Peer education program to improve fluid consumption in primary schools-lessons learned from an innovative pilot study.

Background: Although it is widely recognized that more attention needs to be paid to children's fluid intake, there is little information on how to improve it. Peer education has been suggested as an effective approach to changing health behaviors among school children. As a new approach, our study piloted a peer education program to improve children's fluid intake in primary schools. Methods: University students were prepared for their role as peer educators in an elective university course, including the concept of peer education and different pedagogical methods. The peer educators evaluated the training process by completing a questionnaire. The intervention took place during a School Health Day led by the peer educators. An anonymous survey with a questionnaire on knowledge of fluid intake was administered two weeks before, at the end of, and 15 weeks after the intervention. Changes in hydration knowledge were tested using repeated measures ANOVA. Results: The pilot program showed increased knowledge about fluid consumption (p < 0.001) in lower and upper primary school children (N = 326) at the end of the School Health Day compared to pre-intervention measures. A positive change was observed after 15 weeks only in upper primary students. Feedback from peer educators was useful for fine-tuning the program. Conclusions: This innovative program induced positive changes in knowledge about fluid intake in primary school children. The persistence of the changes differed between lower and upper primary school children. Based on the results, the intervention should be replicated to adapt the program to the needs of lower primary school children. Because the training of peer educators and the peer education program appeared to be successful, this program is worthy of international replication. This approach may also be suggested for other behavior change issues.

Recovery of transient pericardial constriction following steroid administration.

A case of transient idiopathic constrictive pericarditis is presented. Following steroid treatment there was resolution of the pericardial effusion, resolution of constriction and disappearance of the fibrin layer. The patient was followed-up for one year without any need for further treatment. Transient pericardial constriction is a rare outcome of acute pericarditis and should be promptly diagnosed before any consideration for pericardectomy.

Sexual dysfunction among patients treated with antidepressants--a Hungarian retrospective study.

The authors have investigated the incidence and several aspects of sexual problems in Hungarian outpatients (N = 637) treated by antidepressive medication. In this multicentre epidemiological survey the sexual dysfunctions (SD) was assessed by psychiatrists using structured interviews. Seventy-eight of the sample has sexual problems, more than half of them mentioned SD after starting antidepressive medication. Comparing various groups of antidepressants, patients taking a RIMA compound reported the occurrence of SD not so often as in TCA or SSRI groups, where the rate of SD was very high. Authors pointed out that physicians have to pay special attention to this problem in everyday clinical practice, since the recognition and treatment of sexual dysfunction is critical for the patient's satisfaction, medication compliance and the quality of life.

Hypertension and clusters of risk factors in different stroke subtypes (an analysis of Hungarian patients via Budapest Stroke Data Bank).

Our aim was to determine the frequency of hypertension in the Hungarian stroke population, and to compare it with the data of other stroke registries. We attempted to find characteristic cluster-like associations between hypertension and another nine risk factors in different stroke subtypes and to ascertain the role of hypertension in leukoaraiosis, in early mortality, in stroke recurrence and in the case fatality rate up to 10 years. Risk factor profile of 500 unselected acute stroke cases of the Budapest Stroke Data Bank were analysed. We compared data of hypertensive stroke patients to those of unaffected ones. LIFEREG procedure of the SAS software package, cluster analysis, logistic regression, Pearson's correlation coefficient and Student's t-test were used as statistical methods. Hypertension was documented in 75% of the patients. The largest clusters were formed by the following groups: atherosclerotic stroke, hypertension with ischaemic heart disease; lacunar stroke and haemorrhage, hypertension with elevated serum cholesterol, cardiogenic embolism, ischaemic heart disease with atrial fibrillation. The case fatality rate was significantly higher in the group of hypertensive patients with ischaemic heart disease relative to those without it during the 10 years follow-up period. In the leukoaraiosis-group, systolic blood pressure was significantly higher than in the non-leukoaraiosis group. The rate of hypertension was higher than in other stroke registries. Hypertension appears to be the most frequent risk factor in stroke patients but case fatality rate is determined by presence or absence of ischaemic heart disease.

Gender differences in major depressive disorder in a Hungarian community survey.

INTRODUCTION: The aim of this study was to investigate the characteristics of Major Depressive Disorder (MDD) in males and females in a sample of the Hungarian adult population. METHOD: 2953 randomly selected subjects between 18 and 64 years old were interviewed using the Hungarian version of the Diagnostic Interview Schedule (DIS), which generated DSM-III-R diagnoses. RESULTS: The lifetime and period prevalences of MDD were more than twice as high in women than in men. The gender difference appeared in early adolescence and continued up until the age of 50. An increased risk for anxiety disorders was found in patients with MDD, irrespective of gender, and in the majority of cases (65%) the anxiety symptoms preceded the onset of MDD. Depressed women tended to have more symptoms and a more marked tendency for recurrence than men. The preponderance of females was twice as high in MDD with comorbid anxiety than in MDD without it, in spite of the fact that the likelihood of the coexistence of MDD and anxiety disorders did not differ by gender. CONCLUSION: The higher MDD prevalence rate in women might be the consequence of a higher rate of pre-existing anxiety disorder(s).

[Risk factors for early death and recurrence in stroke]. / A stroke korai halálozását és az ismételt stroke kialakulását meghatározó tényezók.

The early case fatality rate (28-day mortality) in 500 acute stroke patients of Budapest Stroke Data Bank was 17% and it was 25% within the first year with an increase between 1-3% annually. In the group with early death significantly higher age (p < 0.0001), more serious neurological symptoms, impaired consciousness (p < 0.0001), and higher volume of the lesions (p < 0.0001) have been detected. In this group significantly more stroke in the territory of vertebrobasilar system, a higher number of ischemic heart disease, and atrial fibrillation have been registered. According to the stroke subtypes there were significantly more cardiogenic embolisms, and hemorrhages, but less lacunar infarcts. The level of blood sugar at admission, and the rate of low platelets were higher among patients, who died within 28 days. Significantly higher percentage of the regions in the right frontal, right parietal, right occipital lobes and right thalamus have been affected in the early death group than in the survivors' group, however no such difference have been found in the lesions of the left homological structures. Severity of recurrent strokes have been more serious, and among patients with repetitive stroke significantly more ischemic heart diseases have been demonstrated. Atherosclerosis is the main risk for a new cerebrovascular accident. The case recurrent rate in the first 28 days is 7%, and it is 16% within the first year. The annual increase was between 1-5%. 71% of the recurrent strokes had the same mechanism as the first one.

Suicide attempts in the Hungarian adult population. Their relation with DIS/DSM-III-R affective and anxiety disorders.

Prevalence of suicide attempts and their relationship with DIS anxiety and affective disorder diagnoses were investigated in a Hungarian adult community sample. Despite the high suicide mortality rate, the rate of suicide attempts was similar to that reported in other studies using similar methods. Suicide attempts occurred more frequently among women and previously married persons. Although the presence of any lifetime anxiety and/or affective disorder increased the rate of reported suicide attempts, the effect of co-morbidity, recurrence and chronicity might be considered significant predictors. The highest odds of an attempt were related to the diagnoses of dysthymic or bipolar disorders. Agitation was the only depressive symptom, which increased the odds of a suicide attempt.

[Prevalence of mood and anxiety disorders in the Hungarian adult population]. / A hangulat- és szorongásos zavarok elöfordulása a felnött magyar lakosság körében.

The prevalence rates of affective and anxiety disorders in the Hungarian adult population were assessed with a well-structured questionnaire which has been successfully applied in several multinational epidemiological studies. The Hungary material showed significantly higher lifetime and period prevalence rates of bipolar disorders than is found in most of related literature. However, the frequency of other affective disorders and the anxiety states strongly corresponded with international findings.

The prevalence of major depressive and bipolar disorders in Hungary. Results from a national epidemiologic survey.

In order to estimate the prevalence of affective disorders in Hungary a sample of the Hungarian adult population (18-64 years) selected at random was interviewed using the Diagnostic Interview Schedule (DIS) which generated DSM-III-R diagnoses. The lifetime rate for Major Depressive Disorder (MDD) was 15.1%, and for Bipolar Disorders (BD) 5.1%. The female-to-male ratio was 2.7 for MDD and nearly equal for BD. The 1-year and 1-month period prevalence rates were 7.1% and 2.6% for MDD and 0.9% and 0.5% for manic episodes. A higher rate of divorced or separated persons was found among individuals with a lifetime diagnosis of MDD. Besides these, the lifetime diagnosis of BD coexisted with higher rates of the never-married state. The highest hazard rate for the development of BD or MDD was in the range 15-19 years but in MDD another peak was also found in the range 45-50 years. The first peak was characteristic of the recurrent, and the other one of the single form of MDD. Insomnia, loss of energy, decreased interest, concentration problems were the most common symptoms during the depressive episode, independent of polarity. Higher rates of lifetime diagnosis of dysthymia and all kinds of anxiety disorder were revealed among persons with MDD. BD was associated with GAD (Generalized Anxiety Disorder), and panic disorder more often than chance.

Hypothesis testing: is clozapine's superior efficacy dependent on moderate D2 receptor occupancy?

BACKGROUND: How clozapine exerts superior antipsychotic efficacy in treatment-resistant schizophrenia is not known. Moderate (rather than "full") occupancy of D2 postsynaptic receptors may be crucial, perhaps by achieving a more effective D1/D2 or serotonin-2a/D2 ratio. The objective of this study was to test the moderate occupancy hypothesis of clozapine's superior efficacy. METHODS: Data from the New York effectiveness of clozapine study were used to compare 6-week clozapine treatment results in patients discontinuing oral neuroleptic medication with similar patients discontinuing long-acting depot neuroleptic. The latter group is assured "full" D2 occupancy during the 6-week clozapine treatment. RESULTS: If moderate occupancy is crucial for superior efficacy, the oral discontinuation group should manifest more improvement. Both groups showed the 6-week improvement expected with clozapine therapeutics [31% and 29% reduction in Brief Psychiatric Rating Scale (BPRS) scores in the depot and oral groups, respectively]. An analysis of covariance (for baseline BPRS) revealed no difference in change scores (df = 1,100; F = 0.17; p = ns). CONCLUSIONS: The reduced D2 occupancy hypothesis is rejected.

Investigation of vehicle driving ability in two diagnostic groups of epileptic patients with special neuropsychological approach.

The driving abilities of two groups of epileptic patients (temporal lobe epileptics: 44 and idiopathic generalized epileptics: 26) and control group of healthy volunteers were compared. A computerized device (MST-CARAT), was used validated by comparing the test performance measures with the results of the practical driving tests. Our results show that the neuropsychological aspects deserve greater attention in temporal lobe epileptic patients in general and in those epileptic patients receiving non-monotherapy (especially on Phenobarbital). The level of driving skill of well-treated idiopathic generalized epileptic patients was similar to that of normal drivers.

Vascular disease risk factors and findings in patients with Alzheimer's disease.

Vascular risk factors and data of different examinations relating to extracerebral vascular conditions were analysed in demented patients. Data of demented patients subsequently admitted to the Memory Clinic of the National Institute of Psychiatry and Neurology between March 1995 and February 1996 were registered in a specially designed data sheet. Three vascular examinations (ECG, Doppler examination of main extracerebral arteries on the neck, ophthalmoneurological examination) were carried out. The risk factors and vascular alterations were condensed in two factors. Neither the descriptive data nor the two factors showed statistically significant differences in the main groups (probable Alzheimer's disease--n=24, vascular dementia--n=23, mixed forms--n=15). Based on our results: vascular risk factors and pathological changes can occur in probable form of Alzheimer's disease; they can be present in early onset form as well; the most marked changes are in the vascular dementia group; relevant findings lack any correlation with each other in the point of severity of vascular changes. The extremely high cardio-cerebrovascular morbidity in Hungary seems to be reflected in the results. The role of vascular risk factors and (subclinical) pathological findings seem worth exploring further in Alzheimer's disease.

Neuroleptics in acute mania: a pharmacoepidemiologic study.

OBJECTIVE: To provide an epidemiologic descriptive analysis of the acute drug treatment of inpatients with bipolar mania in state psychiatric facilities in 1990. METHODS: We surveyed the first 3 weeks of drug treatment of all inpatients with bipolar mania who were admitted to 22 New York State adult psychiatric facilities during a 6-month period (n = 528). RESULTS: Almost all patients with mania were treated with neuroleptics. The mean +/- SD neuroleptic dosage was 684 +/- 543 mg/d chlorpromazine equivalents. Sixty-one percent of the patients received lithium and 12% received carbamazepine or valproate. Neuroleptic dosage was related to age, with older patients receiving lower dosages. Patients receiving combination treatment of a neuroleptic with either lithium, an anticonvulsant, or a benzodiazepine received a mean neuroleptic dosage similar to that of patients treated with a neuroleptic alone. CONCLUSIONS: Although their use has been widely discouraged for mood disorders, neuroleptics have been the standard treatment for acute mania.

[The level of use of statistical data in articles in the Orvosi Hetilap]. / Tanulmány az orvosi hetilap közleményeinek statisztikai színvonaláról.

The objective was to assess the level of use of statistics in the articles of the Orvosi Hetilap (OH). Eight clinical and 25 randomly selected general medical papers (published in 1992) were evaluated with the help of checklists used in the British Medical Journal (BMJ). The result was compared with the survey conducted in the BMJ (Gardner and Bond, JAMA, 1990, 263, 1355-1357). Two clinical studies were found suitable for publication without further revision. All the general papers needed revision and in 8 studies no changes appeared to be sufficient for publication. For the clinical and general articles, respectively, loglinear modelling showed a 4 and 6 times higher likelihood for satisfactory qualification in the BMJ than in the OH. In the OH, the quality of the analysis and presentation was rated the least satisfactory while the design was assessed the best among all checklist items. The main source of methodological flaws were either the lack of any statistical method or the inappropriate selection of them. The validity of the results published in the papers evaluated was often diminished by multiple testing or neglecting potential confounders. Contribution of statisticians appears desirable in planning and evaluating the investigation. Following the practice in the major medical journals, introduction of statistical review in the OH was suggested. In the view of the authors, reforms in medical education and research seem to be unavoidable for responding to the challenge of today's medical methodology.

Characteristics of state hospital patients arrested for offenses committed during hospitalization.

OBJECTIVE: The study was a preliminary exploration of the relatively new phenomenon of arresting psychiatric inpatients for offenses committed in the hospital. METHODS: A retrospective record review at two New York state hospitals identified all 73 inpatients arrested over a 30-month period for an offense committed while they were hospitalized. Logistic regression was used to compare arrestees with a control group of 1,438 non-arrested inpatients. RESULTS: The number of arrests at the two hospitals significantly increased over the study period. Seventy-nine percent of arrests resulted from a violent incident. At least 68 percent of arrestees had been arrested previously. Compared with the control group, arrestees were more likely to be young, male, and black and to have a shorter length of stay. Axis I diagnoses did not differentiate arrestees from control patients. Ninety percent of arrestees had a diagnosis of substance use or personality disorder or both. The sample more closely resembled the population of criminal offenders in the community than the psychiatric inpatient population. Prosecution resulted in jail or prison terms for 11 percent of arrestees. CONCLUSIONS: This descriptive preliminary study was limited by its retrospective nature and reliance on records of varying quality. Although the increase in arrests is clear, the cause of the increase and the impact of arrests on arrestees and hospitals remain to be clarified.

The disposition of criminal charges after involuntary medication to restore competency to stand trial.

The United States Supreme Court, in the recent case of Riggins v. Nevada, extended its examination of the issue of involuntary treatment with anti-psychotic medication to the mentally disabled facing criminal trial. Although this was an extreme case where the defendant faced a possible death sentence, the involuntary administration of anti-psychotic medication to restore 'competency to stand trial' always raises unique medical and moral questions. This highly controversial issue has received little empirical investigation. We report here on the first study to follow-up on the disposition of the criminal charges of persons committed to a hospital for the restoration of 'competency to stand trial' who refused anti-psychotic medication and for whom involuntary treatment was sought. We have previously reported on the characteristics of these cases (N = 68) and aspects of their outcome in the hospital. This cohort of patients represents virtually all indicted felony offenders in New York state who were incompetent to stand trial and for whom involuntary treatment with anti-psychotic medication was requested between 1986 and 1990. The present retrospective report focuses on the disposition of the criminal charges for such cases, in a state that does not have a death penalty. Tentative inferences are considered based on the findings that persons who were involuntarily restored to 'competency to stand trial' had a variety of dispositions of their criminal charges, including plea negotiations that resulted in foreshortened incarceration and several cases of insanity acquittals. Suggestions for further and more conclusive studies are proposed.

Pharmacoepidemiology of clozapine in 202 inpatients with schizophrenia.

OBJECTIVE: To evaluate clozapine in a field trial for hospitalized patients with treatment-resistant schizophrenia. METHOD: The setting consisted of a large, state-operated, public psychiatric system. The protocol called for the treating psychiatrist to provide symptom- and adverse-effect ratings at four times following the start of drug therapy. The outcome criteria included the Sandoz study outcome measure of symptom improvement as well as discharge status for one year of follow-up. To assess the validity of the ratings, several measures of internal consistency were determined. Clozapine therapy was started in 227 patients, and symptom data are available for 202. RESULTS: Overall, 33 percent (n = 66) of the patients were improved at the end of one year of treatment; 12 percent (n = 24) maintained symptom improvement at all three evaluation times. Modest, statistically significant improvement after 12 weeks compared with baseline Brief Psychiatric Rating Scale (BPRS) total scores was observed for the patients continuing medication (n = 152); the emergence of a previously unimproved group (n = 26) explains this modest improvement. However, in the analysis of all patients (n = 202), (including dropouts), there was no significant symptom improvement after 12 weeks. Lower baseline BPRS scores predicted significant symptom improvement after 12 weeks of treatment. Among those medicated for one year, the pattern of symptom improvement showed that the probability of late improvement was 0.26 for those previously unimproved, and the probability of a 12-week responder losing improvement was 0.23, resulting in a net group gain of 3 cases in 100. By the end of one year, 8 percent (n = 17) of the cohort was discharged, and 3 percent (n = 7) was transferred to another facility while continuing to receive clozapine. Of the 227 original patients started on clozapine therapy, medication was discontinued for adverse effects in 11 percent (n = 25): white blood cell count (WBC) decrease (but no agranulocytosis) in 5 percent (n = 12), seizures in 1 percent (n = 3), one patient with seizures and decreased WBC count, and other events (e.g., cardiovascular changes, fever, or possible neuroleptic malignant syndrome) in 4 percent (n = 9). Patient refusal was reported for 6 percent (n = 13) of those starting treatment. CONCLUSIONS: Although only 19 percent of the patients exhibited improvement at 6 weeks, the response rate at 12 weeks (29 percent) for this naturalistic study cohort was similar to that in the major, double-blind, six-week, controlled, clinical trial of clozapine. The impersistence of response as symptoms were followed for up to one year is a finding that deserves rigorous evaluation.

Involuntary medication of patients who are incompetent to stand trial: a descriptive study of the New York experience with judicial review.

The United States Supreme Court, in the recent case of Riggins v. Nevada, extended its examination of the issue of involuntary treatment with antipsychotic medication to the mentally disabled facing criminal trial. A criminal defendant who is "incompetent to stand trial" cannot be subjected to trial. Many such persons are committed to hospitals to be treated and rendered "competent to stand trial," and some of these patients refuse medication. The involuntary administration of antipsychotic medication to such patients raises important and unique medical and moral questions. This highly controversial issue has been understudied. We report here on the first study of persons committed to a state hospital in order to be rendered competent to stand trial who refuse antipsychotic medication and for whom judicial review is requested to allow involuntary treatment, and in which results are given specifically for these subjects. This is a retrospective study to determine the characteristics of such cases and aspects of their outcome in the hospital. We reviewed all cases (N = 68) of application for treatment over objection, filed since the inception in 1986 of the new laws and regulations requiring judicial review through 1990, among patients in the two facilities that receive over 95 percent of all indicted felony offenders in New York State who are incompetent to stand trial. Tentative conclusions are formulated based on the findings that, according to clinical reports, no patient gave only rational reasons for medication refusal, clinicians always indicated the clinical appropriateness of the proposed treatment, judges apparently never found that someone who is "incompetent to stand trial" is "competent" to refuse medication, 93 percent of patients treated involuntarily had a good clinical response, and 87 percent of patients treated involuntarily were restored to "competency to stand trial."