptotic levels of sensitized locomotor activity similar to those seen in rats given MDMA alone, but the development of locomotor sensitization was delayed by coadministered GHB. GHB also delayed the development of MDMA-induced hyperthermia. After a washout period of 5 weeks, rats pre-exposed to MDMA, GHB and MDMA/GHB showed no hyperactivity when tested drug-free in the context in which they had previously received drugs, but displayed a sensitized locomotor response to a low challenge dose of MDMA (2.5 mg/kg). The response to a low dose of methamphetamine (0.5 mg/kg) did not differ among groups. Neurochemical analysis using high-performance liquid chromatography revealed few lasting changes in serotonin, dopamine or their metabolites in the striatum or prefrontal cortex of MDMA- or GHB-pre-exposed rats. These results indicate that GHB modulates the locomotor and hyperthermic response to acute MDMA and that pre-exposure to GHB can sensitize the locomotor response to low doses of MDMA.

Locked inpatient units in modern mental health care: values and practice issues.

Locked inpatient units are an increasing phenomenon, introduced in response to unforseen abscondences and suicides of patients. This paper identifies some value issues concerning the practice of locked psychiatric inpatient units. Broad strategies, practicalities and ethical matters that must be considered in inpatient mental health services are also explored. The authors draw on the published research and commentary to derive relevant information to provide to patients and staff regarding the aims and rationales of locked units. Further debate is warranted in relation to best practice. Inpatient staff need to be aware of their practice values, be able to access education and supervision and negotiate apparent contradictions. Further patient/clinician focused enquiry is necessary to mitigate the negative and stigmatising effects of locked mental health units.

Characteristics of animal hoarding cases referred to the RSPCA in New South Wales, Australia.

OBJECTIVE: To describe the characteristics of animal hoarding in New South Wales, Australia. DESIGN: Cross sectional study of consecutive referred cases. METHODS: Files of animal hoarding cases referred to RSPCA NSW in 2013-15 were examined. Details concerning animal hoarding cases and supportive services, living conditions and factors believed to have contributed to animal accumulation were recorded. Data were analysed. RESULTS: Data were available regarding 48 properties where 50 persons (78% female) were found to be hoarding animals. Most were over 50 years of age; 40% lived alone; 15 (30%) had contact with mental health services and/or community social services. Animal hoarders were categorised as 'breeders' (30%), 'overwhelmed caregiver' (24%), 'rescuers' (22%), 'exploiters' (10%) or 'incipient hoarders' (14%); 24% were associated with animal rescue networks. Accumulation of animals was attributed most commonly to unplanned breeding (60% of properties) and collecting strays (38%). Other reasons for accumulation included receiving donations of animals and planned breeding; in 38% of cases there was only one identified reason. The median number of animals was 35 (range, 6-300), with cats hoarded on 75% of properties and dogs on 52%. In 75% of cases, the living conditions of animals were rated as 'very unsanitary' or 'filthy'. CONCLUSIONS: This study provides reasons for recommending increased regulatory control of companion animal breeding and management, and training and support for veterinarians to help reduce the human and animal suffering caused by animal hoarding. There is widespread agreement that psychiatric and personality problems underlie cases of animal hoarding. Closer links between animal welfare organisations and mental health services are desirable.

Cat odor, but not trimethylthiazoline (fox odor), activates accessory olfactory and defense-related brain regions in rats.

Cat odor and trimethylthiazoline (TMT, a component of fox feces) are two stimuli widely used in rodent models of fear and anxiety. Recent studies suggest that these odorants have distinct behavioral effects, raising questions as to whether TMT is a true "predator odor." Here we used c-Fos immunohistochemistry to compare patterns of neural activation produced by cat odor and TMT. Rats were exposed to either (1) three pieces of a collar that had been worn by a domestic cat, (2) three collar pieces impregnated with TMT (30 microl/piece), (3) three collar pieces impregnated with 4% formaldehyde (200 microl/piece, an acrid but non-predatory odor), or (4) three control (no odor) collar pieces. Odors were presented in a small well-ventilated plastic box. All odorants (cat odor, TMT and formaldehyde) produced increased defecation in rats compared with the control group, and formaldehyde exposure also decreased rearing. Cat odor increased contact with the stimulus relative to all other groups, while TMT increased contact compared with the formaldehyde and clean air groups. Only cat odor decreased grooming and elicited escape attempts. In addition, only cat odor caused pronounced activation of Fos in the accessory olfactory bulb and its projection areas, anterior olfactory nucleus, medial prefrontal cortex, striatum, and a medial hypothalamic circuit associated with defensive behavior. In contrast, the only areas activated by TMT were the internal granular layer of the main olfactory bulb and central amygdala, while both cat odor and TMT activated the glomeruli of the main olfactory bulb, piriform cortex, ventral orbital cortex and anterior cortical amygdala. Results indicate that the effects of cat odor and TMT are easily distinguished both behaviorally and at a neural level, and suggest that TMT lacks the "pheromone-like" quality of cat odor that engages key hypothalamic sites involved in defensive behavior.

From ultrasocial to antisocial: a role for oxytocin in the acute reinforcing effects and long-term adverse consequences of drug use?

Addictive drugs can profoundly affect social behaviour both acutely and in the long-term. Effects range from the artificial sociability imbued by various intoxicating agents to the depressed and socially withdrawn state frequently observed in chronic drug users. Understanding such effects is of great potential significance in addiction neurobiology. In this review we focus on the 'social neuropeptide' oxytocin and its possible role in acute and long-term effects of commonly used drugs. Oxytocin regulates social affiliation and social recognition in many species and modulates anxiety, mood and aggression. Recent evidence suggests that popular party drugs such as MDMA and gamma-hydroxybutyrate (GHB) may preferentially activate brain oxytocin systems to produce their characteristic prosocial and prosexual effects. Oxytocin interacts with the mesolimbic dopamine system to facilitate sexual and social behaviour, and this oxytocin-dopamine interaction may also influence the acquisition and expression of drug-seeking behaviour. An increasing body of evidence from animal models suggests that even brief exposure to drugs such as MDMA, cannabinoids, methamphetamine and phencyclidine can cause long lasting deficits in social behaviour. We discuss preliminary evidence that these adverse effects may reflect long-term neuroadaptations in brain oxytocin systems. Laboratory studies and preliminary clinical studies also indicate that raising brain oxytocin levels may ameliorate acute drug withdrawal symptoms. It is concluded that oxytocin may play an important, yet largely unexplored, role in drug addiction. Greater understanding of this role may ultimately lead to novel therapeutics for addiction that can improve mood and facilitate the recovery of persons with drug use disorders.

Psychosocial treatment programs for people with both severe mental illness and substance misuse.

Over 50% of people with a severe mental illness also use illicit drugs and/or alcohol at hazardous levels. This review is based on the findings of 25 randomized controlled trials which assessed the effectiveness of psychosocial interventions, offered either as one-off treatments or as an integrated or nonintegrated program, to reduce substance use by people with a severe mental illness. The findings showed that there was no consistent evidence to support any one psychosocial treatment over another. Differences across trials with regard to outcome measures, sample characteristics, type of mental illness and substance used, settings, levels of adherence to treatment guidelines, and standard care all made pooling results difficult. More quality trials are required that adhere to proper randomization methods; use clinically valuable, reliable, and validated measurement scales; and clearly report data, including retention in treatment, relapse, and abstinence rates. Future trials of this quality will allow a more thorough assessment of the efficacy of psychosocial interventions for reducing substance use in this challenging population.

High ambient temperature increases 3,4-methylenedioxymethamphetamine (MDMA, "ecstasy")-induced Fos expression in a region-specific manner.

3,4-Methylenedioxymethamphetamine (MDMA, "Ecstasy") is a popular drug that is often taken under hot conditions at dance clubs. High ambient temperature increases MDMA-induced hyperthermia and recent studies suggest that high temperatures may also enhance the rewarding and prosocial effects of MDMA in rats. The present study investigated whether ambient temperature influences MDMA-induced expression of Fos, a marker of neural activation. Male Wistar rats received either MDMA (10 mg/kg i.p.) or saline, and were placed in test chambers for 2 h at either 19 or 30 degrees C. MDMA caused significant hyperthermia at 30 degrees C and a modest hypothermia at 19 degrees C. The 30 degrees C ambient temperature had little effect on Fos expression in vehicle-treated rats. However MDMA-induced Fos expression was augmented in 15 of 30 brain regions at the high temperature. These regions included (1) sites associated with thermoregulation such as the median preoptic nucleus, dorsomedial hypothalamus and raphe pallidus, (2) the supraoptic nucleus, a region important for osmoregulation and a key mediator of oxytocin and vasopressin release, (3) the medial and central nuclei of the amygdala, important in the regulation of social and emotional behaviors, and (4) the shell of the nucleus accumbens and (anterior) ventral tegmental area, regions associated with the reinforcing effects of MDMA. MDMA-induced Fos expression was unaffected by ambient temperature at many other sites, and was diminished at high temperature at one site (the islands of Calleja), suggesting that the effect of temperature on MDMA-induced Fos expression was not a general pharmacokinetic effect. Overall, these results indicate that high temperatures accentuate key neural effects of MDMA and this may help explain the widespread use of the drug under hot conditions at dance parties as well as the more hazardous nature of MDMA taken under such conditions.

A role for oxytocin and 5-HT(1A) receptors in the prosocial effects of 3,4 methylenedioxymethamphetamine ("ecstasy").

The drug 3,4 methylenedioxymethamphetamine (MDMA; ecstasy) has a widely documented ability to increase feelings of love and closeness toward others. The present study investigated whether oxytocin, a neuropeptide involved in affiliative behavior, may play a role in this effect. A moderate (5 mg/kg, i.p.) dose of MDMA increased social interaction in male Wistar rats, primarily by increasing the amount of time rats spent lying adjacent to each other. MDMA (5 mg/kg) activated oxytocin-containing neurons in the supraoptic and paraventricular nuclei of the hypothalamus, as shown by Fos immunohistochemistry. MDMA (5 mg/kg i.p.) also increased plasma oxytocin levels and this effect was prevented by pre-treatment with the 5-HT(1A) antagonist N-[2-[4-(2-methyoxyphenyl)-1-piperazinyl]ethyl]-N-2-pyridinylcyclohexanecarboxamide maleate salt (WAY 100,635; 1 mg/kg i.p.). The oxytocin receptor antagonist tocinoic acid (20 microg, i.c.v.) had no effect on social behavior when given alone but significantly attenuated the facilitation of social interaction produced by MDMA (5 mg/kg). The 5-HT(1A) agonist 8-hydroxy-2-(di-n-propylamino)-tetraline) (8-OH-DPAT, 0.25 mg/kg, i.p.) increased social behavior in a similar way to MDMA and this effect was also significantly attenuated by tocinoic acid. Taken together, these results suggest that oxytocin release, stimulated by MDMA through 5-HT(1A) receptors, may play a key role in the prosocial effects of MDMA and underlie some of the reinforcing effects of the drug.

Heterozygous neuregulin 1 mice display greater baseline and Delta(9)-tetrahydrocannabinol-induced c-Fos expression.

Cannabis use may increase the risk of developing schizophrenia by precipitating the disorder in genetically vulnerable individuals. Neuregulin 1 (NRG1) is a schizophrenia susceptibility gene and mutant mice heterozygous for the transmembrane domain of this gene (Nrg1 HET mice) exhibit a schizophrenia-related phenotype. We have recently shown that Nrg1 HET mice are more sensitive to the behavioral effects of the main psychoactive constituent of cannabis, Delta(9)-tetrahydrocannabinol (THC). In the present study, we examined the effects of THC (10 mg/kg i.p.) on neuronal activity in Nrg1 HET mice and wild type-like (WT) mice using c-Fos immunohistochemistry. In the lateral septum, THC selectively increased c-Fos expression in Nrg1 HET mice with no corresponding effect being observed in WT mice. In addition, THC promoted a greater increase in c-Fos expression in Nrg1 HET mice than WT mice in the central nucleus of the amygdala, the bed nucleus of the stria terminalis and the paraventricular nucleus of the hypothalamus. Consistent with Nrg1 HET mice exhibiting a schizophrenia-related phenotype, these mice expressed greater drug-free levels of c-Fos in two regions thought to be involved in schizophrenia, the shell of the nucleus accumbens and the lateral septum. Interestingly, the effects of genotype on c-Fos expression, drug-free or following THC exposure, were only observed when animals experienced behavioral testing prior to perfusion. This suggests an interaction with stress was necessary for the promotion of these effects. These data provide neurobiological correlates for the enhanced behavioral sensitivity of Nrg1 HET mice to THC and reinforce the existence of cannabinoid-neuregulin 1 interactions in the CNS. This research may enhance our understanding of how genetic factors increase individual vulnerability to schizophrenia and cannabis-induced psychosis.

The patient's view of need and caregiving consequences: a cross-sectional study of inpatients with severe mental illness.

This cross-sectional study was conducted across inpatient facilities of a metropolitan mental health service in Sydney, Australia. Given shorter lengths of stay in acute inpatient facilities, it is important to ascertain differences between patients' and carers' perceptions of need and support in order to guide delivery of care in the community. The objectives were to: (1) assess the needs of patients recently admitted to hospital and ascertain the level of carer involvement while in hospital; (2) compare the degree of agreement between patients' and carers' perceptions of need and caregiver burden; and (3) determine the relationship between levels of need and carer burden prior to hospitalization. Over a 2-month period, consecutive patients (n = 200) were interviewed using the Camberwell Assessment of Need Short Appraisal Schedule and a modified version of the Involvement Evaluation Questionnaire to assess basic needs and patient perceptions of caregiver burden, respectively. Of the 200 patients interviewed, 68% (n = 135) identified a carer. Patients with schizophrenia had most met needs, those with affective disorders had most unmet needs and patients with other diagnoses recorded the lowest number of needs overall. The level of agreement between patient and carer perceptions of need was low, possibly because of confusion about the definition of need or different views about the support required to fulfil a need. Patients underestimated the consequences of caregiving, especially the impact of strained atmosphere, global burden, worrying about their future and encouragement to undertake an activity, indicating that carers were more burdened than patients perceived them to be.

The plasma dexamethasone window: evidence supporting its usefulness to validate dexamethasone suppression test results.

Two doses of dexamethasone (DEX) (0.5 and 1.0 mg) were administered in a randomized crossover design to 31 patients with major depression, 9 healthy controls, and 14 nondepressed psychiatric patients. Using this modified Dexamethasone Suppression Test (DST), minimum DEX levels of 6 nmol/liter at 8:00 AM and 2.0 nmol/liter at 4:00 PM were required to achieve reliable suppression of cortisol in healthy controls and nondepressed psychiatric patients. Failure to achieve these minimum plasma DEX levels was associated with similar rates of nonsuppression in both depressed and nondepressed patients, thereby reducing the specificity of the DST. Conversely, high DEX levels greater than 13 nmol/liter at 8:00 AM or 4.0 nmol/liter at 4:00 PM were associated with abnormal "suppressibility" in depressed patients, thereby reducing the sensitivity of the test. Controlling for plasma DEX concentrations by selecting a test result that fell within a plasma DEX window at 8:00 AM and 4:00 PM increased the sensitivity and specificity of the DST. Significant differences in plasma DEX between suppressors and nonsuppressors were no longer evident when comparing patients with adequate DEX levels, thus ensuring that cortisol escape reflected HPA axis changes associated with depression and not peripheral mechanisms responsible for the availability of DEX. These results suggest that the clinical utility of the DST would be significantly enhanced by extending the standard 1.0-mg DST and retesting those patients with levels outside the DEX window with a higher or lower dose. The data also indicate that the measurement of plasma DEX is essential to validly interpret DST status and highlight the need to standardize DEX assays to compare DST results between research centers.