Personality disorder in a probation cohort: Demographic, substance misuse and forensic characteristics.

BACKGROUND: The occurrence of personality disorder among community supervised offenders may have important implications for their management. There is, however, a dearth of contextual information on personality disorder in such populations. AIMS: This study aimed to identify demographic, substance use and forensic features that distinguish community-sentenced offenders with personality disorder from those without. METHODS: One hundred and seventy-three offenders under community supervision were screened for personality disorder using the Standardised Assessment of Personality--Abbreviated Scale. Alcohol and drug misuse, demographic and forensic data were also recorded. RESULTS: Nearly half of the sample (82, 47%) had probable personality disorder. Compared with those without personality disorder, they were younger, more likely to be unemployed, less likely to be divorced, more likely to have been convicted of robbery and more likely to be alcohol or illicit drug misusers, as well as under drug rehabilitation requirements. Multivariate analyses confirmed that only alcohol and drug abuse were independently associated with personality disorder in this group, and only the latter was significant. CONCLUSIONS: In this broadly representative sample of offenders serving community sentences in a defined geographical area, those with personality disorder were not more likely to attract higher risk of recidivism ratings, but they were more likely to have problems with heavy alcohol and/or illicit drug misuse.

Prediction of survival in Alzheimer's disease--the LASER-AD longitudinal study.

OBJECTIVES: Alzheimer's disease (AD) is associated with variable but shortened life expectancy. Knowing expected survival time may empower people with AD and their families, but clinicians currently have limited predictive information. Our objective was to identify determinants of survival in a cohort of people with mild to moderate AD and test these on a separate validation cohort. METHODS: We followed a representative cohort of 158 people for 42 months and identified independent determinants of shorter survival. From these we constructed the Survival in Alzheimer's Model (SAM), and tested this on a validation cohort. RESULTS: Baseline constructional apraxia, age and gait apraxia independently predicted shorter survival: about half of those scoring 2 on the SAM survived > or =3.5 years compared to 85% of those scoring 0. CONCLUSIONS: The SAM is a potentially useful tool for clinicians who previously had very limited specific and quantitative prognostic information to tell AD patients and carers. This model predicted survival from age, constructional and gait apraxia. This may be because constructional and gait apraxia are relatively free from educational or cultural bias and thus are better indicators of severe neuropathology than global cognitive tests. Alternatively, they may increase falls or immobility, or represent disease sub-types with worse prognoses. Oncology services are able to inform patients and their families about 5-year survival rates. This step towards such provision in AD is new and of potential importance to patients and their carers.

Reducing emotional distress in people caring for patients receiving specialist palliative care. Randomised trial.

BACKGROUND: Caring for relatives with advanced cancer may cause psychological and physical ill health. AIMS: To evaluate the effectiveness of increased support for distressed, informal carers of patients receiving palliative care. METHOD: The sample was composed of 271 informal carers who scored over 5 on the 28-item General Health Questionnaire (GHQ-28). The intervention comprised six weekly visits by a trained advisor. Primary outcome was carer distress (GHQ-28) at 4-week, 9-week and 12-week follow-up. Secondary outcomes were carer strain and quality of life, satisfaction with care, and bereavement outcome. RESULTS: Scores on the GHQ-28 fell below the threshold of 5/6 in a third of participants in each trial arm at any follow-up point. Mean scores in the intervention group were lower at all time points but these differences were not significant. No difference was observed in secondary outcomes. Carers receiving the intervention reported qualitative benefit. CONCLUSIONS: The intervention might have been too brief, and ongoing help might have had accruing benefits. Alternatively, informal carers of patients with cancer may already receive considerable input and the advisor's help gave little additional advantage; or caring for a dying relative is extremely stressful and no amount of support is going to make it much better.

The incidence of delirium associated with orthopedic surgery: a meta-analytic review.

BACKGROUND: The aim of this study was to perform a systematic review and meta-analysis of the literature regarding the incidence of delirium following orthopedic surgery. METHODS: Relevant papers were sourced from online databases and gray literature. Included studies used a validated diagnostic method to measure the incidence of delirium in a prospective sample of adult/elderly orthopedic patients. Data were subject to meta-analysis after stratification by type of surgery (elective v. emergency) and inclusion/exclusion of pre-existing cognitive impairment. A funnel plot assessed for publication bias. RESULTS: 26 publications reported an incidence of postoperative delirium of 4-53.3% in hip fracture samples and 3.6-28.3% in elective samples. Significant heterogeneity was evident, and this persisted despite stratification. Hip fracture was associated with a higher risk of delirium than elective surgery both when the cognitively impaired were included in the sample (random effects pooled estimate = 21.7% [95% CI = 14.6-28.8] vs. 12.1% [95% CI = 9.6-14.6]), and when the cognitively impaired were excluded (random effects pooled estimate = 25% [95% CI = 15.7-34.7] vs. 8.8% [95% CI = 4.1-13.6]). The funnel plot showed a deficit of small studies showing low risk and large studies showing high risk. In eight hip fracture studies, the proportion of delirium cases with a preoperative onset ranged from 34 to 92%. CONCLUSIONS: Delirium occurs more commonly with hip fracture than elective surgery, and frequently has a preoperative onset when associated with trauma. Recommendations are made with the aim of standardizing future research in order to further explore and reduce the heterogeneity and possible publication bias observed.

A randomized, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement.

OBJECTIVES: This was a pilot, phase 2a study to assess methodological feasibility and the safety and efficacy of donepezil in preventing postoperative delirium after elective total hip replacement surgery in older people without pre-existing dementia. The hypothesis was that donepezil would reduce the incidence of postoperative delirium. METHODS: A double blind, placebo controlled, parallel group randomized trial was undertaken. Patients were block randomized pre-operatively to receive placebo or donepezil 5 mg immediately following surgery and every 24 h thereafter for a further three days. The main outcome was the incidence of delirium (using the Delirium Symptom Interview). The secondary outcome was length of hospital stay. RESULTS: Thirty-three patients (mean age 67 years; 17 males, 16 females) completed the study (19 donepezil, 14 placebo). Donepezil was well tolerated with no serious adverse events. Postoperative delirium occurred in 21.2% of subjects. Donepezil did not significantly reduce the incidence of delirium. The unadjusted risk ratio (donepezil vs placebo) for delirium was 0.29 (95% CI = 0.06,1.30) (chi(2) ([1]) = 3.06; p = 0.08). Mean length of hospital stay was 9.9 days for the donepezil group vs 12.1 days in the placebo group; difference in means = -2.2 days (95% CI = -0.39,4.78) (t([31]) = 1.73: p = 0.09). CONCLUSIONS: The experimental paradigm was feasible and acceptable. Donepezil did not significantly reduce the incidence of delirium or length of hospital stay, however for both outcomes there was a consistent trend suggesting possible benefit. The sample size required for a definitive trial (99% power, alpha 0.05) would be 95 subjects per arm.

Estimating needs in life threatening illness: a feasibility study to assess the views of patients and doctors.

BACKGROUND: Provision of palliative care for patients with non-cancer conditions is hindered by the difficulty of predicting when people will die and fear of causing distress by raising end-of-life issues. OBJECTIVES: To compare patients' and professionals' (1) estimations of prognosis; (2) perceptions of the seriousness of the illness and needs for supportive care; and (3) acceptability of this sensitive research, in end-stage cancer and non-cancer diseases. DESIGN: Prospective cohort study. SETTING: A teaching hospital and a Marie Curie hospice in London. SUBJECTS: Twenty patients with advanced non-malignant disease (heart failure, chronic obstructive pulmonary disease and renal failure) and 20 patients with advanced cancer, and their physicians in charge. METHOD: A feasibility study using vignettes to aid patients and doctors estimate of prognoses. Main outcome measures were (1) patients' and physicians' estimates of health status, care needs and prognosis; and (2) patient survival. RESULTS: Patients were willing and able to estimate their own life expectancy and cancer patients correctly estimated that they had a poorer prognosis than non-cancer patients. Non-cancer patients perceived that they had similar needs for supportive care as cancer patients. Physicians made little distinction in palliative care needs between patients with and without cancer, but tended to make more pessimistic estimates of prognosis in non-cancer patients. CONCLUSIONS: Patients are able to judge their health status and life expectancy and do not object to questions about end-of-life care. Cancer and non-cancer patients have similar needs for supportive care. We need further evidence on the value of self-rated prognosis and how to provide palliative and supportive care for all patients who are near death.

Psychosexual function in women who have undergone reduction mammaplasty.

BACKGROUND: Reduction mammaplasty substantially alleviates physical and psychological symptoms of mammary hyperplasia, but the effect on psychosexual function has not been analyzed so far. The aim of this study was to assess the impact of this common procedure on both operative and psychosexual satisfaction. METHODS: All women who underwent reduction mammaplasty (n = 90) at the Royal Free and University College London Hospitals between 1997 and 2000 were sent a series of questionnaires on their psychosexual health and satisfaction with operative outcome and postoperative sexual function. RESULTS: Of the 80 women who responded (response rate, 89 percent), 76 percent were satisfied with their operative results. Postoperative sexual satisfaction was improved in 28 percent, worsened in 19 percent, and unchanged in 53 percent of patients. Nobody dissatisfied with surgical outcome reported improved sexual satisfaction. A strong correlation was found between these two main outcome measures and General Health and Female Sexual Function Index scores. Significant correlations were also noted for breast shape, sensation, and symmetry (p < 0.001) and change in nipple sensation (p < 0.01). In contrast, breast size and scars did not significantly affect patient operative and sexual satisfaction (p > 0.1). When compared with the satisfied group, women unhappy with surgical results were more likely to suffer from postoperative anxiety (58 versus 18 percent) and depression (42 versus 8 percent). CONCLUSIONS: This study confirms that operative outcome following breast reduction does correlate with postoperative psychosexual function, mental health, and some breast parameters. Now that the link is identified, a prospective analysis may clarify the precise relationship between the patient's preoperative psychological status and operative and psychosexual satisfaction.

Older adults' attitudes to death, palliative treatment and hospice care.

BACKGROUND: Cancer patients who receive care from specialist palliative care services in the UK are younger than those who do not receive this care. This may be explained by age-related differences in attitudes to end-of-life care. OBJECTIVE: To determine the relationship between age and i) attitudes to death and preparation for death; and ii) knowledge about, and attitudes to, cancer and palliative care. DESIGN: Interviews with older people, using a novel questionnaire developed using nominal groups. Main comparisons were made between people aged 55-74 with those aged 75 years and over. SETTING: General practices in London. SUBJECTS: 129 people aged 55-74 and 127 people aged 75 years or over on the lists of general practitioners. METHODS: A cross-sectional survey to determine knowledge and experience of hospice care; preparation for end-of-life; and attitudes to end-of-life issues. RESULTS: Participants were knowledgeable about specialist palliative care and almost half had some indirect contact with a hospice. People aged >74 were less likely than younger participants to want their doctor to end their life in a terminal illness. Although they believed death was easier to face for older people, they did not believe that younger people deserved more consideration than older people when dying, or that they should have priority for hospice care. Education, social class, hospice knowledge and anxiety about death had little influence on overall attitudes. CONCLUSIONS: The relative under-utilization of hospice and specialist palliative care services by older people with cancer in the UK cannot be explained by their attitudes to end-of-life issues and palliative care.

Spiritual beliefs may affect outcome of bereavement: prospective study.

OBJECTIVE: To explore the relation between spiritual beliefs and resolution of bereavement. DESIGN: Prospective cohort study of people about to be bereaved with follow up continuing for 14 months after the death. SETTING: A Marie Curie centre for specialist palliative care in London. PARTICIPANTS: 135 relatives and close friends of patients admitted to the centre with terminal illness. MAIN OUTCOME MEASURE: Core bereavement items, a standardised measure of grief, measured 1, 9, and 14 months after the patients' death. RESULTS: People reporting no spiritual belief had not resolved their grief by 14 months after the death. Participants with strong spiritual beliefs resolved their grief progressively over the same period. People with low levels of belief showed little change in the first nine months but thereafter resolved their grief. These differences approached significance in a repeated measures analysis of variance (F=2.42, P=0.058). Strength of spiritual belief remained an important predictor after the explanatory power of relevant confounding variables was controlled for. At 14 months the difference between the group with no beliefs and the combined low and high belief groups was 7.30 (95% confidence interval 0.86 to 13.73) points on the core bereavement items scale. Adjusting for confounders in the final model reduced this difference to 4.64 (1.04 to 10.32) points. CONCLUSION: People who profess stronger spiritual beliefs seem to resolve their grief more rapidly and completely after the death of a close person than do people with no spiritual beliefs.

The development of a scale to measure concepts of schizophrenia: experience among Brazilian psychiatrists

Foi desenvolvida uma escala para medir aderência ao conceito Bleuleriano Schneideriano de esquizofrenia entre psiquiatras trabalhando em Säo Paulo, analisando relaçöes entre variáveis sociodemográficas e de formaçäo sobre o escore obtido. Questionário contendo escala visual analógica com dezessete enunciados sobre conceitos Schneideriano e Bleuleriano de esquizofrenia, foi distribuído para 150 psiquiatras. As sub-escalas Bleuleriana e Schneideriana foram avaliadas por métodos psicométricos de consistência interna, estrutura das subescalas e confiabilidade test-reteste. Completaram o questionário 117 psiquiatras. A sub-escala Schneideriana demonstrou melhor consistência interna e melhores coeficientes de correlaçäo intraclasse. Näo houve associaçäo negativa entre os escores das sub-escalas. Discordância com o conceito Bleuleriano predominou entre profissionais treinados na USP. A baixa confiabilidade da sub-escla Bleuleriana limita a confiabilidade do instrumento como um todo, embora contribua para a discussäo dos modelos em questäo. Argumenta-se que o modelo Bleuleriano, por exigir maior inferência, torna-se propenso a baixa confiabilidade