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Schizophrenia affects 1% of the population. Clozapine is the only medication licensed for treatment-resistant schizophrenia and is intensively monitored to prevent harm from neutropenia. Clozapine is also associated with increased risk of pneumonia although the mechanism is poorly understood.
To investigate the potential association between clozapine and antibody deficiency.
Patients taking clozapine and patients who were clozapine-naive and receiving alternative antipsychotics were recruited and completed a lifestyle, medication and infection-burden questionnaire. Serum total immunoglobulins (immunoglobulin (Ig)G, IgA, IgM) and specific IgG antibodies to haemophilus influenzae type B, tetanus and IgG, IgA and IgM to pneumococcus were measured.
Immunoglobulins were all significantly reduced in the clozapine-treated group (n = 123) compared with the clozapine-naive group (n = 111). Odds ratios (ORs) for a reduction in clozapine:control immunoglobulin values below the fifth percentile were IgG, OR = 6.00 (95% CI 1.31–27.44); IgA, OR = 16.75 (95% CI 2.18–128.60); and IgM, OR = 3.26 (95% CI 1.75–6.08). These findings remained significant despite exclusion of other potential causes of hypogammaglobulinaemia. In addition, duration on clozapine was associated with decline in IgG. A higher proportion of the clozapine-treated group reported taking more than five courses of antibiotics in the preceding year (5.3% (n = 5) versus 1% (n = 1).
Clozapine use was associated with significantly reduced immunoglobulin levels and an increased proportion of patients using more than five antibiotic courses in a year. Antibody testing is not included in existing clozapine monitoring programmes but may represent a mechanistic explanation and modifiable risk factor for the increased rates of pneumonia and sepsis-related mortality previously reported in this vulnerable cohort.
Declaration of interest
S.J. has received support from CSL Behring, Shire, LFB, Biotest, Binding Site, Sanofi, GSK, UCB Pharma, Grifols, BPL SOBI, Weatherden, Zarodex and Octapharma for projects, advisory boards, meetings, studies, speaker and clinical trials.
This study sought to assess the effectiveness of ultrasound simulation as a component of high-fidelity trauma simulation, in training diagnostic capabilities of resident and attending physicians participating in simulated trauma scenarios.
Twelve residents and 20 attending physicians participated in 114 trauma simulations. Participants generated a ranked differential diagnosis list after a physical exam and subsequently after a simulated extended focused assessment with sonography for trauma (E-FAST) ultrasound scan. We compared reports to determine whether the addition of ultrasound improved diagnostic performance.
The primary diagnosis accuracy improved significantly with the addition of simulated ultrasound (p<0.0001). Median diagnostic ranking scores also improved (p<0.0001). Further, participants reported a higher confidence in their diagnoses (p<0.0001) and narrowed their differential diagnosis list (p<0.0001).
We demonstrated that a low-cost ultrasound simulator can be successfully integrated into trauma simulations, resulting in an associated improvement in measures of diagnostic accuracy, confidence, and precision for participating resident and attending physicians.
Anorexia nervosa is a potentially fatal illness that affects women and a smaller proportion of men. When a patient becomes so severely ill that admission to a medical unit is required, the risk of a poor outcome is high. Most medical services do not have sufficient expertise, without psychiatric help, to manage the nutritional, medical, behavioural and family problems that often appear. These problems interact and this can adversely affect outcome. This article discusses, with reference to the MARSIPAN report, the procedure that should be followed when such a patient presents to an acute medical service. It considers diagnosis, risk assessment, consent, re-feeding syndrome, underfeeding syndrome and treatment-sabotaging behaviours. It stresses the importance of collaboration between expert medical and psychiatric staff, and involvement of the family. When these issues are adequately addressed, the outcome for the patient is more likely to be positive.
•Be confident in diagnosing individuals with anorexia nervosa and identify when urgent in-patient medical treatment is required
•Be confident in assessing and managing physical risk in individuals with anorexia nervosa
•Be aware of the Royal College of Psychiatrists’ MARSIPAN report and its implications for the management of individuals with eating disorders in medical settings
Individuals of lower socioeconomic status (SES) display increased attentiveness to others and greater prosocial behavior compared to individuals of higher SES. We situate these effects within Pepper & Nettle's contextually appropriate response framework of SES. We argue that increased prosocial behavior is a contextually adaptive response for lower-SES individuals that serves to increase control over their more threatening social environments.
A controversy at the 2016 IUCN World Conservation Congress on the topic of closing domestic ivory markets (the 007, or so-called James Bond, motion) has given rise to a debate on IUCN's value proposition. A cross-section of authors who are engaged in IUCN but not employed by the organization, and with diverse perspectives and opinions, here argue for the importance of safeguarding and strengthening the unique technical and convening roles of IUCN, providing examples of what has and has not worked. Recommendations for protecting and enhancing IUCN's contribution to global conservation debates and policy formulation are given.
The music of John Adams has grown far away from its roots in Minimalism, but even in complex works like American Berserk (2001) and the Saxophone Concerto (2013) one can detect the working of a compositional mind conditioned by procedures relating back to earlier periods of the composer's output. A feature of Adams recent work is a continuing concern with various repetition strategies but in a far more veiled and multilayered manner. Another feature of both works is the deployment of ‘pushing up’ and ‘pushing down’ material manipulated rhythmically and raised to a structural level. Two strategies are adopted and adapted to investigate these features. The first, is from Rebecca Leydon's ‘Towards a Typology of Minimalist Tropes’, which considers the qualities of repetition in Minimal music, and the second is an idea borrowed from David Osmond Smith's monograph on Berio's Sinfonia, Playing on Words, where he considers ‘levels of obliteration’ of an underlying text (Mahler 2 Scherzo ‘In Ruhig Fliessender Bewegung’) in the third movement of the Sinfonia.
Air pollution makes us feel bad when we think about it – but do bad air days really affect our subjective well-being (SWB) when we are not thinking about them? And if so, do they affect the range of possible measures of SWB in similar ways? Using data from over 165,000 individuals in the UK, we model evaluative, experiential and eudemonic SWB as a function of demographic and local area characteristics including the background concentration of particulate matter. Our results indicate that air pollution adversely affects all of the positive measure of SWB included in our analysis; how satisfied people report being with their lives overall, how happy they report feeling on the previous day and how worthwhile they rate their activities as being, and that it does so over and above its effects on self-reported health. These effects can be monetized and may imply greater priority being afforded to pollution abatement programs than is currently warranted based on existing estimates of the health effects alone.
Patients with severe and enduring eating disorders (SEED) may constitute a specific group. It is proposed that patients with anorexia nervosa (SEED-AN) or bulimia nervosa (SEED-BN) that requires the regular attention of a multidisciplinary team and is of a duration known to have a low recovery rate should be included in the SEED group. These patients present with a combination of severe symptoms and long-term illness, and may experience serious chronic physical sequelae (e.g. osteoporosis and renal failure), marked social isolation and stigma. Their carers suffer from the stress of caring for them over a prolonged period. Symptoms, treatment and crisis management of SEED-AN are discussed. SEED is a relatively recently described area of eating disorders psychiatry that requires research and service development so that patients and carers are helped to cope with very serious chronic, but not incurable, conditions.
•Understand the definition of SEED-AN and SEED-BN.
•Be able to assess the physical and psychological state of patients with SEED-AN and SEED-BN.
•Be able to plan the monitoring and treatment of patients with SEED, involving their carers and families.