Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology.

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

Cognitive behaviour therapy for improving social recovery in psychosis: a report from the ISREP MRC Trial Platform Study (Improving Social Recovery in Early Psychosis).

BACKGROUND: This study reports on a preliminary evaluation of a cognitive behavioural intervention to improve social recovery among young people in the early stages of psychosis showing persistent signs of poor social functioning and unemployment. The study was a single-blind randomized controlled trial (RCT) with two arms, 35 participants receiving cognitive behaviour therapy (CBT) plus treatment as usual (TAU), and 42 participants receiving TAU alone. Participants were assessed at baseline and post-treatment. METHOD: Seventy-seven participants were recruited from secondary mental health teams after presenting with a history of unemployment and poor social outcome. The cognitive behavioural intervention was delivered over a 9-month period with a mean of 12 sessions. The primary outcomes were weekly hours spent in constructive economic and structured activity. A range of secondary and tertiary outcomes were also assessed. RESULTS: Intention-to-treat analysis on the combined affective and non-affective psychosis sample showed no significant impact of treatment on primary or secondary outcomes. However, analysis of interactions by diagnostic subgroup was significant for secondary symptomatic outcomes on the Positive and Negative Syndrome Scale (PANSS) [F(1, 69)=3.99, p=0.05]. Subsequent exploratory analyses within diagnostic subgroups revealed clinically important and significant improvements in weekly hours in constructive and structured activity and PANSS scores among people with non-affective psychosis. CONCLUSIONS: The primary study comparison provided no clear evidence for the benefit of CBT in a combined sample of patients. However, planned analyses with diagnostic subgroups showed important benefits for CBT among people with non-affective psychosis who have social recovery problems. These promising results need to be independently replicated in a larger, multi-centre RCT.

Cerebral white matter lesions in bipolar affective disorder: relationship to outcome.

BACKGROUND: Twenty per cent of patients with bipolar affective disorder suffer an illness that responds inadequately to treatment and has a poor outcome. Many patients, but not all, with bipolar disorder show white matter abnormalities on T(2)-weighted magnetic resonance imaging (MRI). AIMS: To explore the hypothesis that white matter abnormalities on MRI are seen more frequently in subjects whose illness has a poor outcome compared with those with a good outcome or controls. METHOD: Two groups of age- and gender-matched patients with bipolar disorder (14 with a good outcome and 15 with a poor outcome) and 15 controls, aged 20-65 years, were studied. Axial T(2)-weighted MRI scans were examined for the presence and severity of white matter abnormalities. RESULTS: Significantly more poor outcome group members had deep subcortical punctate, but not periventricular, white matter hyperintensities than the good outcome group (P:=0.035) or controls (P:=0.003) and these abnormalities were of greater severity (P:=0.030 and P:<0.014, respectively). CONCLUSIONS: Subcortical white matter lesions are associated with poor outcome bipolar disorder.

Mood, neuropsychological function and cognitions in premenstrual dysphoric disorder.

BACKGROUND: Neuropsychological function and cognitive correlates of depression have not previously been examined in a rigorously defined population of patients suffering from premenstrual dysphoric disorder (PMDD). METHOD: MOOD, neuropsychological function and cognition were measured in 10 PMDD patients and 10 age-matched controls in both phases of the menstrual cycle in a random order, counter-balanced design. RESULTS: The BDI was significantly elevated in the luteal phase of PMDD patients only while other cognitive measures showed no significant differences. Working memory was impaired in the luteal phase of the menstrual cycle with no significant differences between PMDD and control subjects. CONCLUSION: Despite the small sample size, these results show that the BDI is sensitive to the mood fluctuations of PMDD patients. An impairment in working memory was also found although this is a general menstrual cycle effect.

Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose.

OBJECTIVE: To determine whether naloxone administered i.v. to out-of-hospital patients with suspected opioid overdose would have a more rapid therapeutic onset than naloxone given subcutaneously (s.q.). METHODS: A prospective, sequential, observational cohort study of 196 consecutive patients with suspected opioid overdose was conducted in an urban out-of-hospital setting, comparing time intervals from arrival at the patient's side to development of a respiratory rate > or =10 breaths/min, and durations of bag-valve-mask ventilation. Subjects received either naloxone 0.4 mg i.v. (n = 74) or naloxone 0.8 mg s.q. (n = 122), for respiratory depression of <10 breaths/min. RESULTS: Mean interval from crew arrival to respiratory rate > or =10 breaths/min was 9.3 +/- 4.2 min for the i.v. group vs 9.6 +/- 4.58 min for the s.q. group (95% CI of the difference -1.55, 1.00). Mean duration of bag-valve-mask ventilation was 8.1 +/- 6.0 min for the i.v. group vs 9.1 +/- 4.8 min for the s.q. group. Cost of materials for administering naloxone 0.4 mg i.v. was $12.30/patient, compared with $10.70/patient for naloxone 0.8 mg s.q. CONCLUSION: There was no clinical difference in the time interval to respiratory rate > or =10 breaths/min between naloxone 0.8 mg s.q. and naloxone 0.4 mg i.v. for the out-of-hospital management of patients with suspected opioid overdose. The slower rate of absorption via the s.q. route was offset by the delay in establishing an i.v.

Discovering new points of differentiation.

Most profitable strategies are built on differentiation: offering customers something they value that competitors don't have. But most companies concentrate only on their products or services. In fact, a company can differentiate itself every point where it comes in contact with its customers--from the moment customers realize they need a product or service to the time when they dispose of it. The authors believe that if companies open up their thinking to their customer's entire experience with a product or service--the consumption chain--they can uncover opportunities to position their offerings in ways that neither they nor their competitors though possible. The authors show how even a mundane product such as candles can be successfully differentiated. By analyzing its customers' experiences and exploring various options, Blyth Industries, for example, has grown from a $2 million U.S. candle manufacturer into a global candle and accessory business with nearly $500 million in sales and a market value of $1.2 billion. Finding ways to differentiate one's company is a skill that can be nurtured, the authors contend. In this Manager's Tool Kit, they have designed a two-part approach that can help companies continually identify new points of differentiation and develop the ability to generate successful differentiation strategies. "Mapping the Consumption Chain" captures the customer's total experience with a product or service. "Analyzing Your Customer's Experience" shows managers how directed brainstorming about each step in the consumption chain can elicit numerous ways to differentiate any offering.

Designing organizations to compete.

The ability of corporations to defend or take market share from competitors varies with the corporations' strengths and weaknesses, may of which spring from their own structures. The challenge is not to design organizational structures that are perfect, but to design structures that are better than those of competitors.

Creating competitive weapons from information systems.

As the pace of competition intensifies in the 1980s, information systems will emerge as critical new weapons in the battle to gain an advantage over competitors. The authors show how a business can use modern information technologies to create a competitive edge by adding value to present products and services.

Achieving pharmacist proficiency in pharmacokinetic dosage adjustments.

A pharmacokinetics training and certification program for staff pharmacists in a community hospital is described. A pharmacokinetics committee consisting of six pharmacists with extensive clinical experience in pharmacokinetics was formed to implement the program. A self-teaching module incorporating basic pharmacokinetic concepts and sample problems was developed. Specific guidelines for calculating dosages of the aminoglycosides and theophylline were also developed, as were indications for the appropriate ordering and serum sampling of these drugs. These guidelines were used in the didactic training of pharmacists, and their knowledge of this information was evaluated by written examinations. Pharmacists were also required to calculate drug dosages for patients in the hospital. These pharmacokinetics calculations were evaluated by the pharmacokinetics committee at periodic meetings. Of the 12 pharmacists included in the training program initially, 9 completed the entire training and certification process. All new pharmacists are now required to obtain certification in pharmacokinetics; yearly recertification of all pharmacists is obtained by participation in patient case presentations involving calculation of drug dosages. This pharmacokinetics training program ensures a standard level of competency among staff pharmacists and may increase physicians' reliance on pharmacists for adjusting drug dosages.

Preemptive strategies.

Preemptive strategies often offer the best opportunity to gain advantage over competitors and upset industry balance. Preemptive moves exist all along the industry chain if one knows where to look for them. Companies can preempt their rivals in myriad ways, ranging from threatening major investments and securing critical skills to cornering raw materials and components and positioning products in a unique way.

Liquoid-induced renal lesions in the dog.

The role of fibrin in the pathogenesis of renal glomerular scarring in the dog was studied. Fibrin deposition, resulting from disseminated intravascular coagulation, was induced by intravenous injection of Liquoid (sodium polyanethol sulphonate). Thirty-eight puppies were killed from 30 minutes to 39 days after treatment, and the renal lesions examined by light, electron and immunofluorescence microscopy. The major acute lesions in the glomeruli were capillary thrombosis, mesangial and endothelial cell swelling and phagocytosis of fibrin, polymorphonuclear leukocyte infiltration and necrosis. Animals that recovered from this acute phase had focal glomerular scars. Affected glomeruli showed combinations of mesangial enlargement, focal tuft hypercellularity, collagen formation, thickening, wrinkling and duplication of the glomerular basement membranes, and some capsular adhesions. These observations indicate that fibrin deposition can be an important mechanism in glomerular scarring in the dog.

Screening for breast cancer by mammography: an Australian experience.

Four years' experience of screening well women for breast cancer by mammography is described. Twenty-six cancers were detected in 11,927 women (2-2 per 1,000), of which 20 were unsuspected by the patient and 12 were impalpable. Of the 26 cancers detected, 18 had no histological evidence of tumour in axillary lymph nodes, and 10 were impalpable and had unaffected axillary nodes. Four patients whose mammograms did not suggest malignant disease were subsequently found to have cancer, within 12 months.