(Un)Reliable detection of menstrual blood in forensic casework - evaluation of the Seratec® PMB test with mock samples.

The identification of the type of body fluid in crime scene evidence may be crucial, so that the efforts are high to reduce the complexity of these analyses and to minimize time and costs. Reliable immunochromatographic rapid tests for specific and sensitive identification of blood, saliva, urine and sperm secretions are already routinely used in forensic genetics. The recently introduced Seratec® PMB test is said to detect not only hemoglobin, but also differentiate menstrual blood from other secretions containing blood (cells) by detecting D-dimers. In our experimental set-up, menstrual blood could be reliably detected in mock forensic samples. Here, the result was independent of sample age and extraction buffer volume. It was also successfully demonstrated that all secretions without blood cells were negative for both, hemoglobin (P) and D-dimer (M). However, several blood cell-containing secretions/tissues comprising blood (injury), nasal blood, postmortem blood and wound crust also demonstrated positive results for D-dimer (M) and were therefore false positives. For blood (injury) and nasal blood, this result was reproduced for different extraction buffer volumes. The results of this study clearly demonstrate that the Seratec® PMB test is neither useful nor suitable for use in forensic genetics because of the great risk of false positive results which can lead to false conclusions, especially in sexual offense or violent acts.

[Reduced mobility in the elderly due to medication, alcohol, and cannabinoids]. / Einschränkungen der Mobilität von älteren Verkehrsteilnehmern durch Medikamente, Alkohol und Cannabis.

Many diseases are accompanied by symptoms that can impair the ability to perform complex everyday tasks, such as active participation in road traffic. If a cure is not possible, the aim of drug therapy is to alleviate the symptoms to such an extent that the patient no longer has any restrictions in everyday life. However, around 20% of the approximately 100,000 medicines licensed in Germany have traffic-relevant side effects that can also lead to driving impairment.It is assumed that the effect of a drug is at least partially responsible for one in four traffic accidents and that one in ten victims of fatal road accidents has taken psychotropic drugs before driving. In addition to alcohol and drugs, medications from the benzodiazepine, opioid, and antidepressant groups are suspected of impairing driving safety in particular. The effects of these substances on young people have been described many times, but this review deals specifically with the traffic-relevant (side) effects of various classes of drugs on elderly people (aged 65 and over).Older people in particular often have to take different medications, which are metabolized differently compared to younger people due to underlying diseases and can also interact with each other. It was found that (1) older people often react more sensitively to substances, (2) not all representatives of a drug class have the same effect on driving safety, and (3) a general assessment of a drug's safety is not possible, since the effects also depend on other factors such as underlying diseases, treatment regimen, and the time of day the medication is taken.

More than just blood, saliva, or sperm-setup of a workflow for body fluid identification by DNA methylation analysis.

The determination of cellular origin of DNA is a useful method in forensic genetics and complements identification of the DNA donor by STR analysis, since it could provide helpful information for the reconstruction of crime scenes and verify or disprove the descriptions of involved people. There already exist several rapid/pre-tests for several secretions (blood, sperm secretion, saliva, and urine), RNA-based expression analyses (blood, menstrual blood, saliva, vaginal secretion, nasal secretion, and sperm secretion), or specific CpG methylation analyses (nasal blood, blood, saliva, vaginal secretion, nasal secretion, and sperm secretion) for determining the cell type.To identify and to discriminate seven different body fluids and mixtures thereof in a simple workflow from each other, assays based on specific methylation patterns at several CpGs combined with pre-/rapid tests were set up in this study. For each of the seven secretions listed above, we selected the CpG marker achieving the highest possible discrimination (out of 30 markers tested). Validation studies confirmed a definite identification for saliva, vaginal secretion, and semen secretion in 100% of samples as well as discrimination from all other secretions. Moreover, the unambiguously correctly determined proportion of nasal samples, blood and menstrual blood varied between 61% (nasal blood) and 85% (nasal secretion).In summary, our workflow proved to be an easy and useful tool in forensic analysis for the identification and discrimination of seven different body fluids often found at a crime scene.

The "Mellanby effect" in alcoholised e-scooter drivers.

PURPOSE: Several studies tried to discuss and clarify the so-called Mellanby effect: Similar blood alcohol concentrations (BACs) supposedly lead to more signs of impairment in the phase of alcohol resorption than elimination. To assess this effect for alcoholised e-scooter driving, results of a real-driving fitness study were subanalysed. METHODS: Sixteen subjects (9 females; 7 males) who completed runs at comparable BACs in the phases of alcohol resorption and elimination were chosen to assess a possible "Mellanby effect". The data of the subjects was taken from a prior e-scooter study by Zube et al., which included 63 subjects in total. RESULTS: In the phase of alcohol resorption, the relative driving performance was approx. 92% of the phase of elimination (p value 0.21). Statistically significant more demerits were allocated to the obstacle "narrowing track" in the phase of resorption than elimination. Subjects also needed significantly more time to pass the obstacles "narrowing track", "driving in circles counterclockwise" and "thresholds" in the phase of resorption than elimination. DISCUSSION: The most relevant obstacle to discriminate between the two different states of alcoholisation was the narrowing track. Insofar, measurements of the standard deviation of the lateral position (SDLP) might also be a sensitive component for the detection of central nervous driving impairment during shorter trips with an e-scooter. Additionally, driving slower during the phase of alcohol resorption seems to be the attempt to compensate alcohol-related deficits. CONCLUSION: The results of the study suggest a slight Mellanby effect in e-scooter drivers.

Formation of phosphatidylethanol and ethylglucuronide after low to moderate alcohol consumption in volunteers with a previous three-week alcohol abstinence.

AIMS: Phosphatidylethanol (PEth) is only formed when ethanol is present in blood. This direct alcohol marker has been widely discussed, including the minimum amount of ethanol being necessary to form as much PEth as to exceed the threshold of 20 ng/mL in previously PEth negative subjects. In order to corroborate hitherto existing results, a drinking study including 18 participants after a 3-week alcohol abstinence was performed. METHODS: They consumed a pre-calculated amount of ethanol to reach a blood alcohol concentration (BAC) of at least 0.6 g/kg. Blood was drawn before and periodically seven times after alcohol administration on day 1. Blood and urine were also collected the next morning. Dried blood spots (DBS) were prepared immediately from collected venous blood. BAC was determined by head space gas chromatography and the concentrations of both PEth (16:0/18:1, 16:0/18:2 and five additional homologues) and ethyl glucuronide (EtG) were analysed using liquid chromatography-tandem mass spectrometry. RESULTS: Out of 18, 5 participants had concentrations of PEth 16:0/18:1 above the threshold of 20 ng/mL, and 11 out of the 18 subjects had concentrations between 10 and 20 ng/mL. In addition, four persons had PEth 16:0/18:2 concentrations above 20 ng/mL the following morning. All test subjects tested positive for EtG in DBS (≥ 3 ng/mL) and urine (≥100 ng/mL) upon 20-21 h after alcohol administration. CONCLUSION: By combining both a lower cutoff of 10 ng/mL and the homologue PEth 16:0/18:2, the sensitivity to detect a single alcohol intake after a 3-week abstinence increases to 72.2%.

Core body temperatures during final stages of life-an evaluation of data from in-hospital decedents.

Temperature-based methods are widely accepted as the gold standard for death time estimation. In the absence of any other information, the nomogram method generally assumes that a person died with a core body temperature of approximately 37.2 °C. Nevertheless, several external and internal factors may alter the body temperature during agony. A retrospective medical record analysis was carried out on in-hospital death cases from two consecutive years of surgical intensive care units to determine the effects of factors influencing the core body temperature at the point of death. Data from 103 case files were included in the statistical data evaluation. The body temperature fluctuated between and within individuals over time. No clear correlation to certain death groups was observed. Even primary cardiac deaths showed broad intervals of temperatures at the point of death. Men seem to die with higher body temperatures than women. The presented data highlight potential biases for death time estimations when generally assuming a core body temperature of 37.2 °C. In conclusion, the estimation of the time of death should include various methods, including a non-temperature-dependent method. Any uncertainties regarding the body temperature at point of death need to be resolved (e.g. by identifying fever constellations) and elucidated if elimination is not possible.

Cycling under the influence of alcohol-criminal offenses in a German metropolis.

INTRODUCTION: Real or simulated cycling tests under the influence of alcohol might be biased by laboratory settings. Accident analyses consider incidents with injuries only. Herein, criminal offenses consisting of drunk cycling are evaluated in detail to fill this gap. MATERIAL AND METHODS: All police-recorded cases of cycling under the influence of alcohol that took place in Düsseldorf, Germany, from 2009 to 2018 were identified. A total of 388 respective prosecutor's files were available for analyses. RESULTS: Mean blood alcohol concentrations were approximately 2 g/kg in both men and women. Men were overrepresented (6:1). Almost 60% of the cases were recorded between Friday and Sunday (the "weekend"). The average blood alcohol concentration (BAC) at night (01:00-05:59) was 0.39 g/kg lower than that during the day (06:00-17:59). Drinking after cycling allegations appear almost irrelevant among (German) cyclists. On average, the legal outcomes show 33 daily rates (median: 30). Additionally, the presented data raise doubts about whether the utilized medical tests or the ways in which they are carried out reliably discriminate between different grades of intoxication. Negative tests did not exclude high BACs, nor did positive tests correlate well with BACs. DISCUSSION/CONCLUSION: In practice, CUI is seen with BACs above 1.60 g/kg in most cases. BACs below 1.60 g/kg either seem to be a minor problem or they have been incompletely addressed thus far. In summary, to be prosecuted, drunk cyclists have to ride their bikes in either a highly insecure or rude manner or they must cause an accident.

E-scooter driving under the acute influence of alcohol-a real-driving fitness study.

PURPOSE: To assess the effects of alcohol on the ability to drive an e-scooter, driving tests reflecting real-life situations accompanied by medical examinations focusing on balance were conducted at different blood alcohol concentrations (BACs). METHODS: Fifty-seven subjects who consumed alcohol (28 female, 29 male) and 6 consistently sober subjects (3 female, 3 male) participated in the study. Alcohol was administered on a fixed schedule, and the individual drinking quantity was individually calculated in advance using the Widmark formula. Repeated runs through a fixed course were performed. Following each ride, a blood sample was taken for BAC determination, and medical tests were performed. RESULTS: Even at low BACs (0.21-0.60 g/kg), subjects showed a significant decrease in driving performance, to approximately 60% of the initial level. Differences in driving performance at different BAC ranges were observed for different obstacles, especially for the narrowing track, gate passage, slalom, and driving in circles obstacles. Furthermore, worse Romberg and Unterberger test results were correlated with worse driving performance. It cannot be assumed that learning effects during the study had a relevant effect, as shown in the comparison of the driving performance of the alcohol-consuming group with that of the control group. Sex-specific differences were not found. DISCUSSION: Significant deteriorations in driving performance at BACs below 1.10 g/kg confirmed alcohol-related risk potential when using e-scooters. At this time, these findings may lead to the assumption of "relative driving impairment" in Germany. The Romberg and Unterberger tests could be considered a complementary investigation method for the assessment of e-scooter driving impairment. CONCLUSION: Even at rather low BACs between 0.21 and 0.40 g/kg, there was a significant deterioration in driving performance under the influence of alcohol compared to sober, which highlights the negative effects of alcohol on e-scooter driving.

A rare cause of sudden unexpected death syndrome (SUDS) in the first year of life: endomyocardial fibroelastosis (EFE) due to two compound heterozygous MYBPC3 mutations.

BACKGROUND: Autopsies regularly aim to clarify the cause of death; however, relatives may directly benefit from autopsy results in the setting of heritable traits ("mortui vivos docent"). CASE PRESENTATION: A case of a sudden unexpected cardiac death of a 5.5-months-old child is presented. Autopsy and thorough postmortem cardiac examinations revealed a massively enlarged heart with endomyocardial fibroelastosis. Postmortem molecular testing (molecular autopsy) revealed an unusual combination of two biparental MYBPC3 gene mutations likely to underlie the cardiac abnormalities. Thus, the molecular autoptic findings also had consequences for the relatives of the deceased child and impact on further family planning. CONCLUSIONS: The presented case highlights the need for clinical autopsies including cardiac examinations and postmortem molecular testing; it also paves the way for further cascade screening of family members for cardiac disease, if a distinct genetic disorder is suspected.

Care for children with dental neglect: identification of problems and approaches to solving them.

Dental neglect may have serious consequences for children's health. Moreover, it may indicate general negligence and it can be associated with child abuse. Therefore, a highly professional case management is of utmost importance, but also poses a great challenge for dentists. In order to develop effective strategies for an optimization of dental care in cases of dental neglect, a better understanding of the situation, and in particular an investigation into the unsolved questions of dentists in these cases, is needed. A prospective clinical examination with ten dentists was carried out to identify their challenges in the treatment of and the care for children facing suspicion of dental neglect. The practice of dental care in the cases of 102 children with suspicion of dental neglect (ages 3-14 years) was analyzed by collecting quantitative data (questionnaires) as well as qualitative data (focus group interviews). Severe and complex challenges in the handling of dental neglect in dental practice were identified. The study revealed that steps towards an optimization of the care for children with suspicion on dental neglect, which is much more than the treatment of caries, are needed. As such steps, we propose (1) the drafting of precise guidelines, (2) the education and training of dental students and dentists in general, (3) mandatory periodical dental health screenings, (4) the establishment of an interdisciplinary cooperation within the public health system, (5) the education of families, and (6) an adequate financial compensation for a professional and optimized case management. The establishment of efficient strategies of prevention and treatment of dental neglect and associated risks for the health of affected children will only be achieved with intense public and governmental support.

On the impact of cannabis consumption on traffic safety: a driving simulator study with habitual cannabis consumers.

To contribute to the ongoing discussion about threshold limits of Δ9-tetrahydrocannabinol (THC) in road traffic, a driving simulator study with 15 habitually cannabis consuming test persons was conducted. Probands were tested on different routes after consumption of a maximum of three cannabis joints, each containing 300 µg THC/kg body weight (sober testing as well as testing directly, 3 and 6 h after cannabis consumption). Accompanying the drives, medical examinations including a blood sampling were performed. Driving faults and distinctive features in the medical examinations were allocated certain penalty points, which were then summed up and evaluated using the ANOVA model. The results showed that very high CIF values > 30 as well as serum THC concentrations > 15 ng/ml significantly increased the number of penalty points, but no direct correlation to the THC concentrations in serum and/or CIF values was detected. Instead, the point in time after cannabis consumption seems to play an important role concerning driving safety: significantly more driving faults were committed directly after consumption. Three hours after consumption, no significant increase of driving faults was seen. Six hours after consumption (during the so-called subacute phase), an increase of driving faults could be noted although not significant. Considering the limitation of our study (e.g. small test group, no placebo test persons, long lasting test situation with possible tiredness), further studies focusing on the time dependant impact of cannabis consumption on road traffic are required.

Ornithine transcarbamylase deficiency of a male newborn with fatal outcome.

Ornithine transcarbamylase deficiency (OTCD) is the most common malfunction of ureagenesis. The case of a male newborn who died at the age of 2 days for clinically unclear reasons is presented. The post-mortem routine and esoteric testing methods that finally led to the diagnosis of a fatal case of OTCD are outlined here.

The effect of cannabis on regular cannabis consumers' ability to ride a bicycle.

To assess the effects of cannabis on the ability required to ride a bicycle, repetitive practical cycling tests and medical examinations were carried out before and after inhalative consumption of cannabis. A maximum of three joints with body weight-adapted THC content (300 µg THC per kg body weight) could be consumed by each test subject. Fourteen regular cannabis-consuming test subjects were studied (12 males, 2 females). In summary, only a few driving faults were observed even under the influence of very high THC concentrations. A defined THC concentration that leads to an inability to ride a bicycle cannot be presented. The test subjects showed only slight distinctive features that can be documented using a medical test routinely run for persons under suspicion of driving under the influence of alcohol or drugs.

The effect of alcohol hangover on the ability to ride a bicycle.

To investigate the effects of alcohol on the ability to ride a bicycle, practical cycling tests were carried out at different blood alcohol concentrations (BAC). For this purpose, various alcoholic beverages could be consumed from around 2 p.m. until 11 p.m. Afterwards, the test persons spent the night on the trial site and were provided with dormitory sleeping accommodation. On the following morning, beginning at around 8 a.m., a final cycling test was performed. The performances of those test persons who had returned to state of soberness and of those with residual blood alcohol levels were compared to the performances on the day before. The practical ability to ride a bicycle was significantly reduced in the postalcoholic state compared to the rides of the day before. The relative cycling performance in the postalcoholic state was comparable to the rides under the influence of BAC of around 0.30 g/kg. There were no remarkable differences between the groups with and without residual blood alcohol levels regarding the rides on the next morning. Therefore, it can be assumed that the direct influence of residual blood alcohol levels plays a minor role for the ability to ride a bicycle in the postalcoholic state. Instead, the side effects of the high amounts of alcohol that were consumed the night before are crucial.

Differences between male and female cyclists' performances under the acute influence of alcohol.

To examine the effects of alcohol regarding the fitness required to ride a bicycle, practical cycling tests, accompanied by medical examinations, were carried out at different blood alcohol concentrations. Seventy-eight persons were included in the trials (41 males, 37 females). Eighty-three evaluable trials were obtained. Men committed less coordinative driving faults with comparable blood alcohol concentrations. Single highly alcoholized men were able to safely ride their bicycle; however, each of the female test persons had at least one severe driving fault at blood alcohol levels above 1.43 g/kg. Women tended to exhibit signs of alcoholization in the medical examination reports earlier than men.

Regarding the fitness to ride a bicycle under the acute influence of alcohol.

To determine the threshold for the absolute inability to ride a bicycle, practical cycling tests and medical examinations at different blood alcohol concentrations were performed. Special attention was given to additional medical examinations, reaction tests and alcohol consumption under real-life conditions. Seventy-eight test subjects were included in the trials (37 females, 41 males). Five test subjects participated twice; thus, there were a total of 83 evaluable trials. Alcohol-related deficits were already identifiable at very low BACs. A significant increase in gross motoric disturbances compared to the soberness state did not regularly occur until a BAC of at least 0.8 g/kg was reached. At the BAC of 1.4 g/kg and above, no test subjects were able to achieve or surpass their sober driving results. Isolated highly alcoholised test subjects rode the bike in a manner that was not conspicuously different than the other sober test persons. Contrary to the assumptions of current German legal practise, it cannot be stated that all people are 'absolutely impaired' to the point of being incapable of riding bicycle at BACs of at least 1.6 g/kg.

Perphenazine for schizophrenia.

BACKGROUND: Perphenazine is an old phenothiazine antipsychotic with a potency similar to haloperidol. It has been used for many years and is popular in the northern European countries and Japan. OBJECTIVES: To examine the clinical effects and safety of perphenazine for those with schizophrenia and schizophrenia-like psychoses. SEARCH METHODS: We updated our original search using the Cochrane Schizophrenia Group's register (September 2013), references of all included studies and contacted pharmaceutical companies and authors of included studies in order to identify further trials. SELECTION CRITERIA: We included all randomised controlled trials that compared perphenazine with other treatments for people with schizophrenia and/or schizophrenia-like psychoses. We excluded trials of depot formulations of perphenazine. DATA COLLECTION AND ANALYSIS: Two review authors independently inspected citations and, where possible, abstracts. We ordered papers, inspected and quality assessed them. We extracted data, again working independently. If loss to follow-up was greater than 50% we considered results as 'prone to bias'. For dichotomous data, we calculated risk ratios (RR) and for continuous data we calculated mean differences (MD), both with the 95% confidence intervals (CI). We assessed quality of data using the GRADE (Grading of Recommendations Assessment, Development and Evaluationtool) and assessed risk of bias for included studies. MAIN RESULTS: Thirty-one studies fulfilled the inclusion criteria, with a total of 4662 participants (of which 4522 were receiving the drugs relevant to our comparison) and presented data that could be used for at least one comparison. The trial centres were located in Europe (especially Scandinavia), Japan and Northern America.When comparing perphenazine with placebo, for our primary outcome of clinical response, results favoured perphenazine with significantly more people receiving placebo rated as either 'no better or deterioration' for global state than people receiving perphenazine (1 RCT, n = 61 RR 0.32 CI 0.13 to 0.78, very low quality evidence). More people receiving placebo relapsed, although not a statistically significant number (1 RCT, n = 48, RR 0.14 CI 0.02 to 1.07, very low quality evidence). Death was not reported in the perphenazine versus placebo comparison. Experiences of dystonia were equivocal between groups (1 RCT, n = 48, RR 1.00 CI 0.07 to 15.08, very low quality evidence); other outcomes not reported in this comparison include serious adverse events, economic outcomes, and service use and hospitalisation.For the comparison of perphenazine versus any other antipsychotic drugs, no real differences in effect between the drugs were found. There was no significant difference between groups for those considered 'no better or deterioration' (17 RCTs, n = 1879, RR 1.04 CI 0.91 to 1.17, very low quality evidence). For mental state outcome of 'no effect' of the study drug, there was again no significant difference between groups (4 RCTs, n = 383, RR 1.24 CI 0.61 to 2.52, very low quality evidence). Death was not reported in any of the included studies. There was no significant difference in rates of dystonia with perphenazine versus any other antipsychotic drugs (4 RCTs, n = 416, RR 1.36 CI 0.23 to 8.16, very low quality evidence), nor was there a significant difference between groups for serious adverse events (2 RCTs, n = 1760, RR 0.98 CI 0.68 to 1.41, very low quality evidence). AUTHORS' CONCLUSIONS: Although perphenazine has been used in randomised trials for more than 50 years, incomplete reporting and the variety of comparators used make it impossible to draw clear conclusions. All data for the main outcomes in this review were of very low quality evidence. At best we can say that perphenazine showed similar effects and adverse events as several of the other antipsychotic drugs. Since perphenazine is a relatively inexpensive and frequently used compound, further trials are justified to clarify the properties of this classical antipsychotic drug.

[Fatal electric accident due to adverse error situation]. / Tödlicher Stromunfall aufgrund ungünstiger Fehlerkonstellation.

Despite wearing high-impedance shoes, a young male died while trying to connect a garden pump (230 V). The cause of death could easily be determined on the basis of testimonies of eye-witnesses and an electric mark on the body. Histological and electron microscopic examinations showed metallisation of the electric mark (pure iron). Intensive investigative efforts were needed, however, to reproduce the current path, which resulted from three different coactive failures. The electrotechnical characteristics of the case and the resulting current path are described.

[Lethal intravenous injection of benzine]. / Intravenöse Injektion von Waschbenzin mit tödlichem Verlauf.

A man who suffered from chronic pain syndrome died two days after intravenous injection of 2 ml benzine. Previous suicide attempts by drug intoxication and strangulation had failed. Death occurred due to multi-organ failure. We present the results of the clinical, morphological and toxicological examinations performed.

Perazine for schizophrenia.

BACKGROUND: Perazine is an old phenothiazine derivative used for the treatment of people with schizophrenia and is reputed to have a low level of extrapyramidal adverse effects. As far as we are aware, its use is limited to Germany, Poland, the former Yugoslavia and the Netherlands. OBJECTIVES: To examine the effects of perazine for those with schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medications. SEARCH METHODS: We searched the Cochrane Schizophrenia Group Trials Register, which includes relevant randomised controlled trials from the bibliographic databases Biological Abstracts, CINAHL, The Cochrane Library, EMBASE, MEDLINE, PsycLIT, LILACS, PSYNDEX, Sociological Abstracts and Sociofile. We searched the references of all included studies for further trials. We contacted pharmaceutical companies and authors of trials. We updated this search on 16th July 2012. SELECTION CRITERIA: We selected all randomised controlled trials that compared perazine with other treatments for people with schizophrenia or schizophrenia-like psychoses, or both. DATA COLLECTION AND ANALYSIS: The review authors (SL, BH, BHe) independently inspected the citations and where possible abstracts and ordered papers for re-inspection and quality assessment. We independently extracted data. We calculated the risk ratio (RR) and 95% confidence interval (CI) using a random-effects model. For continuous data, we calculated mean differences (MD). We inspected all data for heterogeneity, assessed trials for risk of bias and created summary of findings tables using GRADE. MAIN RESULTS: The review now includes seven trials with a total of 479 participants. In only one trial, with 95 participants, perazine appeared superior to 'active placebo' (trimipramine) at five weeks for the outcome of 'no important global improvement' (n = 95, RR 0.43 CI 0.2 to 0.8, low quality evidence), but there was no statistically significant difference in most measures of mental state. Perazine did not induce more general adverse events than placebo but more participants received at least one dose of antiparkinson medication (n = 95, RR 4.50 CI 1.0 to 19.5, very low quality evidence).Six small trials comparing perazine with other antipsychotics, including 384 participants in total, were incompletely reported and the outcomes were presented in various ways so that meta-analysis was not possible on most occasions. In the six studies, a similar number of participants receiving perazine or comparator antipsychotics (amisulpride, haloperidol, olanzapine, ziprasidone, zotepine) left the studies early (n = 384, RR 0.97 CI 0.68 to 1.38, low quality evidence). The results on efficacy could not be meta-analysed because the authors presented their results in very different ways. No obvious differences in adverse events between perazine and other antipsychotics could be derived from the limited data. Two haloperidol comparisons did not present extrapyramidal side-effects in a way that was suitable for use in meta-analysis, but three small comparisons with the second-generation antipsychotics zotepine and amisulpride showed no higher risk of akathisia (n = 111, RR 0.31 CI 0.1 to 1.1), dyskinesia (n = 111, RR 0.47 CI 0.1 to 3.5), parkinsonism (n = 81, RR 1.21 CI 0.5 2.8) or tremor (n = 40, RR 0.80 CI 0.3 to 2.6) with perazine. AUTHORS' CONCLUSIONS: The number, size and reporting of randomised controlled perazine trials are insufficient to present firm conclusions about the properties of this antipsychotic. It is possible that perazine is associated with a similar risk of extrapyramidal side-effects as some atypical antipsychotics but this is based on small comparisons. This should be clarified in larger, well-designed trials.