Effectiveness of interventions to promote physical activity and/or decrease sedentary behaviour among rural adults: a systematic review and meta-analysis.

Physical inactivity and overweight and obesity are more prevalent among rural than urban populations. This study aimed to review published evidence of the effectiveness of interventions to increase physical activity (PA) and/or decrease sedentary behaviour (SB) among rural adults and to identify factors associated with effectiveness. Seven electronic databases were searched for controlled trials of a PA or SB intervention. Meta-analysis was conducted using random effects models and meta-regression. Thirteen studies were included in the qualitative synthesis (n = 4,848 participants) and 12 in the meta-analysis (n = 4,820). All studies were interventions to increase PA. Overall, there was no effect on PA (standardized mean difference [SMD] 0.11; 95% confidence interval [CI] -0.04, 0.25) or SB (SMD 0.07; 95% CI -0.33, 0.20). In PA subgroup analyses, studies employing objective outcome measures demonstrated effects in favour of the intervention (SMD 0.65, 95% CI 0.30, 1.00), while those using self-reported measures did not (SMD 0.00; 95% CI -0.11, 0.10). This review highlights significant gaps in our understanding of how best to promote PA and reduce SB among rural adults. Future studies should use objective measures of PA as study outcomes. The absence of interventions to decrease SB is of concern, with immediate action required to address this large knowledge gap.

Psychological autopsy in the investigation of serial neonaticides.

While the use of psychological autopsies has at least a 50-year history in the investigation of equivocal deaths and suicides, we report a case where, after the discovery of a woman who died of natural causes, a subsequent search of her home found three deceased newborn infants. The infants were born on three separate occasions; the most recent was delivered approximately 2 weeks before the death of the mother. Using her own diaries and interviews with family and friends along with the physical autopsy and scene investigation data, we built a psychological autopsy that addressed the mother's mental state over the period of time when the infants' deaths took place. While the use of the psychological autopsy was not employed to distinguish the manner of death of the mother, it did provide explanatory power over circumstances of the crime scene and the behavioral disturbance of the mother.

Maternal neonaticide following traumatic childbirth: a case study.

Recent work has documented the relatively high incidence of Posttraumatic Stress Disorder (PTSD) symptoms in women during the birth delivery process and afterwards, even in uncomplicated births. This phenomenon, however, has yet to be linked with cases of neonaticide (child homicide in the first 24 hr of life) or infanticide (child homicide within the 1st year of life). Women are more likely to experience mental disorder after childbirth than at any other time in their lives, and the intentional killing of an offspring by a mentally ill mother is likely underreported. The immediate postpartum period is a time of heightened vigilance by health providers and, when the tragic death of an infant occurs, forensic professionals should specifically assess for PTSD. As an illustration, the authors present a case of maternal neonaticide that was directly linked to PTSD without any other concomitant mental disorder. PTSD is a viable mitigating factor to be examined in legal defenses of infanticide either in isolation or in conjunction with other factors.

On the witness stand: learning the courtroom tango.

OBJECTIVE: To summarize the steps primary care physicians should follow when they are asked to testify in court. To describe standard Canadian courtroom procedures and to suggest practical, tested ways to give successful expert testimony. SOURCES OF INFORMATION: I drew on personal experience from more than 750 trial appearances and the literature on effective testimony. MAIN MESSAGE: Family physicians are in a unique position to offer comprehensive and relevant medical information to judges and juries to assist them in legal decision making. To give effective expert testimony, physicians must recognize the differences between legal and medical "culture" and appreciate the basic rules and structure of courtroom evidence. Employing their skills as patient educators, family physicians can speak confidently about their patients' conditions and needs. CONCLUSION: Increasing demand for family physicians to testify in court requires that they equip themselves with a solid understanding of what expert status enables them to do and that they learn techniques for presenting clear and persuasive evidence.

Sumatriptan responsiveness and clinical, psychiatric and psychologic features in migraine patients.

OBJECTIVE: To compare sumatriptan responders and nonresponders in a migraine population with regard to a number of clinical, psychiatric and psychologic features. METHODS: Patients were drawn from a referral headache clinic population, and classified as responders or nonresponders. Clinical features were assessed by a written questionnaire. The lifetime prevalence of several psychiatric disorders was determined by the National Institute of Mental Health diagnostic interview schedule and personality factors were measured by the 16 Personality Factors (16PF) Questionnaire. RESULTS: Nonresponders indicated less influence on their migraine by menstrual factors, had a higher lifetime prevalence of generalized anxiety, and showed 16PF scores indicating greater shyness, self-sufficiency and perfectionism. Nonresponders were also more imaginative and less socially outgoing. CONCLUSION: Although they must be interpreted with caution due to small sample size and the multiple comparisons made, our results indicate that there may be differences between sumatriptan responders and nonresponders with regard to a number of clinical, psychiatric and psychologic factors. These results suggest that biological differences exist between the two patient groups which likely account for both the differences in their responses to sumatriptan and in the clinical features noted above.

Hospital days in risperidone-treated patients.

OBJECTIVE: To compare inpatient hospital days of a group of "real world" schizophrenia-spectrum patients for 3 years prior to and 3 years after risperidone initiation. METHOD: This is a retrospective cohort study using a mirror-image design of hospital days in 120 patients over a 6-year period. Hospital admission and discharge information was obtained from chart review and database extraction at 3 outpatient treatment sites. The sample comprised all patients attending these clinics who were prescribed risperidone during the first year of the drug's release. RESULTS: Patients separated into 3 treatment groups: those who were prescribed risperidone for 3 uninterrupted years (N = 35), those who interrupted but resumed risperidone use and were prescribed the drug at 3 years (N = 8), and those who discontinued risperidone during the 3-year follow-up period (N = 77). The group continuing risperidone to 3 years demonstrated a significant decrease in hospital days after risperidone treatment, in contrast to the other 2 groups. The reduction in inpatient days for the total sample was not statistically significant. CONCLUSION: In this outpatient clinic sample, the 29% of patients who continued on risperidone showed a significant reduction in inpatient hospital days, from an average of 17.2 days per year in the 3 years before risperidone treatment to an average of 2.1 days per year for the 3 years of risperidone treatment.

Hospital days in clozapine-treated patients.

OBJECTIVE: To examine inpatient hospital days used by a group of patients with treatment-resistant schizophrenia for 3 years before and 3 years after clozapine initiation. METHOD: A retrospective chart review of 26 consecutive admissions to an outpatient clozapine clinic was conducted for a 6-year period. The total number of hospital days was recorded. RESULTS: Patients separated into 3 groups: those who used clozapine for 3 uninterrupted years (N = 11, 42.3%), those who interrupted but resumed clozapine and continued on to 3 years (N = 4, 15.4%), and those who abandoned clozapine treatment (N = 11, 42.3%). Only the group that was continuously on clozapine showed a decline in percentage of inpatient days during the 3-year follow-up period. Three of the 11 patients who discontinued clozapine died during the posttreatment period: 2 suicides and 1 "death by misadventure." CONCLUSIONS: Continuous clozapine treatment significantly reduces days in hospital; this reduction was sustained throughout 3 years' follow-up. While the sample size is small, all patients were tracked over a 6-year period, and both drug continuers and dropouts were followed. The reduction in inpatient days may be lost if patients stop and then restart clozapine. For patients who do not respond to or abandon trials of clozapine, there is an urgent need to develop more effective treatment strategies.

Cognitive failures and stress.

138 healthy volunteers in four age groups completed the Cognitive Failures Questionnaire (Self and Other) as well as measures of attention, freedom from distractibility, daily stress, and trait-state anxiety. Self-reported and observed cognitive failures were strongly associated with stress and anxiety. Higher self-reported cognitive failure in one age group appeared tied to this finding. We discuss the usefulness of self-report of cognitive failures for neuropsychological practice.

Elizabethan madness: on London's stage.

During the reign of Elizabeth I (1558-1603) a renaissance of both literary and political history occurred. The stage was transformed from primitive echoes of the morality plays to a vibrant and diverse exploration of human endeavor and man's place in the universe. The titanic literary figure of Shakespeare today veils a group of friends and challengers whose pens strove for the same goal. The depiction of madness was ubiquitous during plays of this time and reflection on the views of this group of men gives us a more reliable insight into mental illness then and today.

The clozapine experience from a family perspective.

OBJECTIVE: To examine how the lives of family members of clozapine-treated patients with schizophrenia have been affected by this treatment. METHODS: Through the use of a questionnaire and an interview of family members, this qualitative study focused on the families' perceptions of change in their family member and the impact on the family unit. RESULTS: Fourteen patients and their family members participated. The family interview was conducted an average of 1.78 years after clozapine initiation (range 0.58 years to 3.73 years). Global ratings of behavioural change were positively and significantly correlated between all raters: patients, family members, and clinicians. Family members were positive about clozapine's effect on their relatives and the impact on the family. CONCLUSION: A positive response to clozapine decreases the burden on the family. This is in part the result of a decreased need for rehospitalization.

Clomipramine treatment and behaviour therapy with agoraphobic women.

The separate and combined effects of clomipramine hydrochlorzide and behaviour therapy on agoraphobic symptoms were investigated in a 28-week placebo-controlled double-blind clinical trial. One hundred and eight women diagnosed as agoraphobic were randomly assigned to one of four treatment conditions: clomipramine alone, behaviour therapy alone, clomipramine and behaviour therapy or placebo. Sixty women completed the assigned treatment. Clomipramine was prescribed in weekly increments to a maximum of 300 mg per day, with a mean dosage at week 8 of 94.6 mg per day. Behaviour therapy focused on graded in vivo exposure therapy. Assessments of patients were performed at six points prior to and during the trial and included standardized questionnaires, daily diaries and a Behavioral Approach Test. Significant main effects for both clomipramine and behaviour therapy on 15 and 12 of the dependent measures respectively were found but no interaction of treatments emerged.

The use of chloral hydrate and sodium amytal during clozapine initiation.

Sedative hypnotics are frequently a necessary adjunctive to neuroleptic treatment. The recently released antipsychotic agent clozapine poses a challenge in this regard since the manufacturer advises caution when using clozapine with patients receiving benzodiazepines. The effectiveness of alternate agents sodium amytal and chloral hydrate when initiating clozapine was evaluated in a group of 15 patients suffering from schizophrenia. These medications were observed to be both safe and effective.

Terms of madness: historical linguistics.

The etymological origins of commonly used descriptors of mental conditions are explored. In reviewing history for signs of mental disorders, we need to understand the terms used previously to indicate abnormalities. A wealth of terms is evident indicating that, contrary to the conclusions of some historians, mental illnesses have an extended and broad history.

Nurse participation in ethical decision making in the clinical setting.

Nurses, in their day-to-day practice, are required to combine clinical expertise with skill in moral judgment. Because of the nurse's unique relationship with the patient and a collaborative practice with the physician, the nurse often is at the forefront of identifying ethical dilemmas. In addition to identification of the ethical dilemma, the nurse often actively participates in the decision-making process. Ethical decision-making models bear some resemblance to the nursing process. The nurse plays an active role in each step of assessment, planning, implementation, and evaluation. An increasing number of nurses are formally participating in ethical decision making as a member of hospital ethics committees. The three primary tasks of these committees are: (1) education; (2) policy development; and (3) case consultation. Nursing ethics committees also are being developed to address issues specific to nursing, such as nurse staffing ratios and allocation of nursing resources. Nurses can use ethical rounds or retrospective case studies to perpetuate the study of ethics at the bedside.