Practical guidelines on the use of paliperidone palmitate in schizophrenia.

OBJECTIVE: Paliperidone palmitate is an atypical long-acting injectable (LAI) antipsychotic that has been approved for use in the US, EU, Australia and numerous other countries for acute and maintenance therapy of schizophrenia. LAI antipsychotics are often viewed as a 'last-resort' treatment for difficult-to-treat patients, however this article considers their role more broadly in the management of partial or non-adherence in schizophrenia. METHOD: A search of MedLine, CTR and PsychInfo was conducted to identify relevant publications and clinical trials (search term 'paliperidone palmitate', up to December 2010). The findings were discussed in a number of teleconferences and the manuscript was finalized with a face-to-face meeting of the authors group. MAIN FINDINGS: Relapse prevention in schizophrenia requires a comprehensive approach to treatment, which includes antipsychotic medication and psychosocial measures as well as family and/or carer involvement. Good symptom control and the interconnected issue of treatment adherence are arguably the most crucial factors for success. Carer and patient feedback should be carefully considered. Negotiation about commencing LAI therapy done early in course of disease is easier than many clinicians believe, although it is not often attempted in practice. Paliperidone palmitate is useful in both the acute and maintenance phases of treatment. COMMENTARY: A case-based approach is presented to suggest various opportunities where use of paliperidone palmitate could be considered within the disease course of schizophrenia. CONCLUSIONS: Paliperidone palmitate offers some advantages in terms of tolerability, simplicity of treatment initiation and long duration between injections. The consensus of the authors is that rather than reserving paliperidone palmitate for use in difficult-to-treat or refractory patients, it could be used to promote adherence and prevent relapse earlier in the course of the illness.

Preoperative hair removal to reduce surgical site infection.

BACKGROUND: Although preparation of people for surgery has traditionally included removal of hair from the incision site, some studies claim that preoperative hair removal is harmful, causes surgical site infections (SSIs), and should be avoided. OBJECTIVES: To determine if routine pre-operative hair removal (compared with no removal) and the timing or method of hair removal influence rates of SSI.. SEARCH METHODS: For this second update we searched the Cochrane Wounds Group Specialised Register (searched 12 August 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (1950 to August Week 1 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations August 11, 2010); Ovid EMBASE (1980 to 2011 Week 31) and EBSCO CINAHL (1982 to 11August 2011). No date or language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials (RCTs) or quasi randomised trials (QRCTs) that compared:1) hair removal with no hair removal; 2) different methods of hair removal; 3) hair removal at different times before surgery; and, 4) hair removal in different settings (e.g. ward, anaesthetic room). DATA COLLECTION AND ANALYSIS: Three authors independently assessed relevance and quality of each trial. Data were extracted independently by two authors and cross-checked. MAIN RESULTS: We included 14 trials (17 comparisons) in the review; three trials involved multiple comparisons. Six trials, two of which had three comparison arms, (972 participants) compared hair removal (shaving, clipping, or depilatory cream) with no hair removal and found no statistically significant difference in SSI rates however the comparison is underpowered. Three trials (1343 participants) that compared shaving with clipping showed significantly more SSIs associated with shaving (RR 2.09, 95% CI 1.15 to 3.80). Seven trials (1213 participants) found no significant difference in SSI rates when hair removal by shaving was compared with depilatory cream (RR 1.53, 95% CI 0.73 to 3.21), however this comparison is also underpowered. One trial compared two groups that shaved or clipped hair on the day of surgery compared with the day before surgery; there was no statistically significant difference in the number of SSIs between groups however this comparison was also underpowered.We identified no trials that compared clipping with depilatory cream; or investigated application of depilatory cream at different pre-operative time points, or hair removal in different settings (e.g. ward, anaesthetic room). AUTHORS' CONCLUSIONS: Whilst this review found no statistically significant effect on SSI rates of hair removal insufficient numbers of people have been involved in this research to allow confidence in a conclusion. When it is necessary to remove hair, the existing evidence suggests that clippers are associated with fewer SSIs than razors. There was no significant difference in SSI rates between depilatory creams and shaving, or between shaving or clipping the day before surgery or on the day of surgery however studies were small and more research is needed.

To be or not to be a clinical director?

OBJECTIVE: This article is designed to raise the interest of psychiatrists in the position of clinical director. CONCLUSIONS: The clinical director can improve the recovery of large numbers of mental health consumers by influencing the direction of local mental health policy, planning and funding. The effective clinical director will be an experienced psychiatrist with clinical credibility, who is present and available, leads by example, is flexible, energetic, delegates, can "manage up" and has probably undergone management training.

Development of an attrition risk prediction tool.

AIM: To review lecturers' and students' perceptions of the factors that may lead to attrition from pre-registration nursing and midwifery programmes and to identify ways to reduce the impact of such factors on the student's experience. BACKGROUND: Comparable attrition rates for nursing and midwifery students across various universities are difficult to monitor accurately; however, estimates that there is approximately a 25% national attrition rate are not uncommon. The financial and human implications of this are significant and worthy of investigation. METHOD: A study was carried out in one medium-sized UK school of nursing and midwifery, aimed at identifying perceived factors associated with attrition and retention. Thirty-five lecturers were interviewed individually; 605 students completed a questionnaire, and of these, 10 were individually interviewed. Attrition data kept by the student service department were reviewed. Data were collected over an 18-month period in 2007-2008. FINDINGS: Regression analysis of the student data identified eight significant predictors. Four of these were 'positive' factors in that they aided student retention and four were 'negative' in that they were associated with students' thoughts of resigning. CONCLUSION: Student attrition and retention is multifactorial, and, as such, needs to be managed holistically. One aspect of this management could be an attrition risk prediction tool.

Psychiatrically impaired medical practitioners: an overview with special reference to impaired psychiatrists.

OBJECTIVE: This paper will define and describe impairment in medical practitioners due to mental illness, with special reference to the specialty of psychiatry, and then review the prevalence and identification of impaired practitioners. METHODS: The quantitative and qualitative evidence regarding the incidence and impact of medical practitioner impairment due to mental illness (and, to some extent, substance use), with special reference to impaired psychiatrists, is reviewed. RESULTS: Medical practitioner impairment due to mental illness has a severe impact on their lives and their families due to both the effects of the disorder and the experience of communal, professional and self stigma. CONCLUSIONS: The consequences of impairment among medical practitioners and specialist psychiatrists as well as the under-reporting of impaired practitioners is a significant problem.

Psychiatrically impaired medical practitioners: better care to reduce harm and life impact, with special reference to impaired psychiatrists.

OBJECTIVE: The aims are to briefly review treatment outcomes for impaired practitioners, and to explore how preventive and early intervention, and the accessing of and retention within treatment systems for impaired medical practitioners, and particularly psychiatrists, could be improved to maximize the doctors' chances of full recovery and to minimize danger to self and others. METHODS: The literature on the treatment and care of medical practitioner impairment due to mental illness, and substance use, with special reference to impaired psychiatrists is briefly reviewed. The implications of deficiencies of usual clinical management of doctors impaired by mental illness and opportunities for improvement in services for them are explored, including the impact of the experience of being an impaired medical practitioner under psychiatric treatment. The roles of medical boards and advisory services are examined. RESULTS: Medical practitioner impairment due to mental illness has a severe impact on doctors' lives and the lives of their families due to both the effects of the disorder and the experience of communal, professional and self stigma and discrimination. Deficiencies in usual practice in the treatment and rehabilitation of such individuals are identified, and alternatives explored. CONCLUSIONS: Prevention, early detection, intervention, and treatment programs that are more continuous more sensitive to the needs of impaired practitioners, that are more continuous, better structured, and rehabilitation and recovery focused, may be more likely to produce a positive outcome.